South Sudan: a network of volunteers tackling malnutrition and malaria

South Sudan ranks 15th highest in the world in mortality rates for children under five. Malaria and malnutrition are amongst the leading health threats in the country. As a result, Malaria Consortium has been working to provide an integrated response to malnutrition and common childhood diseases in the country. This is the story of Paul Malong, a community health worker, trained by Malaria Consortium and partners, in Gueng Village, South Sudan.

Pual Malong is a community nutrition worker in Gueng Village in Mariem East Payam, Aweil West County. He has been a community nutrition worker since 2011 when he was first trained by Malaria Consortium. Previously he had been a supervisor for 133 community drug distributors.

“When the nutrition programme was introduced to treat severe malnutrition cases, the community again selected me to be the community nutrition worker. I was then trained again by Malaria Consortium, after I had received the initial ICCM programme training. So far I have received two ICCM and three nutrition trainings and I have got all the skills for carrying out ICCM and as a community nutrition worker.”

Malong’s training has meant he is able to not only help his community with ICCM care, but he is also able to help tackle malnutrition, which is a common problem for children in the area, increasing the risk of disease and mortality. Malong screens children brought to his outpatient therapeutic feeding (OTP) site, where he provides general health education. He screens the children for severe acute malnutrition and provides nutritional supplements (Plumpy’nut) to those who need it and refers more complex cases to the nearest health facility or Aweil Hospital. He has enrolled 32 children in the malnutrition and ICCM programme at his OTP site. Malong’s work has been well received by his community, especially by community leaders and caregivers, who are now able to access malaria and malnutrition treatment, recognise common disease symptoms and seek appropriate healthcare for their children.

“The caregivers like the programme and they use the service, especially now they are able to recognise some danger signs in their children and immediately go to health facility or to the OTPs. The treatment they receive at the OTP site and the daily Plumpy’nut supply for malnourished children helps so much.”

Malong was concerned, however about delays in the supply of Plumpy’nut and some of the drugs used for ICCM. He also commented that the lack of storage facilities for the supplies needed to be improved as they are currently stores at his house. A simple shelter for OTP days in the rainy season would also be good, he added hopefully. His usual location is under a tree.

But despite these concerns, he is generally very pleased with how his work is going. “The nutrition and ICCM programmes work well based on my experience as an ICCM supervisor and community nutrition worker. We refer most of the cases that might be beyond the capacity of the ICCM and nutrition programmes, based on the danger signs.”

“The programme is liked by all in the community and the leaders appreciate it and encourage the programme’s continuity in the community to serve their children.”

You can read more about the programme in South Sudan by viewing or downloading the full learning paper here.

Health care starts at home

Effective health care starts at home and in the community. Leila Noisette, Malaria Consortium’s Advocacy Officer in Uganda, explains how Malaria Consortium works with communities, providing training and tools that they can use to improve their own health and that of their children

Though close to Kampala – the capital city of Uganda – and close to a major highway, Kiboga District is essentially rural and the main means of income are from crops and livestock. Most of the local residents rely on subsistence agriculture. Malaria has been a major cause of child mortality here and has affected the productivity of adults working in the fields.

Adera Nakato, a young grandmother explained that falling sick from malaria used to be common in the area: “I could hardly work for money and had limited food for my children. I used to buy nets but they were not effective because they were not treated; it gave us false confidence and we continued to suffer from malaria.”

Three years ago, Malaria Consortium distributed long-lasting insecticidal nets in the area. Adera received nets through the distribution for her family:

“Ever since we started using them, none of us here has suffered from malaria fever,” she told us.

Every household in four districts of mid-western Uganda benefited from the net distribution, a universal coverage campaign undertaken by Malaria Consortium through the Pioneer project funded by Comic Relief.

Tumusiime Mildred, a 32 year old mother of five children also benefited from the distribution of nets: “What can I say about the nets? It is just evident when you look at my children playing. They look happy and healthy.”

Mildred’s husband is a teacher but she had to stop work after a complication during the birth of her youngest child. She explains that nets have helped to reduce the amount of money her family have to spend on health care: “Treating the whole family was costly. Now, we no longer frequent hospitals due to malaria. My last born is two years old and she has never suffered from malaria yet. When the older ones get sick, they are taken to Ssunna, the village health team member, and they get better in a few days,” Mildred adds.

Ssunna is one of a number of community members who have been trained by Malaria Consortium to act as village health team members (VHTs), providing basic health care to young children in the community. He learnt to diagnose and treat malaria, as well as other leading causes of child death including pneumonia and diarrhoea in children under the age of five.

“I am glad that I am here to serve my community as a VHT,” Ssunna explains.

As well as diagnosis and treatment, VHTs also actively work with communities to share information about disease prevention and basic sanitary measures that families can follow to stay healthy. Ssunna received training to conduct community dialogues. The dialogues, part of a community outreach initiative supported by Malaria Consortium and the District Health Authorities, encourage communities to express their views and share experiences related to health, sanitation and hygiene. “With the village chairperson, we organise community dialogues every month where we discuss prevention of diseases such as malaria. These dialogues have yielded good results. In fact I can now spend a whole month without seeing a child suffering from malaria, diarrhoea or pneumonia.”

Catherine Nassiwa, a senior nursing officer, is the Malaria Focal Person in Kiboga District Health Team. A lot has improved as a result of the partnership between the district health team and Malaria Consortium, she explains: “Awareness of malaria has increased… sanitation, hygiene and care-seeking behaviour have improved, which, combined with the use of nets has reduced the morbidity in the district. Thanks to reduced expenditure for treatment, families can invest their money elsewhere. The relationship between community members and health workers has also improved. This has built health workers confidence and increased community members trust in the public health services.”

As the Pioneer project draws to a close, Ssunna talks about the lasting impact the project will have on the area. He hopes that, with support from active residents like himself, the community will continue taking care of their health without relying on support from partners.

“I am looking at a strategy to continue working with the community without waiting for support form Malaria Consortium.”

A new cross-border approach in the move to malaria elimination

The booth with its big banner catches your eye as you approach Phsar Prum, on the Cambodia border with Thailand. There are people there, clustered under the multi-language message about malaria and the colorful logos representing Malaria Consortium and our project partners. Once you pass through the checkpoint, a Malaria Consortium field assistant in a bright green jersey approaches, asking permission to talk with you about malaria, offering you a chance to be tested.

The team is good at what they do. The village chiefs, local health workers and the ‘Village and Mobile Malaria Workers’ are actively engaged and, though it’s only two weeks since the project launched, over 500 people have already been screened at checkpoints in Steung Treng, Rattanakiri and Pailin provinces.

“We explain very clearly what we are doing and why first, before they are asked to join,” says Malaria Consortium field assistant, Sokhoeun Chum. “At first some are scared about the finger prick, but when we explain, most agree to the test and are not worried about what we are going to do.”

All this activity is part of an innovative new study Malaria Consortium is leading focused on the special challenge Cambodia faces in identifying and treating migrants and other travelers, difficult-to-reach populations who may be at risk for malaria and transmission of drug-resistant parasites.

“It is the right thing to do in a right time for mobile and migrant people, and it is very important as a new approach for active case detection to do the screening at the cross borders,” adds Sophal Uth, field office coordinator, Malaria Consortium Pailin Field Office.

The goal? To develop a screening strategy that will help reduce the number of malaria parasites crossing Cambodia’s borders. Doing so could make a big contribution towards elimination of malaria and containment of drug resistance, goals of both Cambodia and the Greater Mekong Sub-Region. By locating check points in three different border provinces, this study presents a unique opportunity to compare and contrast their findings, enriching the strength of the recommendations that will be shared with the Cambodian National Programme for Parasitology, Entomology and Malaria Control (CNM) and others across the region next spring.

These early successes reflect careful planning, coordination and positive working relationships among individuals and organizations across Cambodia: the Ministry of Health and CNM; provincial government and health officials; police and immigration officers, village chiefs, village malaria workers, mobile malaria workers and local health workers; partner NGOs, like FHI360, Institut Pasteur du Cambodge and the London School of Hygiene & Tropical Medicine, as well as the project’s funder, the UK Department for International Development (UKaid).

Mafalda’s commitment to her community

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Fernando Bambo, Malaria Consortium’s Training Manager in Mozambique, recounts meeting Mafalda José Ngonhamo, one of almost 800 community health workers who received training in case management of childhood diseases from Malaria Consortium and partners in Mozambique in July and August 2013

The weather forecast said that the southern part of Mozambique would be hit by a heat wave, with temperatures reaching around 36 degrees celsius. True to the forecast, the temperature is scorching. It is our “spring” here in Mozambique, we are still transitioning from winter to summer and it will be cool again tonight.

We arrive at the Eduardo Mondlane Resource Center for Inclusive Education, a centre in southern Mozambique providing day care and access to education for children with disabilities. We are here to conduct a refresher training course for local community health workers. We will be reviewing prior training that the health workers have had in health promotion and the case management of malaria and other simple childhood diseases in the community.

The children at the center welcome us with curiosity. Interacting with them, I realise my relative illiteracy. They are using sign language to communicate with us but we are unable to understand.

Mafalda José Ngonhamo, 37 years old, is one of the community health workers participating in the training. She lives in Bilene District in Gaza province. She has four children: two girls and two boys, the oldest 15 years old. She is pregnant and expecting her fifth child soon.

The coordinator responsible for community health workers in the district had informed Mafalda about the training and suggested that because of the advanced stage of her pregnancy, she need not participate.

But Mafalda did not agree. She felt she should do her best to participate in the training and uphold her responsibility to her community.

She takes short breaks often but actively participates in the training, always raising her hand to answer questions. She is clearly motivated and determined to be on an equal footing with the other trainees. When I asked her why she decided to come she replied:

“When I heard about the training and that I was not expected to participate, I really felt very sad. Then I gathered forces, I gained courage and communicated that I was willing to participate because I love the work I do as community health worker. I committed to help my community and could not miss this opportunity to learn.”

As we are chatting, Mafalda shows me a poster on the danger signs during pregnancy. It is a new communication material that district authorities have distributed to community health workers to support them in their efforts to improve maternal health.

“This is very useful to me now as I am pregnant, but I will use it in my work to educate other pregnant women about danger signs and the importance of seeking immediate care at the nearest health unit…”

As part of the Project for the Prevention and Control of Malaria funded by the Global Fund to fight AIDS, Tuberculosis and Malaria, Malaria Consortium and partners including World Vision, International Relief for Development and Fundação para o Desenvolvimento da Comunidade, held a series of training sessions in disease prevention, health promotion, proper management of cases at the community level, monitoring and evaluation and proper medicines management.

Mafalda José Ngonhamo, is one of the 785 community health workers who were trained between the months of July and August of 2013. Training was given to both district trainers and community health workers and took place in the provinces Inhambane, Sofala, Manica, Tete, Zambézia, Gaza and Maputo.

Find out more about Malaria Consortium in Mozambique here.

Access to health care for rural communities in Mbale, Uganda

In Mbale district, eastern Uganda, Malaria Consortium is working with the District Health Team with funding from Comic Relief on a project that aims to help reduce child deaths from malaria and other severe childhood illnesses. Malaria is the most common cause of death in Mbale for children and adults, accounting for over 20,000 hospital admissions a year and over 30 percent of all admissions in the district.

In this audio interview, Malaria Consortium speaks to a village chief from Lubaale Parish, an area comprising six villages in Bumasikye sub-county, Mbale. He describes the impact that malaria has on life in his community.

Click here to read more about this project.

Getting essential medicines to the community, by bicycle

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Eder Ismail is a Project Officer for Malaria Consortium’s community-based child health programme in the Inhambane province of Mozambique. Malaria Consortium has been training and supporting community health workers in the province of Inhambane since 2009 with funding from the Canadian International Development Agency and the Planet Wheeler Foundation. The project aims to bring life-saving health care to rural communities living long distances from health centres. Community health workers have been equipped with bicycles, enabling them to travel to health centres more regularly, to replenish essential medicines stock and hold meetings with their supervisors.

Bernardo Dongo is a community health worker, trained in 2010 by the Ministry of Health with Malaria Consortium’s support. Since Bernardo was trained in integrated community case management of common childhood illnesses, he has been working in his catchment area to offer front-line health services. He holds regular community meetings to educate families about disease prevention and health practices, and he diagnoses and treats children under five years of age who present with mild forms of malaria, pneumonia and diarrhoea.

Each month, Bernardo, who is 52 years old, leaves his home behind and rides for 18km on his bicycle to reach the health center in Inhassoro.

Two hours later, Bernardo reaches the health centre. There, he meets his supervisor to review his monthly activity report and visits the pharmacy to collect the monthly essential medicines kit that he will take back to his community in Vuca, a coastal area in Mozambique’s Inhassoro district.

He goes back in the late afternoon at low tide, using a coastal shortcut that saves 1 hour off his journey and allows him to reach his community by early evening. When he arrives, Bernardo opens the medicine kit in the presence of the community leader. He can now resume his normal activities, consisting of both health promotion and treatment for uncomplicated diseases. “There are about 700 people in my community, and on average I see about 160 patients per month”.

People need to know more about the importance of breastfeeding

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Dieterio Magul is a Field Officer for Malaria Consortium’s community based child health programme in the Inhambane province of Mozambique. He works with the provincial health authorities to support the community health programme that has been running for over 30 years. Revitalisation of the programme by the Ministry of Health began in 2010. Malaria Consortium’s role has been to help train community health workers to diagnose and treat simple forms of the three main childhood diseases: malaria, pneumonia and diarrhoea.

Teresa has been living for over 20 years, with her partner and their seven children, in Pangaia – a village on the sandy island of Bazaruto, a few kilometres off the Mozambique coast. Although the island is known as a beautiful beach holiday destination by tourists, for local residents, access to basic health services remains challenging.

In 2011, Teresa was selected by her community to receive training to become a community health worker (CHW).

The three months training, supported by the Ministry of Health and Malaria Consortium, equips community members, like Teresa, with the skills and tools needed diagnose and treat common diseases in young children in their community, as well as to recognise the danger signs that signal a need for urgent attention at a health facility.

Teresa, a community health worker now for two years, is working hard to increase awareness of common diseases in her community and provide information on best practices that can help to improve family health.

Her work is challenging. On Bazaruto, many women work in their homes in the morning, before going to the beach to buy fish from returning fishing boats that they then sell to support their families.

“Young children suffer from this because their mothers are very busy and cannot always take them… and do not find the time to breastfeed them; so I have organised discussions on this topic at the very places where women are waiting for the fishermen. I explain to them that breast milk is very nutritious, and very important for the healthy growth of children. I think people need to know more about the importance of breastfeeding, because this can encourage them to schedule time for it.”

But Teresa’s efforts are bringing results and many women in the community have started to breastfeed their children more often and for longer.

Teresa is happy with the impact her work is having on health in the community and hopes that with support from her community and others she will be able to reach more community members with lifesaving information and drugs in her role as a CHW.

Malaria Consortium’s integrated community case management (ICCM) programme in Mozambique has been supported by the Canadian International Development Agency and the Planet Wheeler Foundation since 2009. Malaria Consortium’s role includes recruitment and training of CHWs to diagnose and treat malaria, pneumonia and diarrhoea appropriately, support to national and local health system to provide supervision and monitoring of community-based activities, as well as health promotion activities to increase awareness of malaria, pneumonia and diarrhoea management and prevention within the communities.

In addition, through funding from the Bill & Melinda Gates Foundation, Malaria Consortium is conducting research into innovative ways to improve the motivation and performance of APEs. This research initiative, the inSCALE project, aims to inform the scale-up of community health worker ICCM programmes to provide access to timely and appropriate treatment for common childhood illnesses across the developing world.

Meet the health workers at the frontlines of disease control: Q&A with a rural health worker

Dorothy Ibrahim is a rural health worker of many years’ standing. She is a proud contributor to the fight against malaria in the rural settlement of Gauraka, just outside Abuja in Niger State. Nigeria is one of the world’s most malaria endemic countries, accounting for approximately a quarter of all deaths from the disease worldwide. Kolo Yakubu, Senior Technical Malaria Officer at Malaria Consortium in Nigeria, spoke to Dorothy about her role as a rural health worker and the impact that SuNMaP – Support to National Malaria Control Programme – a partnership programme led by Malaria Consortium, has had on her role.

You’ve been working for many years in this area. What changes have you seen during that time?

When I first started working here, many years ago, I would do all that the books demanded but still lose the baby. Severe malaria claimed the lives of one in 15 children under-five in my area. The traditional healer would prescribe herbal concoctions and tell parents that their baby would get well before morning. But the baby would die of worsened fever that same night.

Years went by and the local health centre was upgraded to a model primary healthcare centre. There was more modern equipment and training from SuNMaP, as well as long-lasting insecticidal nets (LLINs) and intermittent malaria preventive therapies for pregnant women (IPTp). All these have changed the course of service provision. Nowadays, I never see severe cases of malaria in babies at all.

How would you describe your role in malaria control in Gauraka?

I support the home management of malaria by working with community volunteers that we call community care givers. They work with local people to identify fevers and give drug treatment as necessary. I tell them to refer persistent fever cases to me. I also give talks about how to hang the LLINs properly and take care of them, and encourage environmental sanitation and hygiene.

Since the LLINs and IPTp support to first time mothers started, cases of anaemia and severe malaria have declined. There have been none at all in the three years since SuNMaP began.

Support to National Malaria Control Programme

These positive changes have been facilitated by SuNMaP – Support to National Malaria Programme – and other agencies in collaboration with the State Malaria Control Programme (SMCP). SuNMaP provides support to the Nigerian government and people in tackling the massive burden of malaria in the country. It is implemented by international and local partners, funded by UKAid and managed by Malaria Consortium. SuNMaP works in close co-operation with Nigeria’s National Malaria Control Programme (NMCP), in selected states and Local Government Areas (LGAs) across the country.

In addition to mosquito nets and drugs for malaria treatment, SuNMaP has provided training to senior management staff at the LGA level, which has been cascaded down through the LGA to staff, like Dorothy, in health facilities across Nigeria.

How malaria control can strengthen the health system

Leila Noisette, Malaria Consortium’s Advocacy Officer in Uganda, interviews Dr John Baptist Waniaye, District Health Officer in Mbale, Eastern Uganda, on how support for malaria control in the region, through Malaria Consortium’s Mbale Malaria Control Project – funded by Comic Relief – is benefitting the health system as a whole and how to sustain these benefits.

The Mbale Malaria Control Project started two years ago. What impact have you seen on the delivery of health services and on health more broadly in the district?

The Mbale Malaria Control Project has led to a change in our community. The health seeking behaviour of our people has improved a lot. We recently did a quality assurance survey which indicated that 86.5 percent of people are seeking health services within 24 hours of becoming sick. This has largely been due to the system of village health teams, which aim to help people seek (health) care in time before they get complications.

An addition to that has been the availability of medicines; National medical stores has improved in its quantity and quality of supplies to about 70/80 percent of the needs of the people of Mbale and Malaria Control Project has also been buffering, filling up those gaps. So right now we are talking about availability of essential medicines at 92 percent. Most of the patients who reach our facilities are now able to get the medicines. For those who don’t know, it is very important for us to remind them that the medicines are available and they should be able to use the public health facility if possible.

Another contribution has been the availability of diagnostic equipment. This has improved the way health workers treat the patients, because they feel more confident and are able to diagnose accurately and offer proper medication based on the diagnosis. Because we have received microscopes, wing scales and so on, so we have improved a lot. All these are aimed at diagnosing mainly malaria. But as you know, malaria is an entry point for over 40 percent of health services required in the health sector and this equipment is also used for other common illnesses which cause death in children, so all this is tackled on a more holistic level.

Recently, we also had a citizen satisfaction survey conducted by Strengthening Decentralisation for Sustainability (SDS), a USAID funded project implemented in partnership with the district. Interestingly, it has shown that in the last two to three years, the citizen satisfaction with health services delivery has improved. Three years ago, we were at four percent satisfaction. The recent survey shows that now we are at 64 percent satisfaction with health services delivery. So we think that if we continue with the current trust levels we are going to improve significantly the services to our people.

What do you see as the best way to sustain these results?

In terms of sustainability, the first thing is ownership by the district. We would like to take on this intervention seriously by seeing to it that we plan and budget for some of these activities, like supporting the community referral system, or sustaining the meetings for the village health team members, and how to plan for this at all our levels, district level, sub-county level and village level.

On the side of the community, we also think that in order to sustain this, there should be community contribution at household level. Assessments done by our Community Development Officers indicates that there is some household will to contribute towards sustaining these good achievements. Our job now remains how to sensitise people to take this on, from the district level with the District Council to sub-county and village councils, so that they also go out there and bring people to support sustainability.

The other thing is increasing partnership, networking. We would like to work more closely with partners. We believe that through coordination and networking with other service providers we will be able to sustain the current achievements in the health sector.

What is your personal opinion about this project, as a District Health Officer (DHO), but also as a member of the Mbale community?

I think this is a great project which has touched the real needs of the people and it has satisfied most of our needs. As a DHO I feel very proud to be associated with this project because it has been able to make me fulfil some of my mandates and assignments as a DHO. Then as a citizen from here and a villager from this place, I really feel happy that we can go to a health facility and get diagnosed and receive the drugs largely due to the contribution by this project. I used to receive so many phone calls from my village mate telling me there is no medicine here and there but now I don’t receive these phone calls anymore so I feel there has been a change in the community.

The role of the church in malaria prevention, South Sudan

Malaria is ever present in South Sudan. The ecological environment provides the perfect conditions for Malaria-transmitting mosquitos – long periods of rain, high temperatures and humidity. In most areas malaria is transmitted all year round and the entire population of over eight million people is at risk.

Access to health care is the biggest challenge, with 60 percent of remote locations inaccessible during the rainy season. Only 44 percent of the population lives within a five km radius of a functioning health facility. These statistics represent a collective challenge to the prevention and treatment of malaria.

In 2011, as part of a shared commitment to malaria prevention in South Sudan, Malaria Consortium and its partners began an operational research pilot study in Lainya County, Central Equatoria State. With support from the Ministry of Health, UKAid from DFID, and USAID through ‘NetWorks’, Malaria Consortium began preparations for a long lasting insecticidal nets (LLIN) continuous distribution pilot, to test whether universal coverage can be maintained through a continuous a LLIN distribution system.

The study aimed to test a sustainable method of replacing nets in households where they may have been destroyed, damaged or lacking. The pilot project involved keeping mosquito nets in the community at all times, in storage units established in Primary Health Care Centres/Units including rural hard-to-reach areas and used a ‘pull system’ to ensure storage facilities never ran out of stock.

Community members received net coupons from community level health workers – Net Coupon Holders – who were posted throughout the county at specified times. Coupon recipients were able to redeem from primary health care centres (PHCC/Us) during normal operational hours. The church has played a key role in the pilot, both at the planning and implementation level. Along with other key stakeholders, before the pilot began, ideas were sought from the church on how the pilot might best succeed. More than 80 percent of the population in Lainya attends the Episcopal Church of South Sudan and the church has played a primary role in disseminating information to people during church services, with messaging around malaria prevention and control integrated into the work of the church.

In this audio interview, Reverend Rufus Lemi, Dean of the cathedral for the Diocese of Lainya, Episcopal Church of South Sudan, discusses the church’s involvement in the project.