Mozambique: Community health workers provide care to remote communities

Approx reading time: 2 mins

Dirce Costa, Malaria Consortium’s Malaria Prevention and Control Project Coordinator, and Romeo Carlos from International Relief & Development, interview Felizarda Eugénio on access to health care in Guimereço community, Inhambane.

We visited Felizarda, a young mother and seven months pregnant, who was accompanied by her two year old son Félix, at her home near the National Road, Guimereço community, Inhambane province.

Felizarda takes care of her family and her small farm of cassava, which provides everyone with food. She also sells coconuts. Her husband Delcídio Eugénio is a mason working at a tourist resort around 100 metres from their home. The joint income is enough to cover the costs of daily life. “Gu dukwua dukwana (enough to not leave the family hungry),” Felizarda explained in the regional bitonga language.

Felizarda invited us into her garden where she showed us three rooms; one belonging to Felizarda’s grandmother, another for food storage and the last one where the family sleeps.

We asked Felizarda where she usually goes when she or anyone in her family is sick. She explains that she goes to the health clinic in Jangamo, or to the community APE (community health worker, locally known as agente polivalente elementare), Mrs Arnalda’s house.

Community health programmes have been running for over 30 years in Mozambique with government support. In 2009, revitalisation of the programme was begun by the Ministry of Health. In addition to health promotion and first aid, APEs in Mozambique are now trained to diagnose and treat simple forms of the three main childhood diseases; malaria, pneumonia, diarrhoea. Since 2010, Malaria Consortium has been working with the Inhambane provincial health team providing training, equipment, supplies and supervision for community health workers to carry these new tasks.

Felizarda remembers that she went twice to the APE’s house, firstly when Felix was suffering from a fever and vomiting, and a second time when she had a headache. Felizarda said: “Mrs Arnalda is a good person because the two times when I went looking for treatment, I was treated well. Mrs Armada gave me drugs and healed us..”

Felizarda also explained that she learned how malaria was transmitted: “I had been told about malaria at the health clinic in Jangamo, when I went for my ante-natal consultation.” She was also given a mosquito net, under which she sleeps, protecting her unborn child. The net keeps the mosquitoes away, although her son Felix has had malaria.

In Africa, malaria is the leading killer of children, with 3,500 dying from the disease every day. The universal coverage of mosquito nets through distribution to households is now a national policy being rolled out across the country. The fight against malaria is changing with APEs at the front line, educating families on the importance of sleeping under mosquito nets and bringing basic health services closer to people’s homes.

When Felizarda or her family has health problems, firstly they visit the APE who decides if it is possible to treat them at the community level. If it is not possible, she refers them to the health clinic. At the clinic in the past, Felizarda has waited from early morning until two o’clock in the afternoon to receive medical treatment, so she appreciates the APEs’ being able to treat her and her family within her community.

Resistance in the fight against malaria

Approx reading time: 4 mins

A growing public health risk originating in Asia, drug resistance, is threatening to undermine gains in malaria control

Significant progress has been made in recent years in the fight against malaria. Since 2000, mortality from malaria has decreased by over 25 percent globally. Scale-up of effective malaria interventions, including the use of artemisinin-based combination therapies – the most effective drug for treating the disease – have been instrumental to this success. However, growing resistance to artemisinins by the malaria parasite has been emerging in Southeast Asia and is threatening to reverse the gains that have been made to date. In this interview, Senior Technical Officer at Malaria Consortium, Dr Prudence Hamade, explains how dangerous a spread the spread of parasite resistance to anti-malarial drugs could be in Asia and beyond.

Q: Can you explain what drug-resistant malaria is and what the state of resistance is now in Southeast Asia?

A: Drug-resistant malaria refers to the strain of malaria parasites that have begun to show resistance to the drug currently being used to kill them. It occurs when a parasite is exposed to a specific drug, often over a long period of time, and successfully changes itself to avoid being killed. Increasingly over the last two or three years, we have noticed that artemisinin, the most effective drug we’ve ever had against malaria, is not working as well as it was in the early days, especially in Asia. It is used in combination with a partner drug, so the treatment is known as artemisinin-based combination therapy or ACT. The drugs clear the parasite from the blood very quickly, which in turn reduces the window for transmission of the parasite from one person to another. ACTs still cure the majority of people within 28 days, but in certain parts of Southeast Asia, there is more and more evidence that the parasite is surviving for longer, which indicates that resistance to artemisinin is on the rise.

Q: Where exactly are the problem areas?

A: The major hotspot for resistance to artemisinin is on the Thai-Cambodia border, where resistance was first detected in 2008. It has since been found elsewhere in Asia: on the Thai-Myanmar border and more recently in Vietnam. Although resistance in these areas is not at the levels we are witnessing along the Thai-Cambodia border, it is a clear indication that resistance to artemisinin is on the rise in the region.

Q: Why is Asia referred to as the hotspot for anti-malarial drug resistance?

Resistance to some of the most effective anti-malarial drugs we have used in the past first emerged in Southeast Asia: resistance to chloroquine for example was detected in the 1950s and Sulphadoxine-Pyrimethamine in the 1990s. Resistance to these drugs is now widespread throughout the world in many malaria endemic countries. Why Southeast Asia is the origin of this resistance is not completely clear but has been linked to the fact that artemisinin was introduced earlier there than elsewhere. Issues around the regulation of antimalarial drugs in the region and the use of monotherapies (where artemisinin is used alone rather than in combination treatments) have also been identified as likely contributors.

Q: The number of cases of malaria in Asia is much lower than in sub-Saharan Africa. Why then is artemisinin resistance in Asia such a grave public health concern?

A: If artemisinin was to stop working in Asia, it would mean that the number of cases of malaria in Asia would increase and become much more serious – because we won’t be able to reduce transmission or treat cases as effectively as before – and mortality will increase. The real worry is that this resistance could spread to Africa (where almost 600,000 people died from malaria in 2010), perhaps transferred by migrants, or emerging spontaneously. At the moment, we are still a long way from having another anti-malarial drug that is as effective or tolerated as well by patients as ACTs. It would then be highly likely that we would see an increase in morbidity and mortality from the disease.

Q: So how serious is the potential spread of resistance from Asia to Africa?

A: When resistance to chloroquine spread to Africa in the 80s and 90s, there were not adequate surveillance systems in place and it took a long time to detect. As a result there was an increase in the number of people dying from malaria. Pregnant women and young children in Africa are particularly vulnerable to malaria because they are the most likely to have either low or no immunity to the diseases, so if resistance to artemisinin were to spread to Africa now or in the next couple of years, the number of deaths among these groups in particular are likely to rise. It would also be more difficult to contain the spread of artemisinin resistance in Africa because of the widespread nature of the disease.

Q: What needs to be done to stop the spread of resistance in Asia?

A: The best case scenario would be to eliminate malaria from the region entirely. That would be extremely complicated but it could be possible. The first step to controlling the spread of resistance is to improve surveillance. We need good reporting systems in place because we need to know where the resistant malaria parasites are located in order to treat and eliminate the drug-resistant strains from those patients. That is the only way to stop the resistant strain spreading: to eliminate the resistant parasites as rapidly as possible by curing the patient quickly, thereby reducing the chances of those parasites being transmitted via mosquitoes to other people.

Q: So what is happening now?

A: The Bill & Melinda Gates Foundation funded the Containment Project, the first major initiative to contain artemisinin resistance in Southeast Asia. This project brought together regional governments and partners, including Malaria Consortium, to develop and implement a multi-pronged strategy to contain the resistance. Now, with support from the Global Fund and AusAid, partners in the region are trying to move beyond containing malaria and resistance, to eliminating malaria from the region altogether.

Interview with Wambete Peter, village health worker – audio

Approx reading time: 1 min

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

A very simple guide to the MDGs, global health and what comes next

Approx reading time: 4 mins

It is not clear how the post-2015 goals will be framed, but health will undoubtedly play a crucial role

The Millennium Development Goals (MDGs) will expire in 2015. As we approach the deadline, it is clear that the next development framework needs to be in place to take over. Discussions at the highest level have begun. British prime minister David Cameron is an important player of the process being led by the United Nations. Development agencies and civil society groups are already jostling for position and trying to ensure what they think what should come next is included and the issue of global health is proving to be a particularly fraught one.

With this as the context, it is expected that global news coverage of the future of the global development agenda will increase as the deadline gets closer and decisions are made. This article therefore aims to provide the basics that everyone should know if they want to understand what is at stake.

What are the Millennium Development Goals?

In 2000, world leaders came together at United Nations Headquarters in New York to develop a blueprint agreed by all the world’s countries and all the world’s leading development institutions. This blueprint committed their nations to a new global partnership to reduce extreme poverty and set out a series of eight time-bound targets, otherwise known as the MDGs.

By 2015, the eight MDGs aim to:

MDG 1: eradicate extreme poverty and hunger

MDG 2: achieve universal primary education

MDG 3: promote gender equality and empower women

MDG 4: reduce child mortality

MDG 5: improve maternal health

MDG 6: combat HIV/AIDS, malaria and other diseases

MDG 7: ensure environmental sustainability

MDG 8: develop a global partnership for development

Have they been a success?

To date the answer to this can be yes and no, depending on whom you ask. However, for the most part they can be viewed in a positive light. They have undoubtedly focussed international attention towards achieving a set of tangible results, backed by the UN system, and opened the development sector up to the general public and increased their interest. They have also made donor countries more ambitious in tackling development issues and allowed for greater coherence amongst donors.

In malaria specifically the UN estimates that the global incidence rate of malaria has decreased by 17% since 2000, and malaria-specific mortality rates by 25%. In addition, countries with improved access to malaria control interventions have seen child mortality rates fall by about 20%.

What lessons have we learnt from them?

Despite these impressive outcomes, there are still lessons that can be learned, particularly as some of the goals will not be achieved by 2015. Inevitably when progress has been made in the areas targeted by the MDGs, some issues that were excluded from the process did suffer in terms of attention and funding, with neglected tropical diseases a notable example from the health sector. There has also been a tendency to focus on easy targets which offered the best chance of success, such as immediate results, rather than maximum impact on poverty reduction. This has led to inequity where the goals fail to measure and thus disregard outcomes for vulnerable and marginalized groups. These lessons can help articulate the future goals to be more balanced and context specific.

What will replace the MDGs in 2015?

This is the key question currently being discussed within the development sector and, although new thematic areas are emerging, there is widespread consensus that the future goals should focus on the poorest and most vulnerable people, not nation states. It is also agreed that these discussions must include Southern as well as Northern voices to give the process a global consensus. The post-2015 agenda is likely, therefore, to include new areas of focus such as governance, water, population dynamics, energy and economic growth.

How many goals will there be?

It is widely agreed that the number of goals should be limited to a maximum of ten, maintaining their simplicity. The UK government recently said that they “strongly support a framework with no more than ten goals, all with quantifiable targets”. Any new goals are also likely to follow the current 15 year pattern and so will set the development agenda until 2030.

How does health fit into this new framework?

With the emerging development areas noted above, which are expected to be included in the new framework, the likelihood of health having more than one goal as it does now is small. Instead there is likely to be one overarching health goal that will then be broken down into specific targets.

What will the health goal be?

As the recent WHO and Unicef led health consultation highlighted, three main health goal options have emerged:

Universal health coverage: Simply put, achieving UHC means that all people, including vulnerable, marginalised and stigmatised populations, have access to health information and services of sufficient quality to cover and fulfil the variety of their needs while protecting against the risk of financial hardship from accessing health services.

If this option is taken up then UHC must be articulated with precision and incorporate achievable targets. It also needs to be recognised that the aim of UHC should not be just coverage, but universal access to healthcare.

Healthy life expectancy: The World Health Organisation defines healthy life expectancy as the “average number of years that a person can expect to live in ‘full health’ by taking into account years lived in less than full health due to disease and/or injury”. If incorporated into the post-2015 framework, this goal will address the need for action on the determinants of health and on the root causes of ill-health, preventable disability, and premature death.

MDGs alternative: Another option is for more specific goals that resemble the current MDGs. Proponents of this option believe that the post-2015 development agenda should maintain the priorities of the MDG framework and not be designed to encapsulate everything that development seeks to achieve. The MDG framework generated resonance and buy-in because of the focus on clear, targeted, measurable outcomes that were meaningful to both the general public and policy-makers. With the broader themes offered by the alternatives, this might be lost.

When will these decisions be made?

We are currently in the midst of a number of high level consultations and conferences to discuss the post 2015 agenda. In January 2012, the UN Secretary-General established the UN System Task Team on the Post-2015 UN Development Agenda of which David Cameron is a Co-Chair, to coordinate the development of a new framework in consultation with all stakeholders on each thematic area.

The High Level Dialogue on Health in the Post-2015 Development Agenda took place in Gaborone, Botswana, from 4-6 March, 2013 and produced a report following months of consultations with civil society. This report will feed into the more general post-2015 consultative meeting in Bali, Indonesia on 25 – 27 March 2013. The findings from all the thematic consultations will be presented in a report to the UN General Assembly in September 2013 where the recommendations will be ratified.

Alex Hulme is advocacy officer at Malaria Consortium

Tackling childhood illnesses in Northern Zambia through iCCM

Approx reading time: 3 mins

Integrated Community Case Management (ICCM) of childhood illness works to provide access to community based care for children under-five for pneumonia, malaria and diarrhoea, through the training of community health workers (CHWs). In Zambia in 2010, 36 per cent of deaths of children under-five years old, were due to these three childhood illnesses, accounting for 21,600 deaths.

iCCM is being implemented in all seven districts of Luapula province in Northern Zambia by Malaria Consortium, funded by the Canadian International Development Agency (CIDA).  This includes Samfya district where the local environment – large swamps and vast lakes where people live on small islands – makes it a particularly challenging area in which to successfully implement health interventions.   The CHWs in Samfya district currently see six people per day: four with malaria and two or three with diarrhoea.  To date, in the whole of Luapula province, 1332 CHWs have been trained and are working there.

Access to health care has significantly improved

One of the most significant improvements since the implementation of iCCM is the decongestion of health facilities, noted by two CHWs in Samfya district as well as a member of staff from the local health facility.  The health facility “is now able to cope”.  The numbers of children aged two months to five years visiting the health facility have been dramatically reduced as they are now cared for primarily in the community and are only referred to the facility when necessary.

For the communities, access to health services has greatly increased as a result of the iCCM programme. As one CHW described, they are now able to access health care “right at their doorway” and including during the night because the CHWs are part of the community and are always accessible.   “Community members really appreciate this programme very very much”, one CHW described, explaining that now “they can easily access the medicine”.  Even when there was a recent shortage of drugs, the CHWs explain that they have still been received well by the community and attitudes towards them have not changed.

Overcoming local challenges to iCCM

When iCCM was first implemented in the area, some community members were wary as the rapid diagnostic tests for malaria involve a blood test – a pin prick of blood taken from the patient’s finger – which contributed to an impression amongst some in the area that the CHWs were “bewitched”.  However, the clear support of the iCCM programme by the district health facilities has helped to reassure the community members.  Health facility staff often ask children who visit the health facility why they did not first seek care from the CHWs and encourage them to do so.  This has helped communicate to community members the government’s support for iCCM.

On the whole, there are still some community members who are slow to seek care, but CHWs and Malaria Consortium are working hard to address this by educating and encouraging the community.

For maximum impact, outstanding challenges need to be addressed

Whilst implementation of iCCM has been a success in Luapula province, the two CHWs in Samfya district highlighted some of the obstacles they face in providing health care for their communities.

Firstly, that they need bicycles. In Zambia, CHWs work voluntarily and in many cases earn their primary income, or sustain their families, through farming.  They are required to collect the drugs from the district health facilities on a regular basis and also to deliver a monthly report. They also make routine follow-up visits to their patients to check their recovery.  All of these duties can involve travelling considerable distances on foot. They sacrifice a lot of time, at the expense of their own livelihood and the community often does not have the capacity to support them.

The CHWs also need better torches.  In rural areas, often far from the electricity grid, CHWs struggle to provide care for patients at night with the small – and often faulty – torches that they currently have.

Finally, whilst the government is supportive of iCCM, endorsing guidelines and training manuals, there is as yet no national iCCM policy in place.

For the maximum impact of iCCM to be realised and to ensure the sustained motivation and capacity of the CHWs, these challenges must be addressed.

Malaria Consortium, as part of COMDIS-HSD, is conducting research on ICCM in Luapula province to provide further evidence on the rational use of antibiotics at community level, informing future implementation of iCCM.  For further information on Malaria Consortium, please visit www.

Kirstie Graham is Technical Officer: COMDIS-HSD Project Coordinator at Malaria Consortium

Celebrating World Malaria Day in Ethiopia

Approx reading time: 1 min

On 25 April, hundreds of people travelled to Assosa Stadium – in Ethiopia’s western region of Benishangul-Gumuz – to celebrate World Malaria Day 2012.

Raising awareness of malaria is crucial in Benishangul-Gumuz, one of the few regions in the country where malaria transmission lasts for more than six months in the year.

The event, the first of its kind in the region, was organised by the Regional Health Bureau in partnership with the Ethiopian Ministry of Health, Malaria Consortium, WHO and others. Hundreds of local residents took part in the programme of events which included taekwondo, traditional wrestling and soccer tournaments, as well as music and poetry shows. Over 200 people were tested for malaria on the day.

Malaria Consortium’s Country Director for Ethiopia, Dr. Agonafer Tekalegne, spoke to attendees about the need for a joint effort to tackle malaria in the country. Reminding partners of the global theme of World Malaria Day 2012 – “Sustain Gains, Save Lives: Invest in Malaria” – Dr Tekalegne noted that in the midst of the Global financial crisis, efforts to manage gaps in funding locally would need to be stepped up.

Malaria represents the largest single cause of morbidity in Ethiopia and, due to climatic fluctuations and drought-related nutritional emergencies, large scale epidemics of the disease tend to break-out every five to eight years with devastating effects (UNICEF). Malaria Consortium has been working to complement the efforts of the Government and other actors in the fight against malaria in Ethiopia since 2004.

Read more about our work in the country here.