At the international border checkpoints between Cambodia and Laos, Stung Treng Province, a green booth with various messages inviting people to participate in the malaria surveillance and investigation activity attracted the attention of several passers-by. It is one of the seven screening booths of Malaria Consortium set up to provide malaria blood test for border crossers using rapid diagnostic tests.
Treatment is provided immediately to anyone found to be positive for malaria and the team also collect blood for further laboratory analysis to check for any mutation in the malaria parasite gene.
“There are approximately 70 people per day using this border checkpoint to travel between Cambodia and Laos – mostly tourists,” said Hour Suy, Chief of International Checkpoint, Stung Treng Province.
The number crossing the international checkpoint reflects only one element of the actual population crossing between the two countries. With its border among forested mountain areas, Stung Treng is reported to have at least 12 other informal crossing sites. Some of these link to informal roads on the other side, while others have fences or gates. Many people are known to cross via these informal border points.
See Bia is among one of those crossing via these informal sites. This 35-year-old rice farmer was on her way to cross the border with friends, when she stopped to participate in Malaria Consortium’s surveillance checkpoint. “We normally use this road. Just follow this footpath, and then you can cross to Laos,” she said. Unlike the tourists who need to cross the border at formal checkpoints, many local people like See Bia prefer to use informal borders to access the neighboring country.
The porous border has been another great challenge for malaria control and elimination efforts in addition to general population movement. It can facilitate malaria transmission and spread drug resistance into new areas because some of those crossing may carry the malaria parasite with them. Therefore, screening these populations is vital to understand malaria transmission trends along the border. Early detection of malaria cases will also help stop the spread of the disease.
This surveillance and screening process is part of the second phase of Malaria’s Consortium Cross Border project to compare malaria trends among populations who cross the border at different crossing sites. It will help assess malaria incidence and respective patterns of resistance of malaria transmission, which in the end will benefit the long term plans for malaria control and elimination in this region.
Wanweena Tangsathianraphap is External Communications Officer for Asia
A child with severe malaria. Photo by William Daniels.
In March, Malaria Consortium was invited to a meeting in Kampala, which brought together the partners of the Improving Severe Malaria Outcomes (ISMO) project. During this meeting I was delighted to receive an award for ‘Best Practice for Delivery’ in recognition of my work on the project.
A patient can make a complete recovery from severe malaria if it is caught in time and treated correctly. Unfortunately, however, of the estimated 216 million cases of malaria each year, approximately eight million of which are severe malaria cases, treatment is often too slow and makes use of incorrect drugs.
The ISMO project, comprising a consortium of partners: Medicines for Malaria Venture (MMV), Clinton Health Access Initiative and Malaria Consortium, aims to strengthen the market to accelerate access to, and uptake of, injectable artesunate – the World Health Organisation’s preferred treatment for severe malaria. However, market barriers have hampered its uptake. The treatment is expensive and buyers often have concerns due to there being only one World Health Organisation (WHO) already tested and trusted supplier.
Low uptake of injectable artesunate has affected its accelerated adoption, preventing potential new suppliers to delay in making major commitments to marketing the drug. The treatment has also not been readily accepted by providers and patients, due to a lack of advocacy, education and training at all levels.
It is the role of the ISMO project to successfully create a stable and sustainable market for quality assured injectable artesunate with two or more suppliers, which will guarantee access to the treatment for severe malaria patients. This involves encouraging manufacturers to produce quality assured injectable artesunate and securing a commitment by donors to fund further production of the treatment. The project is active in six countries, with Malaria Consortium focusing on implementation in Ethiopia, Nigeria and Uganda.
A major obstacle for countries implementing this project is the procurement, shipment, clearance and distribution of injectable artesunate. The process is often complicated by delays which lead to drug expiration, stock outs and subsequent poor uptake from clients. The duty of ensuring that these commodities are received and documented at the airport or sea ports is facilitated by the project with support from National Malaria Elimination programme (NMEP) – the government agency responsible for malaria interventions in Nigeria.
One of the key causes of delay is the time it takes for government documentation in support of the commodities to be issued by the Budget Office of the Federation, within the Federal Ministry of Finance, at the request of the Federal Ministry of Health. This cumbersome task normally takes between 8-12 weeks.
However, because of the strong partnership between NMEP, Malaria Consortium, and our partners in the Federal Ministry of Health, I managed to obtain a duty waiver for UNITAID injectable artesunate, to be used as part of the ISMO project, in just 14 days. It is for this that I received my award.
The timely receipt of the duty waiter ensured that the artesunate was cleared and distributed to all health facilities as planned. One of my main recommendations to partners working on this project is for all malaria commodities to be included in countries’ malaria strategic plans. This gives ownership to the government and ease of reference for commodities at the port of entry.
The award demonstrated the results that this project and its staff can achieve when they build networks and partnerships with government stakeholders. Going forward, the network established with key government partners will ensure speedy movement and delivery of commodities required for the next phase of the project.
“Our main purpose is to educate communities about malaria – its effects, how it is transmitted and how to avoid it.” Mugoya Muzamir is one of over two thousand community members in Mbale who has been trained as part of the Mbale Malaria Control project.
Malaria is the most common cause of illness and death in children in Mbale district and, in 2011, at the start of the Mbale Malaria Control Project, the district had the highest malaria burden in Uganda. Now that Mugoya has been trained in malaria case management, it is his responsibility to communicate how to prevent malaria transmission to the communities throughout Mbale. One of the most effective ways of doing this, he has found, is through performance and drama.
Mugoya, and 24 other village health workers (VHTs) trained as part of the project, now travel from community to community, performing dramas that teach how to avoid getting malaria. When I met Mugoya, he told me this was an effective way of communicating to a wide range of people: “When you do something funny, many people will come.”
The method has been successful in conveying messages to people throughout Mbale. Community members told me their families had learnt the importance of sleeping under a mosquito net and that they now clear any stagnant water near their villages. The dramas also include messages of when to contact a VHT, and how to recognise a case of severe malaria.
“When you move round the communities, you notice there has been a change. We have seen that the number of malaria cases has fallen. Last month there was one case of malaria, whereas three months ago there were 27 cases of malaria in that month, so people are picking up on our messages.”
You can check out photos of the drama performance below:
The drama group begins by playing songs, all of them about preventing malaria, in order to attract a crowd.
The community starts to gather in anticipation of one of the drama performances.
One of the actors, who is playing a nurse, waits for her cue to join the performance.
Many children attend these events, and they are encouraged to take notes on how to prevent malaria transmission.
The performances use different characters and humour to keep the community engaged, while teaching them how to prevent the spread of malaria.
Mugoya Muzamir, one of the VHTs trained as part of the project, shows some of the messages they will be teaching in their performance: how to spot symptoms of malaria in pregnancy.
One of the core messages of the drama performances is conveying the importance of sleeping under mosquito nets. Here, the actors show how a net should be hung.
Community members, and in particular the young children, watch as the performers teach them how to hang a mosquito net before going to sleep.
The communities create murals and paintings demonstrating what they have learnt. This is a painting that was on display in the village, demonstrating mosquito net use, keeping stagnant water away from the village and showing the benefits of the boda boda hospital referral system.
The performance teaches the community about severe malaria, and how to contact a boda boda driver if someone is suffering from severe malaria.
Mugoya shows how to pay for a boda boda driver by completing a payment coupon, to be cashed in at the hospital.
The performances show community members how to spot the symptoms of severe malaria.
...And the performers also demonstrate how a child is treated for severe malaria, once they arrive at a district health centre.
A portrayal of family life during the performances also demonstrates preventive behaviour to audiences. Here, a family discusses keeping their house and village clean and getting rid of stagnant water.
Mugoya, acting in the role of a doctor, then emphasises how to prevent malaria being transmitted.
The performers act out various symptoms of severe malaria.
Finally, the drama group uses songs to educate people on how to identify, treat and prevent malaria.
VHTs and drama group members pose at the end of their latest performance.
Children make notes as the performance winds down.
Patrick Lee is Communications Assistant at Malaria Consortium in London.
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.
“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)
A Malaria Consortium está continuamente a apoiar o Programa de Revitalização dos APEs através do projecto RAcE
Os Agentes Polivalentes Elementares (APEs) são membros das comunidades, que promovem a saúde e realizam o diagnóstico e tratamento de casos simples de malária, pneumonia e diarreia em crianças menores de cinco anos, bem como identificam e referem adultos e crianças que necessitam de atenção médica para uma Unidade Sanitária. Os APEs, quando formados para prestar diagnóstico e tratamento de malária, pneumonia e diarreia ao nível da comunidade, podem reduzir a mortalidade infantil causada por estas três doenças em 60%.
A Direcção Provincial de Saúde de Inhambane, através do apoio dado pela Malaria Consortium na melhoria da qualidade dos serviços prestados pelos APEs, esta a assegurar que estes recebam supervisão regular e de qualidade para corrigir erros, melhorar o desempenho e fortalecer as suas capacidades.
Uma ronda de supervisão foi implementada em Novembro de 2014 na província de Inhambane, cujo objectivo principal foi de avaliar as competências clínicas dos APEs e prestar apoio para o aumento das suas capacidades técnicas em diagnóstico, tratamento e serviços de referência para as principais doenças infantis, nomeadamente a Malária, Pneumonia e Diarreia.
No distrito de Inhassoro, encontramos a APE Linda Noé da área de saúde de Macovane. Ela percorreu 21 km na sua bicicleta, durante 3 horas debaixo de um sol ardente próximo dos 40ºc, transportando o seu kit de trabalho de APE e sua filha de 7 meses as costas, para participar numa sessão de supervisão clinica. Nessa sessão, ela prestou atendimento a 3 crianças menores de 5 anos sob a observação de técnicos distritais, nomeadamente, os médicos chefes, coordenadores e supervisores directos dos APEs.
“É a primeira vez para mim; nunca participei numa sessão de avaliação clínica prática; normalmente, são avaliados os relatórios estatísticos; mas essa sessão foi realmente muito especial para mim, porque tinha os meus supervisores que olharam e que poderem me dizer precisamente o que estou a fazer correctamente ou de forma errada”.
Através dessa sessão, a Linda descobriu os seus desafios em avaliar correctamente os sinais de perigo e identificar as crianças que necessitam de transferência imediata para um centro de saúde.
“Gostei de ter vindo fazer essa avaliação clinica, porque tinha muitas dificuldades mas consegui corrigir e espero ter mais oportunidades junto do meu supervisor para melhorar a meu trabalho de APE”.
Elaborado por: Adolfo Guambe (Direcção Provincial de Saúde, Inhambane) & Eder Ismael Zerefos (Malaria Consortium)
2015 is set to be an important – and hopefully transformational – year for international development. Over the next 12 months countries around the world will come together to agree the development framework to replace the expiring Millennium Development Goals. Last month the UN Secretary General released his ‘Road to Dignity’ synthesis report, which outlines 17 goals and proposed framework that will form the basis for intergovernmental negotiations later this year. You can read Malaria Consortium’s response to this report here.
To compliment this process, 2015 has been designated European Year for Development. The aim of this campaign is to raise awareness of the EU’s role in international development, showcase Europe’s commitment to eradicating poverty and educate citizens about the importance of foreign aid. Throughout the year a range of events will be held across the 28 member countries of the EU to involve people in the debate around development and encourage their participation through volunteering. Furthermore, charities, universities and other stakeholders will share their success stories from the field to highlight the long-term impact that foreign aid can have through a range of media.
With numerous activities planned for 2015, it is therefore encouraging that at the start of the European Year for Development a new Eurobarometer survey indicates that international development and foreign aid is widely supported by EU citizens. 67 percent of people surveyed support increasing the EU’s aid budget, an increase of six percent compared to 2013. 74 percent believe that tackling poverty contributes to a more peaceful and equitable world and 64 percent of citizens believe that alleviating poverty should be a main priority of the EU. Health is considered to be the most important area of international aid by 39 percent of survey respondents, followed by peace and security (36 percent) and education (34 percent).
During this critical time for development, the European Year for Development offers us the opportunity to build on already high levels of public support and engage the people of Europe further about the importance of eradicating poverty, disease and inequality in this generation.
Each month during the European Year for Development has been assigned a theme – April is the month for ‘health’. Considering that EU citizens view health as the most important area of development, this offers an excellent opportunity to refocus EU attention upon the critical importance of tackling malaria, neglected tropical diseases and childhood illnesses, with World Malaria Day on 25th April providing the perfect occasion to do so. Malaria Consortium will be organising activities in Europe and across the world to widen the discussion about global efforts to eliminate malaria and engage European policy makers on how the EU can increase its role. All Malaria Consortium events and activities can be found listed in our new events calendar.
For more information about the European Year for Development, see the dedicated EU website. You can also follow the latest news and event information about the European Year for Development via Twitter, at @EYD2015.
Wanweena Tangsathianraphap, External Communications Officer for the Asia region, visited Ratchaburi province in Thailand to report on Malaria Consortium’s Positive Deviance project.
At the community centre in Bor Wee village, Ratchaburi province in the western part of Thailand, a group of 14 positive deviance volunteers were conducting a role play on how to protect oneself from a mosquito bite. A mosquito net had been hung up and a volunteer acting as a mother was encouraging her children to sleep under it. It is simple thing to do, but can yield great results for malaria prevention if the behaviour is adopted by all villagers in the community.
The threat of malaria still exists in Bor Wee village. When Malaria Consortium’s team spoke to the children who participated in the latest positive deviance session, two thirds of them said they had contracted the disease more than once and thought that malaria was just a mild illness, similar to a common cold.
Dao Horla, one of the community health volunteers, shared her story with us: “My child once had a fever from malaria. I had to walk five kilometres to take her to see the doctor at the nearest clinic. At that time, I did not even know what had happened to my girl. She had very high fever and cried from pain. I was so afraid I might lose her.”
Dao’s house is located near a stream and is built in the typical hill-tribe style, on the side of a hill with an open door and window. “I did not realise that I have to use a mosquito net to protect my children. They love to play outside near the stream, and they did not always sleep under the mosquito net. But since I learnt about malaria, I make sure they sleep under the net every night. I do not want them to get malaria or any other mosquito-borne diseases again,” said Dao. As a mother of five, she understood the pain and suffering children undergo because of malaria, and has now volunteered to learn more about the disease and to help raise awareness about malaria in her own community.
“My children no longer get malaria and I would like to tell my neighbours how to protect themselves and their families,” said Dao. Her story is one of the several positive deviance tales that are being shared among the community members.
According to a report by the World Health Organization (WHO) and Department of Disease Control, Ministry of Public Health Thailand, the malaria incidence rates in parts of Thai-Myanmar borders are still high compared with the overall rates for Thailand. This high prevalence is due to the surrounding thick forest environment and the mobile population. With the natural borderline of Tanaosri mountain range, people in the area usually stay overnight in the forest either for work or to travel across the border to Myanmar. Over 80 percent of malaria patients live on this border. It is estimated that 70 percent of the patients diagnosed with malaria are adult males, who are likely to work in the forest.
Baan Huay Pak village is approximately 16 kilometres from the Thai-Myanmar border. Korwa Jorod, known by his community as Uncle Korwa, described his experiences of malaria to Malaria Consortium’s representatives.
“Most men in this area work in the forest and along the border. They usually come home late at night or during the next day. Sometimes they get sick. They are not careful about protecting themselves. I used to be the same,” said Korwa.
“I used to be careless and go to the forest without any protection from mosquitoes and, as a result, I kept getting malaria again and again. I didn’t think it was very serious until a local health organisation visited the village and told us about malaria. I then realised how dangerous the disease really is. My perception was drastically altered. So I joined the volunteer programme to learn more about malaria. I am so glad that I am now much better informed and also that I have a part in helping my community. Protecting people from mosquito bites is the best way to prevent malaria,” Korwa explained.
Apart from being a community health volunteer, Korwa is also the religious leader in the village, and is a member of the community river committee. His roles give him many opportunities to interact with villagers on a regular basis.
“I talk to the villagers like I’m their relative,” Korwa told Malaria Consortium. “Of course, not everyone will listen to me, but I will do my best in my role. One volunteer may not control the disease, but together we may create some changes. Importantly, I know I have the support of the other volunteers and the staff from Malaria Consortium and the Pattanarak Foundation. This encourages me. I feel that every life is worth living and I will do my best to save them.”
Both Korwa and Dao are part of the pilot activity on community mobilisation through positive deviance volunteers. Six villages in a high-risk area of Ratchaburi province were selected to apply this innovative approach on behaviour and social change.
Funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the community mobilisation through positive deviance project is conducted by Malaria Consortium in close collaboration with the Pattanarak Foundation, a local non-profit organisation, as an attempt to improve malaria prevention methods in hard to reach and vulnerable communities. Since the project was launched in April 2014, more than 20 community health volunteers have been recruited and trained. Their work is vital to help bridge the gap between the community and the health authorities. This pilot in Thailand will provide learning about this approach and evidence of impact and, if successful, can be scaled up across the country.
Monica Posada is Malaria Consortium’s behaviour change communication (BCC) technical specialist for the Asia region. She recently visited Cambodia in order to conduct research into behaviour change communication strategies at cross-border sites in the Greater Mekong Subregion (GMS).
Malaria Consortium has conducted a behaviour change communications (BCC) assessment project in Cambodia to assess how effective these strategies are when it comes to improving health conditions, particularly among vulnerable groups.
Behaviour change communication strategies are used to help prevent the spread of diseases by encouraging positive behaviour within a community. By assessing current BCC methods, the intention is to provide recommendations as to how this approach can be improved in the region, and rolled out on a larger scale.
The assessment included a review of BCC strategies and guidelines in Myanmar, Thailand, Cambodia and Laos, and investigated how these are being implemented and targeted toward vulnerable groups. In particular, the assessment focused on BCC interventions among migrant and mobile populations, who travel and work along key border sites where there is a threat of spreading the artemisinin resistant malaria parasite.
A local family showing their hammocks and LLIN at their house in Battambang, Cambodia.
A research team conducted a seven day visit to the cross-border areas of Pailin and Battambang in order to conduct focus group discussions and in-depth interviews. More than 104 participants, including migrant populations, community leaders, community health workers, and NGO workers joined the study.
The interviews and discussions provided a chance to better understand the preventive and treatment-seeking behaviours of at-risk populations. For example, villagers were able to provide feedback on the quality and size of long lasting insecticidal nets and the barriers to treatment for malaria at the community healthcare centre.
The most interesting part of this study was to see that the chief of villages and village malaria workers had a considerable degree of trust among the local, migrant and mobile populations. The BCC approach, which relies on strong interpersonal communications and the discussion of best practices in preventing diseases, seems to be a very effective channel for health education.
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.
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?
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.
Vanney Keo is a Malaria Consortium field assistant, who has been working in Cambodia.
I have been working for Malaria Consortium on a Regional Integrated Vector Management Project in Cambodia, where we have been collaborating closely with the National Dengue Control Programme (NDCP). At a project closing event in the Mongkol Borey district of Cambodia, many community members thanked me for my role in sharing best practices on how to prevent dengue fever. I thought then that I would share my experiences working on this project.
The purpose of the project was to develop community-based methods to improve prevention, recognition and reporting of dengue. The positive deviance (PD) focus of the project involved identifying community members who, despite sharing similar living conditions and resources as the rest of the community, already demonstrated positive behaviours for preventing dengue. These individuals were encouraged to share what they did to preserve their health with the rest of the community by becoming PD volunteers.
At the start of the project I helped to select 16 PD volunteers who were both willing and able to share methods for preventing dengue. This meant four volunteers for each selected village throughout the Banteay Meanchey province. As well as speaking at meetings and seminars, the volunteers visited each household in their allocated village at least twice a month. One benefit of using volunteers from the community to help raise awareness of disease prevention behaviours is that they are recognised in that community and can help to galvanise support for educational events.
It was my responsibility to schedule community meetings so that PD volunteers were able to give seminars on preventing dengue. Their prevention methods include advising individuals to sleep under a mosquito net, even during the daytime; always disposing of containers and cans which can accumulate water; keeping children away from areas with high concentrations of mosquitoes like the forest; wearing long-sleeve clothes, particularly in high-risk areas; using guppy fish in water containers to limit the growth of mosquito larvae; and highlighting the importance of cleanliness.
I kept in regular contact with the volunteers to ensure that their methods were being picked up by the community. By coordinating with the village members on a regular basis, I acted as a bridge between the volunteers and health specialists from NDCP and Malaria Consortium, and helped to monitor the changes in the behaviour of community members.
On one occasion, I helped to organise an event where the villagers were encouraged to create posters explaining the dengue prevention methods they had been taught by the PD volunteers.
One of our seminars was attended by the majority of community members across all four villages (Khtum Reay Keut, Anlong Thngan Keut, Bat Trang Thum Keut, and Bat Trang Touch). Competitions were organised in order to increase community participation, and involved quizzes for the community’s children, which aimed at increasing their understanding of dengue and the threat of mosquitoes.
Positive Deviance volunteers also used the opportunity of cross-community events to give speeches, encouraging community members to continue spreading the messages after the closing ceremony. One positive deviance volunteer said, “Now the households of our community are very clean, and I’m really happy that you have all followed our suggestions”.
These events, and the participation of community members, required the approval of respected leaders within the villages. This meant I frequently met with the village chiefs in order to provide updates on the project and to address any concerns. By the end of the project, I believe that we had successfully broken a cycle of dengue as all of the villagers were maintaining good standards of cleanliness in their home, and were always sleeping under a net. I’m confident these methods will continue now that the project has ended.
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.