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MALARIA

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

ITNs, IPTp, prompt


treatment

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

Frequency of Messages Delivered During HSA and Volunteer


Public Health Talks
Observation of 93 HSAs and 71 Volunteers

Message

HSA

Volunteer

Benefits of ITN use for children under five

87/93 (94%)

62/70 (89%)

Benefits of ITN use for pregnant women

86/93 (93%)

62/70 (89%)

Benefits of ITN use for PLWHA

19/69 (28%)

19/64 (30%)

Pregnant Women should take SP in order to


prevent malaria

80/91 (88%)

62/70 (89%)

SP must be taken twice

70/89 (79%)

46/67 (69%)

LA is the newly recommended drug by the


Government of Malawi

87/93 (94%)

65/71 (92%)

LA must be taken twice a day for three days

60/93 (65%)

32/71 (45%)

FrequencyofMessageRecallFollowing
HSAandVolunteerPublicHealthTalks
Exitinterviewswith336caretakers
Message

HSA

Volunteer

Benefits of ITN use for children under five

70/87 (81%)

53/62 (86%)

Benefits of ITN use for pregnant women

69/86 (80%)

54/62 (87%)

Pregnant Women should take SP in order to


prevent malaria
SP must be taken twice
LA is the newly recommended drug by the
Government of Malawi
LA must be taken twice a day for three days

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

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