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MALARIASCALING UP HOME-BASED
MANAGEMENT FOR CHILDREN
Ciro Franco, Senior Malaria OfficerMegan Shepherd-Banigan, Program Officer
BASICSBasic Support for Institutionalizing Child Survival
September 2, 2009
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About850,000childrenundertheageoffivedie
annuallyduetomalaria;94%ofthesedeaths
occurin
Sub
Saharan
Africa.
Malariaaccountsfor18%ofunderfivemortality
inSubSaharanAfrica;wellabovetheglobal
averageof
8%.
THESITUATION
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Howtoreachchildreninneedofpreventiveand
curativemalariaservices.
Howto
provide
these
services
in
an
efficient
and
effectivemanner.
THECHALLENGE
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WHATISCCM?
Priorityelement:Curativetherapyformalariadeliveredat
thecommunity
level
(through
CHWs,
HSAs,
extension
workers)
Integration*:Curative
therapy
for
malaria,
diarrhea,
and
pneumoniadeliveredatthecommunitylevel
*
Integration
refers
to
the,
organization,
coordination,
and
management
of
multiple
activities
and
resources
to
ensure
the
delivery
of
more
efficient
and
coherent
services
in
relation
to
cost,
output,
impact,
and
use
(acceptability). (WHO,
2006)
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USAID/BASICS MALARIAPROGRAM
ITNs, IPTp, prompttreatment
Malawi
ITNTimor-Leste
CCMSenegal
Malaria CCMRwanda
Malaria CCMMadagascar
Malaria CCMBenin
AREAS OF FOCUSCOUNTRIES
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BASICSbeginning
effortsin5Health
Zonesto
implement
CCMMalaria,aswell
asdiarrhea,nutrition,
and,
hopefully,
ARI.
BENIN
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PreviousCCM
work
undertakenina
numberofdistricts.
CollaborationwithPMI
partners,the
Global
Fund,andthebilateral
tocoordinatethe
implementationof
CCMMalaria
in
away
thatwouldminimize
partneroverlapping.
MADAGASCAR
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Throughlocal
NGOs,
BCCactivitiesto
promoteprompt
treatment,IPTp,andITN
use.
Ongoingin
9out
of
28districts. Some4,000
HealthSurveillance
Assistants
will
be
trained
inCCM.
MALAWI
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AssisttheNationalMalaria
ControlProgram,
in
collaborationwithSPS,in:
AssessingHomebased
management(withand
withoutRDTs)
Draftingnextstepsforthe
integrationofRDTs intoCCM
Conductedastudyonthe
natureofRDTreferralsto
healthcenters.
RWANDA
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AssistedtheMOHto
distributeITNs in5
districts,usinga
partnershipmodel
that
linkedthepublicsector
andcivilsociety.
Evaluationshowedabout
80%
coverage.
TIMORLESTE
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MALAWI
NGOGRANT
REVIEW
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MALARIAGRANTPROGRAMOVERVIEW
BASICSawarded6grantstoNGOstooperatein
7/28districtsinJune2008
CommunitylevelBCC/IECactivitiestopromote
Prompt
treatment ITNuse
IPTp
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After10monthsofimplementation,ask:
What
is
the
added
value
for
malaria
prevention
andcontrolwhenNGOspromoteBCC/IEC
interventionsatthecommunitylevel?
What
is
the
state
of
collaboration
between
the
NGOs,DHMTs andpartners?
Arequalitymessagesbeingdeliveredandretained
by
beneficiaries?
PURPOSEOFNGOREVIEW
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REVIEWMETHODOLOGY
Keyinformantinterviews
DistrictHealth
Management
Teams
(DHMT)
NGOs
CommunityLeadersandHealthSurveillanceAssistants
(HSAs)
Focusgroupdiscussionwithcommunitymembers
Publichealthtalkobservations(HSAs and
volunteers) Exitinterviews(healthtalkattendees,2xtalk)
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Activitiesreachedcommunities
NGOsutilizeddifferentstrategiestoachievevaryingdegreesofdepthversusbreadth
NGOscoveredtargetedpopulation,butcoverage
wasassessedatTraditionalAuthoritylevel
Fiveof6NGOsactivelyengagedwithDHMTs
Message
delivery
was
good,
but
needed
to
be
strengthenedandculturalbarriersaddressed
OVERVIEWOFRESULTS
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32/71 (45%)60/93 (65%)LA must be taken twice a day for three days
65/71 (92%)87/93 (94%)LA is the newly recommended drug by the
Government of Malawi
46/67 (69%)70/89 (79%)SP must be taken twice
62/70 (89%)80/91 (88%)Pregnant Women should take SP in order to
prevent malaria
19/64 (30%)19/69 (28%)Benefits of ITN use for PLWHA
62/70 (89%)86/93 (93%)Benefits of ITN use for pregnant women
62/70 (89%)87/93 (94%)Benefits of ITN use for children under five
VolunteerHSAMessage
Frequency o f Messages Delivered Dur ing HSA and Volun teer
Publ ic Health TalksObservation of 93 HSAs and 71 Volunteers
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MessageHSA 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 10/80 (13%) 8/62 (13%)
SP must be taken twice23/70 (33%) 22/46 (48%)
LA is the newly recommended drug by theGovernment of Malawi 85/87 (98%) 60/65 (92%)
LA must be taken twice a day for three days50/60 (83%) 26/32 (81%)
Frequency
of
Message
Recall
Following
HSA
and
Volunteer
Public
Health
TalksExitinterviewswith336caretakers
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NGOgrantingisaneffectivemechanismtoreach
communitieswith
malaria
BCC
messages
Theprogramshouldbescaleduptootherdistrictsin
Malawi
Granteesrequire
more
than
one
year
of
funding
to
achieve
behaviorchangeatthecommunitylevel
Granteesshouldemphasizetheuseofinteractive
strategies(i.e.
household
visits
and
health
talks)
RECOMMENDATIONS
FROMNGO
REVIEW
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CCMINMALAWI
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Focus:
Managing
commonchildhoodillnesses(fever,pneumonia,diarrhea,redeye)usingIMCI
algorithms. ProvisionofDepo
Provera isincludedintheservicepackage.
BetweenJuly2008and
August2009,
450
clinics
(across 15districts)wereoperationalized.
VILLAGECLINICS
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HealthSurveillance
Assistant
overload
Understandingdrugrequirementsandsupplyingsufficientdrugs(logistics)
Supervision
M&Esystems
VILLAGECLINICSCHALLENGES
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RWANDAHOMEBASEDMANAGEMENT
OFMALARIA
ASSESSMENT
(WITHANDWITHOUTRDTs)
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OBJECTIVESOFTHEASSESSMENT
AssessCHWperformanceaccordingtostandards(complete
assessment,correct
diagnosis
[with
RDT
and
without],
appropriatereferrals,counseling,andtreatment)
Explorecommunityhealthseekingbehaviorsandpreferred
treatmentsfor
young
children
when
they
have
fever
InvestigatecommunitysatisfactionwithCHWs andtheirservices,includingtheuseofRDTs
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Focusgroup
discussions
Indepthinterviews
Observation
Exitinterview
METHODOLOGY
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CHW
practice
relatedtodangersigns
Danger
Signs Practice(n=69)
Convulsion 43%
Difficult
breathing 45%Vomitingmorethan3times 74%
Unabletodrinkandeat 57%
Unconscious 43%CHWthatmentionedallkey
dangersigns
18%
Interviews
and
observation
of
CHWs
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Task Knowledge
(n=24)
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%
CHW
knowledge
and
practice
relatedtoRDTs
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RWANDARetrospectivestudyof
followup
on
RDT
negative
children
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EvaluationoftheCommunityHealthWorkerReferralProgram
forRDTnegativechildrenwithfever
Goal:retrospectivelyexaminetreatmentprovidedto
childrenwith
anegative
RDT
when
they
are
referred
to
theHealthCenter,focusingonthefollowingpoints:
Whattreatments
were
given?
Whattestswereadministered?
Whatweretheoutcomes?
preliminaryfindings
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Methods(aretrospectivestudy)
551childrenwithRDTnegativeidentifiedfromallCHW
referralrecords
(linked
with
4health
centers)
Examinationofhealthcenterrecordsforthesechildren
basedondate,name,andvillage
Followup
at
household
level
to
determine
survival
and,
in
caseofnonsurvival,symptomsassociatedwithdeath
550childrenwerestillalive;onlyonechilddied(from
othercauses)
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TestsadministeredtoRDTnegativechildrenathealth
center(n=551)
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TypesoftreatmentgiventoRDTnegativechildrenathealth
center(n=551)
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16%(n=88)ofRDTnegativechildrentreatedathealth
centerwithCoartem
PatientstreatedwithCoartem
PositiveGE
Negatif
GE
NoGE
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Preliminaryimplications
WhatshouldbetheCHWpolicyfordealingwithRDT
negativechildren
at
community
level?
Shouldtheybereferred?
Whatisthebenefitofthesechildrengoingtothehealthcenter
fromafamilyperspectiveandapublichealthperspective?
Whatshouldbethepolicyforhandlingcasesreferred
fromcommunitylevelwithanegativeRDT?
What
guidelines
should
be
developed
for
health
center
staff
to
managechildrenreferredfromcommunitylevelwithanegative
RDT?
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LESSONSLEARNEDANDTHE
WAYFORWARD
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LESSONSLEARNEDANDTHEWAYFORWARD
Thefeasibility ofCCMmalariaandICCMdepends on
endorsement bytheMOHandthecommunity,anda
clear systemofsupportforCCM.
RDTs at community level arequite feasible,aslongasthe
supportsystemis adequate andclear guidanceforfollow
upof
RDT
results is provided
Scaling upCCMis critical tocontrolmalariaandother
conditions. Itrequires amechanism,such asNGOgrants,
with clearly defined roles tostrengthen collaboration
between thepublic
sector and
civil
society