Category Archives: Africa

Providing mosquito nets for families through school distributions

Copyright Malaria Consortium

“When the rainy season comes, our children fall sick because of the weather. It’s malaria, flu, cough – even measles. It affects us because they miss lessons, and they can’t always catch up when they come back.”

Mary is a teacher at Iyolwa Primary School in Tororo, eastern Uganda. She teaches maths, English and social studies to a class of around 80 students, most of whom are no more than 10 years old. Her students study hard but, like in many parts of the country, their education can be severely disrupted by malaria and other illnesses.

During my visit to check up on Comic Relief’s Operation Health project in the same district, I was fortunate enough to be able to observe an activity from one of our projects that tackles this issue head-on: the distribution of long lasting insecticidal nets that would provide protection for over a thousand children and their families.

Whilst malaria mortality and morbidity in Uganda is generally high, Tororo is the worst hit by the disease. On average, residents are exposed to one to two infectious mosquito bites per night, with malaria accounting for more than 40 percent of patient visits to many health facilities. Sleeping under a long lasting insecticide treated mosquito net is one of the best ways to prevent malaria, but unfortunately they are not always available, or if they are, people don’t know how to use them properly.

The Malaria Control Culture project in Tororo focuses on developing ‘routine’ net distributions, ensuring nets reach those that need them most and encouraging people to use them. At the health facility level, we provide nets for pregnant women (who are at an increased risk of contracting malaria) when they go for antenatal check-ups. We also help ensure good net coverage through annual distribution campaigns for school children in years one and four.

It was one of the school net distributions that I visited, arriving in time to enjoy a lively drama about malaria prevention performed by a group of village health workers and primary school pupils. While the drama was going on, Malaria Consortium staff were speaking with teachers about the logistics of the distribution, while parents and relations gathered in the shade to hear from district officials and other experts about how to use the nets.

“Today we are going to show you exactly what Malaria Consortium has done for the people in the village, and what good things are going on there,” said Saul, head village health team member (VHT) of the sub-county. “We are going to show you through song, and at the same time we are going to make a drama so you can see exactly what is happening.” He told me that he was there with other VHTs to teach the school children how to protect themselves and their families from malaria. This way, children not only bring home a net but can also pass along the lessons they have learnt on preventing malaria, he explained.

When the drama ended, children in Y1 and Y4 began to gather outside the school building, where teachers read out their names from class registers Abbo Kevin, mother of six year-old daughter Stella who received a net that day, told me: “I came to this school when I was younger, but I didn’t receive nets. This is the first time. Before, malaria was so high, but it is now decreasing because of the nets.”

Mary said she and the other teachers are also happy to see a drop in the number of absences: “Since the nets, it has changed. Many have been falling sick, but as of now the numbers have been reduced.”

Take a look at the photo gallery below to see some of the photos from the net distribution:

pStudents teachers parents and community health workers VHTs gather near Iyolwa Primary School for a drama performance that teaches children how to protect themselves and their families from malarianbspp
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Ilya Jones is Communications Officer at Malaria Consortium in London.

Barriers to IPTp uptake in Uganda

Pregnant women are particularly susceptible to malaria partly because of their reduced immunity to the disease, but also because of their vulnerable social and economic status. Their unborn babies are also at high risk, with malaria potentially leading to spontaneous abortion and low birth weight. Babies born with low birth weight will often be weak and more likely to get sick. However, malaria in pregnancy is preventable. The World Health Organization recommends a combination of three interventions for the prevention and treatment of malaria in pregnancy: the use of long-lasting insecticidal nets, prompt diagnosis and effective treatment of malaria infections, and the administration of intermittent preventive treatment in pregnancy (IPTp).

It is this last method that we have been concerned with at Malaria Consortium. IPTp is low-cost, safe and generally acceptable to pregnant women, and can be provided at antenatal check-ups. However, despite generally high antenatal care (ANC) attendance, most countries in sub-Saharan Africa do not come close to meeting the targets set by organisations like Roll Back Malaria, which advocate for universal coverage.  In Uganda, for example, current surveys suggest that only about a quarter of pregnant women receive two doses of IPTp (IPT2, the indicator commonly used to assess IPTp uptake). This suggests that many opportunities for the provision of IPTp are being missed.

Research results

We have coordinated a study conducted in 2014, which explored the barriers that continue to impede IPTp uptake in Uganda. This has involved carrying out in-depth interviews with pregnant women and mothers who attended ANC, health workers, district health officials and community leaders.  Conducted through COMDIS-HSD, a research programme consortium funded by UK aid from the UK government, the study looked at both the supply side (i.e. the health system, including health workers) and demand side factors (i.e. women’s and communities’ perceptions).

The research concluded that, despite a range of minor concerns (for example with regard to taking IPTp on an empty stomach), women and communities have largely positive views of ANC and IPTp. Refusal rates of IPTp are low and given the high ANC attendance figures, the main obstacles to the provision of IPTp are therefore likely to be supply-side challenges. In the past, many health facilities struggled with frequent stock-outs of the drug used for IPTp, although this has been improving thanks to recent efforts from the Ministry of Health. Private facilities on the other hand have to buy their own supplies, which means stock-outs are still a problem.

Another major barrier to the provision of IPTp is health workers’ inadequate knowledge with regard to when and how to provide IPTp. This is compounded by the incoherent and out-of-date information provided in many policy documents and job aids that are supposed to guide health workers. Moreover, the policies in use are not in line with the most recent WHO policy recommendations for the provision of IPTp.

What next?

Malaria Consortium is about to implement a small-scale pilot intervention in collaboration with the Ministry of Health to address some of the key barriers to IPTp uptake in Uganda. The main focus of the intervention is to ensure adequate knowledge of IPTp guidelines among health workers. This will support the Ministry’s plans to roll out a country-wide classroom-based training programme on malaria in pregnancy, which will include updated IPTp guidelines that comply with current WHO recommendations.

However, it is unfortunately not feasible for everyone involved in ANC provision to attend traditional classroom training sessions. Therefore, in order to reinforce the guidelines and ensure all relevant health workers receive the necessary information, we will pilot the use of text messaging to communicate key messages. Following the classroom-based training, health workers providing ANC services at a number of health facilities in West Nile province will receive a series of text messages emphasising the importance of IPTp, explaining the new guidelines and the rationale behind the changes. This approach has recently been shown to be highly effective in communicating clinical recommendations to health workers in China, and we believe that the rapid spread of mobile technology in Africa means that the time is right to test this innovative solution in Uganda.

In order to assess the effect of the intervention, the pilot will also include health workers in a neighbouring district who will only receive the classroom-based malaria in pregnancy training. We will assess knowledge of IPTp at all facilities six months after the training. If text messaging works, we would expect to see better levels of knowledge among those health workers who attended the training and subsequently received the messages compared with those who only received the training. We would also expect that better knowledge of the IPTp guidelines will lead to fewer missed opportunities and hence an increase in IPTp coverage. The pilot is scheduled to start in May 2015 and evaluation results are expected to be available in 2016.

Christian Rassi is COMDIS-HSD Project Coordinator at Malaria Consortium

Agente Polivalente Elementar overcomes tragedy by helping her community

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Caterina Cumbi, a community health worker or Agente Polivalente Elementar (APE) makes a check-up visit to three-year-old  Beldencio who  tested positive for malaria  three days ago; in Jogo, Inhambane (Photo by Ruth Ayisi).

Caterina Cumbi, a community health worker or Agente Polivalente Elementar (APE) as they are known in Mozambique, remembers how in the 1980s she lost three of her eight children to malaria. “There was no health centre nearby, no transport and no APE who could test and treat malaria.”

Today, Caterina, 46, supports her five surviving children, four of whom have gone on to further education. Not only has she been able to provide for her family by selling tangerines and avocados, but since 2010 she also has improved the health of her rural community in Jogo, in Mozambique’s southern province of Inhambane, after being elected by her community to work as an APE.

In 2012 Caterina attended a course supported by the Ministry of Health, in partnership with Malaria Consortium, to learn how to prevent, diagnose and treat malaria, diarrhoea and pneumonia, the three main killer diseases of children under the age of five in Mozambique.

Caterina’s working hours are from 9 am to 2 pm, Monday to Friday, which include consultations and home visits to carry out health promotion activities, including community dialogues around childhood illnesses, their prevention and management. “But sometimes when I return from my home visits I find mothers waiting for me,” says Caterina. “They also come during the night and over the weekends, and mothers from other communities who do not have an APE in their area also bring their children to me.”

Caterina works closely with the health committee, ensuring transparency and involvement of the community. “She always opens the monthly health kit [containing rapid diagnostic tests and medicines] in our presence,” says community leader Pedro Rafael. “We plan our health promotion activities together.” He adds, “Caterina has a lot of influence in our community. Before, most women used to give birth at home, but Caterina has sensitised them to make the journey to the health centre to give birth.”

Her supervisor, Hirondina Bernardo, a nurse at the health centre in Nhancoja, also speaks highly of Caterina and the other two APEs whom she supervises.  “People who did not like coming to the hospital, now come when the APEs refer them, as the APEs are from their own communities and are trusted.”  However, each month Caterina has to ride her bike for 18 kilometres along sandy tracks to collect supplies and deliver her record of consultations and health promotion activities. “The terrain is difficult”, comments nurse Hirondina, “so their bikes had to be replaced, and for a while some of the APEs had to walk each month to bring their records.” Despite the challenges, Caterina too says that she feels she makes a valuable contribution. “I keep the children in my community healthy,” she says.

Malaria Consortium is working with the Agente Polivalente Elementares in Inhambane through the inSCALE project. The inSCALE project is researching innovative ways to increase APE motivation and performance in order to increase the appropriate treatment of sick children.  Since 2013, the APEs in six districts in Inhambane have been using smart phones with an application called inSCALE APE CommCare, which features a multimedia job aid with images and audio to guide APEs through the consultation steps, a closed user group enabling free communication between peers and supervisors, and a data submission tool that enables the APEs to submit their records over the 3G network. To learn more about the work of APEs such as Caterina and the inSCALE project please join us at INSTIDOC – Ciclo do Documentário Institucional on Friday 24th April 19h00 at Centro Cultural Franco-Moçambicano in Maputo, Mozambique to watch our documentary focusing on two APEs “Caterina e Halima”. For further details about the event, please visit the website: https://instidoc.wordpress.com or for more information about the inSCALE project: www.malariaconsortium.org/inscale/.  

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Before, we had no way to prevent malaria. Now the nets protect the whole family

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It’s the second week of August in Lichinga, Niassa Province in northern Mozambique – not far from the Malawi and Tanzania borders. It is a cold and wintery month with grey skies.

After about two months of preparation, our mosquito net distribution campaign using long lasting insecticide treated nets (LLINS) for universal coverage has finally reached the distribution stage. The teams who have been working to support and supervise the campaign will set out for the Ngaúma, Mandimba, Metarica, Nipepe, Marrupa and Majune districts – the six included in the first stage of distribution. Expectations are high for everyone involved. Finally, the campaign will start.

The main ceremonies of the campaign’s launch will take place in the Chimbunila district village of Lumbi, 15 km from the city of Lichinga. Here, in addition to the distribution of LLINs, a new health facility will be opened.

Alifa Rachide’s family was chosen by the community to receive the first LLINs to be distributed in this province. Alifa, 50, will bring his wife Atuege Jemuce, 43, and their seven children to the event. Their daughter attends fourth grade and another child is in year one. Alifa doesn’t know the exact age of his children, but he says the youngest is less than a year old.

The couple, originally from Lumbi, support themselves by cultivating cassava, groundnuts and beans, ensuring a supply of food for the family and generating some extra income. Alifa says this is the first time that his family will receive mosquito nets. “We never had mosquito nets, and so we had no way to prevent the mosquito bites and malaria,” he said. “At home, someone gets sick with malaria most years, but fortunately this year no one has got sick yet. I’m happy because the nets we receive will protect the family from malaria.”

Alifa and his family received four LLINs – a sufficient number to cover the whole family, since two people can usually sleep under a single net. His wife Atuege lets out a smile because the community will have a closer health facility that will reduce the distance they have to walk – involving crossing a river and the risk of crocodile attacks. She says: “Our family was chosen by God – we have received mosquito nets, and we have a health facility. Community leaders visited our house and informed us that we would receive LLINs at a ceremony held by the Government. And here we are.”

The LLIN distribution campaign was implemented by Malaria Consortium, under a project funded by the Global Fund Round 9. The project is being carried out in nine provinces of Mozambique, partnering with World Vision and the Foundation for Community Development (FDC). Malaria Consortium supported the Provincial Health Directorates of Niassa and Nampula to distribute around 1,000,000 LLINs, benefiting more than 400,000 families. In addition to distributing LLINs, the project involves training volunteers and teachers to educate and engage their communities around malaria prevention and control strategies.

Fernando Bambo is Deputy Project Manager in Mozambique

Supportive supervision: improving the quality of community health services

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Community health workers, when trained and equipped to manage simple cases of pneumonia, diarrhoea and malaria in children under the age of five, can reduce child mortality caused by these three diseases by up to 60 percent.

Funded by the World Health Organization (WHO), the Rapid Access Expansion (RAcE 2015) project in Mozambique is a strategic alliance between Malaria Consortium and Save the Children, to support the Mozambican Ministry of Health’s community health programme. The project is focused on improving the quality of care provided by community health workers (locally known as Agentes Polivalentes Elementares or APEs) by strengthening their ability to correctly diagnose, treat and refer children with common diseases and by ensuring that they receive regular supervision to improve performance and correct errors.

In November, Malaria Consortium staff and Provincial Health Directorate authorities carried out supervision visits in Inhambane province, Mozambique, to assess the clinical skills of APEs. In Inhassoro district, we met Linda Noah, a health worker who had cycled 21km on her bike, carrying her seven-month old daughter and her APE kit on her back, to participate in a clinical supervision session. During this session, Linda provided care to three children, all under the age of five, while being observed by district health technicians.

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“This was a first for me,” Linda said. “I have never had a clinical evaluation session like this. My supervisors observed my work and advised me right away on what I was doing right or wrong.”
This session made Linda aware of the challenges in correctly assessing danger signs and identifying those children that need an immediate transfer to a health centre.

“I enjoyed coming to this session. I faced many difficulties but I managed to fix them and I hope I will have even more of these kinds of opportunities with my supervisor to improve my work.”

Written by: Adolfo Guambe (Provincial Health Directorate, Inhambane) & Eder Ismael Zerefos (Malaria Consortium)

Preventing the number one infectious cause of death in children

November 12th is World Pneumonia Day. To mark this occasion, Malaria Consortium interviewed Dr Phanuel Habimana, adviser on child and adolescent health for the World Health Organisation’s Africa region. 

What effect does pneumonia have in Africa economically and in terms of mortality? 

Pneumonia continues to be the biggest killer worldwide of children under five years of age. In 2013, it claimed the lives of close to one million children under five worldwide, 50 percent of them in the WHO African region.

Pneumonia is a disease of poverty. Poverty-related factors such as lack of access to safe water, poor access to health care and inadequate sanitation all increase the likelihood and amplify the effects of pneumonia. Children with deficiencies such as malnourishment, particularly those who are not breastfed or do not consume enough zinc, are at a higher risk of developing pneumonia.

Research has shown that prevention and proper treatment of pneumonia could avert one million deaths in children every year globally. With proper treatment alone, 600 000 deaths could be avoided.

The cost of treating all children with pneumonia in 42 of the world’s poorest countries is estimated at around US$600 million per year. Treating pneumonia in South Asia and sub-Saharan Africa – which account for 85 percent of deaths – would cost a third of this total, at around US$200 million. The price includes the antibiotics themselves, as well as the cost of training health workers, which strengthens the health systems as a whole.

What is the single biggest obstacle to reducing the burden of pneumonia?

The single most important obstacle to reducing the burden of pneumonia is low coverage of essential interventions for the prevention and control of pneumonia due to inadequate care seeking behaviour, access, availability and cost of diagnosis and treatment. Evidence shows that children are dying from pneumonia because effective interventions are not provided equitably across all communities.

Do you think that integrated community case management initiatives, such as those run by Malaria Consortium, are effective?

The integrated community case management initiatives have been very effective in training members of communities to identify treat and/or refer cases of pneumonia. With adequate training and supervision, community health workers can retain the skills and knowledge necessary to provide appropriate care for pneumonia, malaria and diarrhoea. For example:

  • In Malawi, 68 percent of classifications of common illnesses by health surveillance assistants were in agreement with assessments done by physicians, and 63 percent of children were prescribed appropriate medication.
  • In Zambia, a community case management (CCM) study on pneumonia and malaria found that 68 percent of children with pneumonia received early and appropriate treatment from community health workers.
  • In Ethiopia, the health extension workers (HEWs) performed better in terms of doing assessment tasks correctly – 84 percent compared to 70 percent by health facility health workers. HEWs treated the child with pneumonia correctly 72 percent of the time compared with 65 percent by facility health workers.

If pneumonia is an easy disease to both diagnose and treat, why does it cause so many deaths every year, especially among children? 

Many of the reasons, which are associated with poverty conditions, are:

  • Delayed care-seeking: Recognising the symptoms of pneumonia and seeking appropriate care from a health care facility is the first step in reducing deaths from pneumonia. However, sub-Saharan Africa has the lowest care-seeking for pneumonia – 48 percent. Nearly half of early childhood pneumonia is estimated to result from lack of or delay in appropriate diagnosis and treatment.
  • Lack of access to health facilities with well trained staff and essential medicines:  Most vulnerable communities do not have access to health facilities with well-trained health workers and essential medicines to get lifesaving interventions in time. Currently in the African region, only 24 percent children with suspected pneumonia are given proper antibiotic treatment. Stock out of essential antibiotics to treat pneumonia is a major problem.
  • Low coverage of vaccines:  Many countries have not yet introduced pneumococcal vaccines to prevent pneumococcal pneumonia.
  • Low exclusive breastfeeding rate:  Exclusive breastfeeding and continued breastfeeding with complementary feeding reduces pneumonia illness and death in children. However, only 35 percent of infants less than six months are exclusively breastfed.
  • Lack of simple and standardised guidelines in every health facility: The World Health Organisation (WHO) and UNICEF have developed guidelines for the integrated management of childhood illness to improve the quality of care provided to under-five children. However, the training in the use of these guidelines has not been scaled up to reach every health worker managing sick children under five in every health facility in most of the countries in Africa. Therefore, millions of children are still dying because those most at risk are not reached and services are provided piecemeal.

What does the WHO recommend in order to reduce the prevalence of pneumonia in rural and low-resource communities?

WHO and UNICEF, in collaboration with other partners, have developed an integrated plan entitled Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea.  This plan emphasises that the prevention and control of pneumonia and diarrhoea should not be dealt with separately but must be addressed together. Both are caused by a range of pathogens, and no single intervention alone will be adequate to prevent, treat or control either disease. Further, they share several common causes and risk factors, common prevention strategies and interventions, and similar delivery platforms in health facilities and communities.

What can be done at community level to help limit pneumonia?

In most high-mortality countries, facility-based services alone do not provide adequate access to treatment within the crucial window of 24 hours after onset of symptoms. If child mortality is to be adequately dealt with, the challenge of access must be addressed.  Community health workers – appropriately trained, supervised and provided with an uninterrupted supply of medicines and equipment – can identify and correctly treat most children who have pneumonia. A recent review by the Child Health Epidemiology Reference Group estimated that community management of all cases of childhood pneumonia could result in a 70 percent reduction in mortality from pneumonia in children less than five years old. Furthermore, community health workers can empower families and communities to improve care seeking practices and care for the child at home during sickness and wellness.

How has technology contributed to reducing the burden of pneumonia?

The use of vaccines against streptococcus pneumonia and haemophilus influenzae type b, the two most common bacterial causes of childhood pneumonia plus vaccinations against measles and pertussis, substantially reduces the disease burden and deaths caused by pneumonia.  Furthermore, the development of evidence-based simplified Integrated Management of Childhood Illnesses’ (IMCI) guidelines for the identification and treatment of pneumonia at facility and community levels has greatly contributed to the reduction of the burden of pneumonia. At hospital level, the availability and use of pulse oximetry has been a great technological advance to assess the saturation of oxygen in the blood. Oxygen concentrators have been very critical in providing care to very sick children. All those technological advances have enabled health workers to give appropriate lifesaving interventions.

Community health? There’s an app for that

In recent years, there has been a rapid proliferation of mobile phone applications. There seems to be one for everything, from daily reminders to complex navigation. But while most of us don’t think of phone applications as lifesaving tools, in some remote communities where healthcare access is limited, that is exactly what they are.

In many remote villages in Mozambique, community health workers are the first point of contact when a child gets sick. They are trained to diagnose and treat children under five years for some of the deadliest conditions – pneumonia being chief among them – and provide referrals to health facilities for severe conditions.

Community health workers, or Agentes Polivalentes Elementares (APEs) as they are known locally, have been highly effective at bringing healthcare closer to people living in the poorest and most remote communities. However, they face a number of challenges carrying out their work. They often lack the tools necessary to properly assess symptoms, diagnose and treat childhood illnesses and have had limited contact with their supervisors.

Malaria Consortium has been testing the utility of mobile phone applications as a means to improve the motivation and confidence of community health workers who face these obstacles every day.

How are the phones used?

APEs are given a smartphone that comes preloaded with an app called ‘inSCALE APE CommCare’. This application helps them carry out their daily work.

Firstly, this app acts as an interactive job aid, guiding them through all steps of diagnosis, treatment and referral. For pneumonia, the app asks a series of questions regarding symptoms and uses a special counter that helps to assess the respiratory rate of the child. If the child is found to have pneumonia symptoms, the app provides educational messages and treatment instructions for both APE and caregiver. Recommendations for follow-up visits or referrals are given based on the diagnosis and vaccination status of the patient.

Patient data, including diagnosis and vaccination status, is stored on the phone along with weekly aggregated data and medicine stock levels, all of which are sent to the APE’s supervisor. This is then collated into statistics at the provincial and district levels that provide real-time data available to health officials. After submitting the data, the APEs receive feedback messages thanking them for their work.

Communication with supervisors and peers is also significantly improved through the phones. Each APE receives a monthly automated credit allowance for making calls – an initiative that bridges the gap between health workers and their supervisors, ensuring closer coordination and improved performance. Periodic motivational messages also can help increase a sense of collective identity and purpose.

Has it been successful?

The results have been encouraging. A process evaluation was carried out in Mozambique, which showed that 68 percent of APEs always use CommCare in their work. Respondents reported that the application helped them remember the symptoms to look for.

The three most favoured aspects of the inSCALE APE CommCare app were the job aid for newborns, children and pregnant women; improved respiratory rate timer; and treatment and dosing instructions. Mobile phones were also found to improve the community standing and legitimacy of the health workers.

At the heart of the application’s success was its user-centred design. The Mozambique Ministry of Health and the community health workers themselves were heavily involved in each step of the design process, ensuring that the app remained easy-to-use and intuitive. However, most APEs and supervisors were unaccustomed to using smart phones, so introductory sessions were held in addition to the existing CommCare training. This allowed for efficient use of the phone and its software.

You can learn more about the CommCare app by watching the demonstration video below:

*Malaria Consortium’s inSCALE project is funded by the Bill & Melinda Gates Foundation and carried out in partnership with the London School of Hygiene and Tropical Medicine and University College London.

Read more about mHealth in Mozambique here

Ilya Jones is the Communications Officer in London

Malaria Consortium’s RAcE project: Implementing iCCM in Nigeria

Dr Jonathan Jiya is the programme manager of Malaria Consortium’s RAcE project in Nigeria. He recently met with senior leaders of communities in Niger state to discuss the implementation of a project which aims to provide healthcare for 150,000 children under five by 2016.

Malaria Consortium’s Rapid Access Expansion (RAcE) project, funded by the World Health Organization (WHO) and the Canadian Department of Foreign Affairs, Trade & Development (DFATD) aims to improve the community-level management of childhood malaria, pneumonia and diarrhoea in Niger state, Nigeria. In rural areas of Niger state, there is a lack of healthcare services required to treat these conditions, which are the biggest killers of children under five.

The project builds upon existing community-based health interventions, such as integrated community case management (iCCM), and involves working with a number of Nigerian organisations, including the Centre for Communications Programs Nigeria (CCPN) and the Federation of Muslim Women Association Nigeria (FOMWAN).  Malaria Consortium is supporting the Ministry of Health in Niger state to implement iCCM activities in six local government areas (LGAs).

As the project leader for RAcE, I recently met with influential leaders, including senior community leaders and other stakeholders across the six LGAs, in order to mobilise resources and begin implementing iCCM activities. The LGA representatives welcomed the proposed meetings – there were never fewer than 40 people at each one. Discussions focused on the value of iCCM, on reasons why a programme like RAcE is necessary and on how best to select members of each community to take part in the project.

Community leaders and other key stakeholders were briefed on proposed iCCM strategies. As part of the project, Malaria Consortium will train over 1,700 community oriented resource persons (CORPs) and will consequently help to provide basic healthcare by 2016 to over 150,000 children in hard to reach areas of the six selected LGAs. CORPs will be trained to identify and treat the diseases, and will serve as both an access point and a form of continuity of care to existing healthcare systems.

The community leaders I met were asked to select responsible and well-respected members of their communities to be nominated as CORP volunteers. As one objective of the project is to build trust and cooperation between health systems and community members, the input of leaders in selecting role-models from the community is essential. Respected members of the community are in a strong position to influence others and to encourage behaviour changes which can prevent the spread of illnesses.

The second in command to the Emir in Lapai emirate, The Shaba Lapai, welcomed the opportunity to be consulted, saying, “This is the type of project we want. It will save the lives of our children and because the participation of community leaders has been recognised, we will support the project in any way we can for it to succeed”. He went on to say that the community will “support CORPs training and ensure that the community health committees function optimally for progress and abide by the given criteria for selection of CORPs”.

Hajiya Hauwa Usman, a participant at one of the forums, said: “Pneumonia, diarrhoea and malaria bring so much pain to mothers and families each year, especially during the rainy season. Malaria Consortium’s RAcE project will reduce this suffering and help children in their communities.” Mallam Garba Hussaini, an Islamic cleric agreed, stating, “We are appreciative of the effort of the state government and RAcE in selecting our communities to benefit from this project”.

The community forums also provided a chance to clear up logistical issues, such as the problem of a lack of storage facilities for the drugs that are being provided. In this instance, the concerns were addressed by promising the provision of portable storage facilities for each CORP. The most positive outcome of the meetings, however, was seeing that community leaders were appreciative of the opportunity to be included in the planning and implementation of RAcE.

 

Fighting malaria in the classroom

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Fernando Bambo is Malaria Consortium’s Communications and Advocacy Coordinator in Mozambique

One of the most interesting aspects of working at Malaria Consortium for me is tracking its progression over time. It was in December 2005 that I joined the organisation, as Deputy Coordinator of the demand creation component of the project for Sustainable Distribution Systems of LLINs, funded by the UK Government.

This innovative project, initially implemented in Inhambane province in Mozambique and subsequently expanded to Nampula and Cabo Delgado, rested on three pillars. These were:

1)      The free distribution of LLINs to pregnant women at public antenatal care clinics;

2)      Support for the commercial sector to develop a market for mosquito nets that were affordable for all socio-economic groups;

3)      Demand creation for mosquito nets through communication activities, as well as the promotion of proper nets’ use and care.

The communication component had a huge impact on creating demand for mosquito nets in both the public and private sectors. At the time, LLINs were still a novelty in Mozambique, and we all had a lot to learn in almost all areas of implementation. One of our achievements was the development of a communication strategy to promote LLINs using the COMBI approach (Communication for Behavioural Impact) whose principles have since been incorporated in the National Communication Strategy and Advocacy for Malaria (2013-2017).

COMBI was the strategy that gave rise to the popular interactive radio programme ‘MozzzKito.’ In addition to MozzzKito, we also developed a new tool, the “net hat”:  this was an exercise and games worksheet specifically designed for primary school children to help them learn about malaria in a fun way.  The ‘hat’ consisted of a poster with six learning exercises and games, including brain teasers, and “malariamática” (math on malaria). With support from teachers, children solved the exercises in the classroom and afterwards folded the poster into a ‘hat’ with the message – “I am protected, sleeping under a net.” This symbolised the participation of children in the fight against malaria.

Upon leaving the classroom, the children went out onto the street in groups showing their hats, and interacting with the community about malaria. At home, the children read the poster aloud to their parents, and in the end, the parents signed a paper that indicated that they had seen the poster. Finally the children took the “hat” back to school and gave it to the teacher.

Even today, I still think of those earlier projects and look at how far we have come as an organisation. Since I first joined, each project has built on experiences from the last – in this way we have improved our work and generated new ideas. Currently, Malaria Consortium is working on the Malaria Prevention and Control Project – a project that I am a part of. The project aims at engaging communities in defeating malaria through school activities, radio programmes, and capacity building of community-based organisations in conducting behaviour change communication activities. The lessons learned and the accumulated experiences all contribute to better and healthier lives.

Connecting healthcare workers in rural Uganda with mobile technology

Malaria Consortium has encouraged the creation of parish coordinator roles as part of the integrated community case management (iCCM) programme in support of the Ugandan Ministry of Health’s village health team structure and as part of the inSCALE project in Uganda, which seeks to increase coverage of community health services. Acting as the link between village health team members (VHTs) and supervisors, the role of the parish coordinator facilitates the reporting, supervision and mobilisation processes, often through the use of mobile technology.

Bulega Abdul was elected as the coordinator for his parish of Kibugubya in Hoima district, Western Uganda. “Three VHTs were nominated for each parish, from which we elected the coordinator” said Abdul.  “I think they elected me because of the way I do my work. I was happy to be elected. I like it. I don’t mind that I don’t get paid.”

Abdul’s main responsibilities include collecting monthly reports from the 28 VHTs in his parish. “I make monthly home visits to all the VHTs to make sure they’re doing okay. We go through the register together; if I find any mistakes in how they give out drugs, or if there is a discrepancy in drug use and patients seen, we find and correct the mistakes together so that the next time, they can do it right.”

Traveling on his bicycle across the 18km wide parish, Abdul visits at least one VHT most days. “I call a day in advance to let them know I am coming. I used to have to spend my own money – maybe 5,000 shillings per month – making these calls. But now, I make them for free on the inSCALE CUG.” The CUG – or Closed User Group – is part of the inSCALE technology intervention where selected VHTs receive phones allowing free calls between VHTs and their supervisors, as well as functions for mobile submission of reports.

“The CUG really helps me,” Abdul said. “Before, when I was sacrificing my own money, it would be very tiresome. To limit the time on the phone I would call one VHT and ask him to notify his partner, and the calls would be so short – just a few words,” Abdul laughed, mimicking a clipped, abrupt conversation. “There would be misunderstandings and sometimes you would not find that person in the correct meeting place and would have to go back again later. And there would never be time for asking and answering questions on the phone. Now, it’s so much better. We can talk longer and the VHTs can call me if they have any problems with drugs or with their register and I can explain it properly. It really helps the VHTs in their performance.”

VHT performance is partly monitored through the weekly reports submitted on the inSCALE phones. “The reports are very good, because they are short,” Abdul said. “Before, with the written monthly reports, they were long and you could lose information or notes, so there would be more mistakes. The VHTs would often be reluctant to complete them because it would take so long. Now, with the weekly ones, they are quicker and more accurate. To me it is very important that we report exactly what is happening on the ground; it is very important when you deal with medicine that you can account for it.”

The phone software is designed to increase the VHTs level of motivation through regular messages of recognition and appreciation that, according to Abdul, are very important. “The reminders and the messages of thanks are very popular. It is really important to feel that you are working for someone, and to have regular contact with Malaria Consortium as our donors. I really appreciate that; I feel I am part of Malaria Consortium now because the phones have brought us closer.”

And, as Abdul noted, this benefit is mutual. “I think it also helps Malaria Consortium. If they need something urgent, they can just call the VHTs directly. I think it positively affects the success of the programme because they know what is going on at ground level. Surely, these phones are cheaper than the fuel they would need to see us all?”

Just as the phones are helping to connect the VHTs with each other and with Malaria Consortium, they have also improved relations with supervisors and health workers. “Before, many of us VHTs had an inferiority complex with our supervisors and the health workers; there would be a big gap between us. But now that feeling is no longer there. Because of the frequent communication we are more familiar with them. We feel equal; that we are all health workers and all have the same goal. These phones have really done so much good.”

Malaria Consortium has been implementing iCCM projects in Mozambique, South Sudan, Uganda, and Zambia since 2009. To date, over 14,000 community health workers have been trained, providing close to three million treatments for over 2.4 million cases.