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.

Boda-boda riders in Uganda support Village Health Teams to reduce child deaths from malaria

Leila Noisette, Malaria Consortium Advocacy Officer in Kampala, travelled to Mbale in eastern Uganda, for the launch of an innovative new transport system designed to help tackle the burden of malaria.

In Mbale, eastern Uganda, 212 boda‐boda (motorcycle taxi) riders have been trained to handle the transfer of sick children from villages to health facilities as part of an on-going project to reduce child deaths in the region.

Training for boda-boda riders is part of a Malaria Consortium project to improve malaria control and strengthen the health system in Mbale, funded by Comic Relief. The main goal of the project is to contribute to a reduction in child deaths from malaria by establishing and training Village Health Teams (VHTs) to recognise the symptoms of malaria and other childhood illnesses, to ensure the availability of medicines and other health supplies in health facilities, and to establish a functional community-facility referral system.

The project is implemented by Malaria Consortium, in partnership with the Ministry of Health, Mbale Regional Referral Hospital, Mbale District Health Authorities, Central Public Health Laboratories (CPHL) and the local communities.

Training of boda-boda riders is a key element of the project providing timely access to healthcare for rural and remote communities. The training is carried out by the Ugandan police force and Mbale District Health Team and focuses on traffic rules and how to handle a patient and seeks to improve referral times between VHTs and health facilities. VHT leaders in each village provide boda-boda riders with vouchers according to the distance they have to cover to transport patients to a health facility. The riders are then paid by the health worker at the health facility upon presentation of the coupon.

“Access to public health services is very limited in this hilly region,” says Dr. Nathan Kenya‐Mugisha, Programme Manager for the Malaria Consortium project, “Availability and affordability of transport means is crucial for caregivers to follow referral advice from VHTs and health workers to get appropriate treatment for children on time.”

According to Augustine Mafabi, a VHT leader in Jewa Parish, Bufumbo Health Centre IV is the nearest public health facility for most of the communities in the area.

Zainab Nafuna is waiting at the health centre. It took her four hours to reach the health facility from Bumadanda village, carrying her second born child only 10 days after giving birth. Her newborn baby is severely sick and she has been sent to Mbale Regional Referral Hospital. Zainab now has to travel back to her home and prepare again for the journey to the hospital the following day. She says she will feel very happy when transport provided by boda-bodas riders will enable her to access timely healthcare for her two children. Other mothers waiting had also walked hours to reach the facility.

The introduction of this transport system aims to increase the number of children following referral notes from VHTs as well as dramatically reduce the time in which patients who are sick reach the health facility. Ronald Wambede and Badiru Massa, two of the four boda‐boda riders trained in Jewa parish have now agreed to provide 24-hour-a-day transport for sick children referred by the VHTs. They said: “On a boda‐boda, these women would have reached the health centre in 30 minutes.”

With reference to lessons learnt throughout the implementation of the transport system in Bunghoko North, there are plans to scale up the project to the whole district next year. The District Health Officer, Dr. John Baptist Wanyaie, said: “Working together to improve access to healthcare will strengthen the capacity of Mbale district, as a high risk community, to tackle the burden of malaria.” Communities are already being encouraged to think about how to sustain this transport system after the project ends.

Investment needed to continue saving our children’s lives

Malaria Consortium Country Directors Dr Godfrey Magumba and Ruth Allan (Uganda and South Sudan respectively) have written an open letter to the East African community, calling them to action to sustain the life saving integrated community case management (ICCM) programme. The letter, published in a special World Malaria Day supplement of the East African magazine highlights the impact everyone can have in supporting the Ministries of Health to strengthen and scale up the programme which has the potential to reduce childhood mortality from malaria, pneumonia and diarrhoea by 60%.

You can read the full letter below:

As the world celebrates World Malaria Day, it is important to note that malaria, a preventable disease, still remains a major cause of death in children under five years and adults throughout East Africa. As we approach 2015, The Republic of South Sudan and Uganda are still far from the Millennium Development Goal targets in child (Goal 4) and maternal health (Goal 5) as well as in the fight against malaria (Goal 6). Currently, in Uganda 99 children die before their fifth birthday for every 1,000 born; 40 percent of these deaths are caused by malaria, pneumonia and diarrhoea. In South Sudan, malaria accounts for more than 20% of mortality in all age groups.

Working to address the challenge

However, there are many reasons to be optimistic. Major progress has been made in prevention, diagnosis and treatment of malaria and we have many reasons to hope for a better, brighter future. Even if we are to see the amount of foreign aid decrease, the crucial involvement of communities and the commitment of political leaders at local, national and regional level is increasing every day.

As Malaria Consortium celebrates ten years of contributing to the fight against malaria in sub-Saharan Africa, we are proud of the multiple and varied approaches we use and the invaluable partnerships we have formed in order to reduce malaria related morbidity and mortality. For the past 10 years we have worked closely with and supported the Ministries of Health (MoH), to update and disseminate policies and operational guidelines for malaria control and other childhood illnesses.

Our work has focused on activities such as increasing the number of households using long lasting insecticide treated nets (LLINs) and improving access to parasite-based diagnostics and appropriate malaria treatment, especially for children under the age of five, those most susceptible to malaria.

A life saving intervention

Amongst our most effective interventions is the implementation of the Ministry of Health’s Integrated Community Case Management (ICCM) strategy in 17 districts of Mid-western and Central Uganda and in Northern Bahr el Ghazal state in South Sudan. Through ICCM, Malaria Consortium is ensuring that children under five and newborns receive the most appropriate and cost effective treatment in good time. Malaria Consortium has supported the Uganda and South Sudan ministries to train two volunteer health workers per village (known as Village Health Team members in Uganda and community drug distributors in South Sudan) to diagnose and treat malaria, pneumonia and diarrhoea in children as well as to refer severe cases to the nearest health facility.

The proportion of children receiving appropriate treatment for these illnesses has seen a marked increase since the beginning of ICCM implementation. In Malaria Consortium supported districts in Uganda, appropriate treatment for malaria has increased from 16 to 62 percent between 2010 and 2012. In South Sudan, due to the high proportion of children who are underweight and to the inextricable link between malnutrition and childhood disease, the ICCM programme integrates screening for severe acute malnutrition and referral of identified cases for treatment. Volunteer health workers in both countries are provided with medicines to treat sick children and tools to record their work so that it can be tracked by the national health monitoring information systems, providing valuable information on health patterns at village level. They are fully integrated in the national health system and receive regular support supervision from health workers with more advanced training to ensure continuous motivation and provision of high quality of care.

We can all contribute

As donor funding for some of Malaria Consortium supported ICCM work comes to an end, it becomes crucial for all stakeholders to think about how to sustain these activities and the gains achieved so far. We are working closely with the District Health Teams in Uganda and with the State Ministry of Health officials in South Sudan to develop solutions for district and sub-county governments to take over some of the necessary activities to sustain ICCM. In Kiboga District of Uganda, for example, efforts are being made to keep the programme running and activities have been included in the district strategic plan and budget.

Beyond the involvement of local governments, it is crucial for central government and development partners to commit to the continuation of this life saving intervention; it is the only way of sustaining the gains and continuously improving this programme. Using modelling, it is estimated that ICCM in Mid-western Uganda prevented between six and 19 percent of deaths in children from malaria, pneumonia and diarrhoea between 2009 and 2012. This reduction of childhood mortality suggests that if scaled up to other districts and states, ICCM could have a tremendous impact on child health outcomes in these two countries. In South Sudan, the MoH is supporting its partners to scale up ICCM and advocating for further funding.

ICCM represents a major step in the fight against malaria and is one of the reasons we are confident in our ability to defeat malaria. However, as the gains made are still fragile, further investment is vital for the achieved benefits to be maintained and for progress to continuously be made.

Just $40 can pay for the training of six volunteer health workers, who will have a positive impact on the lives of children and families. You can raise awareness about the impact of ICCM and bring it to the forefront of the political health agenda. You can support the Ministries of Health to secure the investment they need to sustain and scale up the programme. We strongly believe investing in ICCM is investing in the future of our children, and you can be a key part of this.

Fighting malaria and childhood illnesses is not just a matter of doctors and nurses, it is not just a matter of mothers and children, it is our fight as a society. Communities, local governments, banks and insurance companies, religious institutions, civil society organisations, businesses of all sizes, MPs, media, ministers, all of us need to play a part and combine our efforts.

On this World Malaria Day, you can “Invest in the future, defeat malaria”.

Yours faithfully,

Dr. Godfrey Magumba, Country Director, Uganda

Ruth Allan, Country Director, South Sudan

Interview with Wambete Peter, village health worker – audio

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.

As part of the project, volunteer village health team members (VHTs) are being trained to sensitise community members on general health issues, identify disease cases in the community and refer community members to health facilities for appropriate care. One of the project’s key objectives is to develop a strong and effective referral system between communities and the different health facility levels, to ensure timely and appropriate treatment, resulting in more lives saved.

Having lost a child to malaria in 2010, Wambete Peter from Muanda Village, Lugale Parish, Mbale region discusses how he feels about being selected as a VHT. Describing the selection process, he also discusses the impact of malaria in his community.

Interviewed by Mike Ndiema, Malaria Consortium’s Communications Officer in Uganda