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SCALING UP HOME-BASED
MANAGEMENT FOR CHILDREN
Ciro Franco, Senior Malaria Officer
Megan Shepherd-Banigan, Program Officer
BASICSBasic Support for Institutionalizing Child Survival
September 2, 2009
THESITUATION
About850,000childrenundertheageoffivedie
annuallyduetomalaria;94%ofthesedeaths
occurinSubSaharanAfrica.
Malariaaccountsfor18%ofunderfivemortality
inSubSaharanAfrica;wellabovetheglobal
averageof8%.
THECHALLENGE
Howtoreachchildreninneedofpreventiveand
curativemalariaservices.
Howtoprovidetheseservicesinanefficientand
effectivemanner.
WHATISCCM?
Priorityelement:Curativetherapyformalariadeliveredat
thecommunitylevel(throughCHWs,HSAs,extension
workers)
Integration*:Curativetherapyformalaria,diarrhea,and
pneumoniadeliveredatthecommunitylevel
*Integrationreferstothe,organization,coordination,and
managementofmultipleactivitiesandresourcestoensurethe
deliveryofmoreefficientandcoherentservicesinrelationtocost,
output,impact,anduse(acceptability). (WHO,2006)
USAID/BASICS MALARIAPROGRAM
COUNTRIES
AREAS OF FOCUS
Benin
Malaria CCM
Madagascar
Malaria CCM
Malawi
Rwanda
Malaria CCM
Senegal
CCM
Timor-Leste
ITN
BENIN
BASICSbeginning
effortsin5Health
Zonestoimplement
CCMMalaria,aswell
asdiarrhea,nutrition,
and,hopefully,ARI.
MADAGASCAR
PreviousCCMwork
undertakenina
numberofdistricts.
CollaborationwithPMI
partners,theGlobal
Fund,andthebilateral
tocoordinatethe
implementationof
CCMMalariainaway
thatwouldminimize
partneroverlapping.
MALAWI
ThroughlocalNGOs,
BCCactivitiesto
promoteprompt
treatment,IPTp,andITN
use.Ongoingin9outof
28districts.Some4,000
HealthSurveillance
Assistantswillbetrained
inCCM.
RWANDA
AssisttheNationalMalaria
ControlProgram,in
collaborationwithSPS,in:
AssessingHomebased
management(withand
withoutRDTs)
Draftingnextstepsforthe
integrationofRDTs intoCCM
Conductedastudyonthe
natureofRDTreferralsto
healthcenters.
TIMORLESTE
AssistedtheMOHto
distributeITNs in5
districts,usinga
partnershipmodelthat
linkedthepublicsector
andcivilsociety.
Evaluationshowedabout
80%coverage.
MALAWI
NGOGRANTREVIEW
MALARIAGRANTPROGRAMOVERVIEW
BASICSawarded6grantstoNGOstooperatein
7/28districtsinJune2008
CommunitylevelBCC/IECactivitiestopromote
Prompttreatment
ITNuse
IPTp
PURPOSEOFNGOREVIEW
After10monthsofimplementation,ask:
Whatistheaddedvalueformalariaprevention
andcontrolwhenNGOspromoteBCC/IEC
interventionsatthecommunitylevel?
Whatisthestateofcollaborationbetweenthe
NGOs,DHMTs andpartners?
Arequalitymessagesbeingdeliveredandretained
bybeneficiaries?
REVIEWMETHODOLOGY
Keyinformantinterviews
DistrictHealthManagementTeams(DHMT)
NGOs
CommunityLeadersandHealthSurveillanceAssistants
(HSAs)
Focusgroupdiscussionwithcommunitymembers
Publichealthtalkobservations(HSAs and
volunteers)
Exitinterviews(healthtalkattendees,2xtalk)
OVERVIEWOFRESULTS
Activitiesreachedcommunities
NGOsutilizeddifferentstrategiestoachieve
varyingdegreesofdepthversusbreadth
NGOscoveredtargetedpopulation,butcoverage
wasassessedatTraditionalAuthoritylevel
Fiveof6NGOsactivelyengagedwithDHMTs
Messagedeliverywasgood,butneededtobe
strengthenedandculturalbarriersaddressed
Message
HSA
Volunteer
87/93 (94%)
62/70 (89%)
86/93 (93%)
62/70 (89%)
19/69 (28%)
19/64 (30%)
80/91 (88%)
62/70 (89%)
70/89 (79%)
46/67 (69%)
87/93 (94%)
65/71 (92%)
60/93 (65%)
32/71 (45%)
FrequencyofMessageRecallFollowing
HSAandVolunteerPublicHealthTalks
Exitinterviewswith336caretakers
Message
HSA
Volunteer
70/87 (81%)
53/62 (86%)
69/86 (80%)
54/62 (87%)
10/80 (13%)
8/62 (13%)
23/70 (33%)
22/46 (48%)
85/87 (98%)
60/65 (92%)
50/60 (83%)
26/32 (81%)
RECOMMENDATIONS
FROMNGOREVIEW
NGOgrantingisaneffectivemechanismtoreach
communitieswithmalariaBCCmessages
Theprogramshouldbescaleduptootherdistrictsin
Malawi
Granteesrequiremorethanoneyearoffundingtoachieve
behaviorchangeatthecommunitylevel
Granteesshouldemphasizetheuseofinteractive
strategies(i.e.householdvisitsandhealthtalks)
CCMINMALAWI
VILLAGECLINICS
Focus:Managing
commonchildhood
illnesses(fever,
pneumonia,diarrhea,
redeye)usingIMCI
algorithms.
ProvisionofDepo
Provera isincludedin
theservicepackage.
BetweenJuly2008and
August2009,450clinics
(across15districts)
wereoperationalized.
VILLAGECLINICSCHALLENGES
HealthSurveillanceAssistantoverload
Understandingdrugrequirementsandsupplying
sufficientdrugs(logistics)
Supervision
M&Esystems
RWANDA
HOMEBASEDMANAGEMENT
OFMALARIAASSESSMENT
(WITHANDWITHOUTRDTs)
OBJECTIVESOFTHEASSESSMENT
AssessCHWperformanceaccordingtostandards(complete
assessment,correctdiagnosis[withRDTandwithout],
appropriatereferrals,counseling,andtreatment)
Explorecommunityhealthseekingbehaviorsandpreferred
treatmentsforyoungchildrenwhentheyhavefever
InvestigatecommunitysatisfactionwithCHWs andtheir
services,includingtheuseofRDTs
METHODOLOGY
Focusgroupdiscussions
Indepthinterviews
Observation
Exitinterview
CHWpractice
relatedtodangersigns
InterviewsandobservationofCHWs
DangerSigns
Practice
(n=69)
Convulsion
Difficultbreathing
Vomitingmorethan3times
43%
45%
74%
Unabletodrinkandeat
Unconscious
CHWthatmentionedallkey
dangersigns
57%
43%
18%
CHWknowledgeandpractice
relatedtoRDTs
Knowledge
(n=24)
Task
Practice
(n=24)
Checkexpirationdate
71%
63%
Putongloves
100%
96%
Positionkithorizontally
92%
100%
Writeidentificationofpersonanddateonkit
71%
96%
Putdropofbufferinfirsthole
95%
100%
Disinfectfingerandusepipettecorrectly
96%
92%
Usethepipettecorrectly
96%
48%
Discardpipetteinwastecontainer
71%
78%
Putentirevolumeofbloodin1sthole
100%
95%
Usekittoinsertitinthefirstholefor10minutes
100%
79%
Usepipettetostirandletstandoneminute
80%
100%
Usedipstickin2ndholefor10minutes
100%
87%
Takeoutstickandthrowawayremainsofkit
96%
96%
Interprettestcorrectly
N/A
91%
GavePRIMOiftestpositive
100%
100%
GavePRIMOiftestnegative
N/A
25%
GavePRIMOandreferredtoHC
92%
14%
RECOMMENDATIONS
Renewfocusonseveraltasksofcasemanagement.
Strengthenthesupervisorysystemsothatsupervisionof
CHWs ismoreconsistentandfocusedoncase
management.
SeveralissuesrelatedtoRDTs needreexaminationbefore
scaleup.
Improvespecificelementsofthepharmaceutical
managementoftheHBMprogram.
Revisittherecommendationfromthe2006HBM
assessmentonmotivationandtheCHWs.
RWANDA
Retrospectivestudyof
followuponRDTnegative
children
EvaluationoftheCommunityHealthWorkerReferralProgram
forRDTnegativechildrenwithfever
Goal:retrospectivelyexaminetreatmentprovidedto
childrenwithanegativeRDTwhentheyarereferredto
theHealthCenter,focusingonthefollowingpoints:
Whattreatmentsweregiven?
Whattestswereadministered?
Whatweretheoutcomes?
preliminaryfindings
Methods(aretrospectivestudy)
551childrenwithRDTnegativeidentifiedfromallCHW
referralrecords(linkedwith4healthcenters)
Examinationofhealthcenterrecordsforthesechildren
basedondate,name,andvillage
Followupathouseholdleveltodeterminesurvivaland,in
caseofnonsurvival,symptomsassociatedwithdeath
550childrenwerestillalive;onlyonechilddied(from
othercauses)
TestsadministeredtoRDTnegativechildrenathealth
center(n=551)
TypesoftreatmentgiventoRDTnegativechildrenathealth
center(n=551)
16%(n=88)ofRDTnegativechildrentreatedathealth
centerwithCoartem
PatientstreatedwithCoartem
PositiveGE
NegatifGE
NoGE
Preliminaryimplications
WhatshouldbetheCHWpolicyfordealingwithRDT
negativechildrenatcommunitylevel?
Shouldtheybereferred?
Whatisthebenefitofthesechildrengoingtothehealthcenter
fromafamilyperspectiveandapublichealthperspective?
Whatshouldbethepolicyforhandlingcasesreferred
fromcommunitylevelwithanegativeRDT?
Whatguidelinesshouldbedevelopedforhealthcenterstaffto
managechildrenreferredfromcommunitylevelwithanegative
RDT?
LESSONSLEARNEDANDTHE
WAYFORWARD
LESSONSLEARNEDANDTHEWAYFORWARD
Thefeasibility ofCCMmalariaandICCMdepends on
endorsement bytheMOHandthecommunity,anda
clear systemofsupport forCCM.
RDTs at community level arequite feasible,aslongasthe
supportsystemis adequate andclear guidanceforfollow
upofRDTresults is provided
Scaling upCCMis critical tocontrolmalariaandother
conditions.Itrequires amechanism,such asNGOgrants,
with clearly defined roles tostrengthen collaboration
between thepublicsector andcivilsociety