Preventing malaria through drama and performance

“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:

pThe drama group begins by playing songs all of them about preventing malaria in order to attract a crowdp
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Patrick Lee is Communications Assistant at Malaria Consortium in London.

Agente Polivalente Elementar overcomes tragedy by helping her community

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

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

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

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

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

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

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

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

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Malaria Consortium’s RAcE project: Implementing iCCM in Nigeria

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

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

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

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

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

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

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

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

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


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

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