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Performance of Community Health Workers in Community Case Management: Uganda.

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Karin Källander 4, inSCAlE Studygroup 5.
Affiliation(s) 1Techinical, Malaria Consortium, Kampala, Uganda, 2Technical, Malaria Consortium, Kampala, Uganda, 3Department of Population Health, London School of Tropical Medicine and Hygiene, London, United Kingdom, 4Technical, Malaria Consortium, Kampala, Uganda, 5Technical, Malaria Consortium, London, United Kingdom.
Country - ies of focus Uganda
Relevant to the conference tracks Advocacy and Communication
Summary Integrated community case management is a key child survival strategy in resource poor settings. There is a paucity of data on the performance of community health workers and how this performance can be assessed. We report on a study that assessed the performance of community health workers using various case vignettes.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM, lay community health workers (CHWs) use a given algorithm provided as a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of the method of choice, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given three case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver, to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough and fever and a history of stiff feet depicting a child with complicated malaria and pneumonia requiring referral and pre-referral treatment due to the danger signs. The last case was about a child with fever and cough essentially with uncomplicated malaria but no pneumonia. Each appropriate action based on the guidelines (i.e. questions the CHW should have asked, tests the CHW should have performed and treatment and health education CHW should have given) was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed, as well as for association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for uncomplicated malaria cases, 59.3 (SD 15.6) for the cases of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea cases, and 23.5 (SD 14.4) for the cases with complicated malaria and pneumonia. Overall, CHW's ability to state the correct treatment and dose for the simulated cases was high, with 93.3% stating the correct treatment for a child with malaria alone, 94.4% stating the appropriate treatment for a case with diarrhoea, and 84.4% being able to refer a case with a history of danger signs. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the complicated malaria and pneumonia case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios were a reflection of a real life situation, our data suggests that the majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to CHWs due to omitted actions, such as provision of pre-referral treatment, health education, counselling and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs, which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills, should be implemented.

Community Case Management of Malaria in Trained Role Model Caregivers of Under Fives, Kaduna Northwestern Nigeria

Author(s) Aisha Ahmed Abubakar1, Kabir Sabitu2, Andreas Jansen3, Nykiconia Preacely 4, Mu'awiyya Sufiyan 5, Suleman Hadejia Idris6, Ikeoluwapo Ajayi7.
Affiliation(s) 1Department of Community Medicine, Faculty of Medicine, , Ahmadu Bello University/ African Program for Advanced Research Epidemiology Training, Zaria, Nigeria, 2Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria, 3Scientific Advice Co-ordination Section, European Centre for Disease Control and Prevention, Stockholm, Sweden, 4Division of Global Health, Centres for Disease Control and Prevention, Atlanta, United States, 5Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria, 6Department of Community Medicine, Ahmadu Bello University Zaria, Zaria, Nigeria, 7Department of Epidemiology and Biostatistics, University of Ibadan, Ibadan, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Infectious Diseases
Summary Use of Role Model Caregivers for Community Case Management of Malaria achieved the 80% treatment target of malaria within 24 hours of onset of symptoms. Continuing training and supervision are necessary for correct dosage to be given.
Background Malaria is Africa’s leading cause of under five mortality, constituting 10% of the overall disease burden. A major strategy for reducing the burden of malaria is prompt access to effective antimalarials. Community Case Management of malaria (CCMm) can be used to achieve the 80% treatment target of uncomplicated malaria within 24 hours of the onset of symptoms. CCMm aims to train selected community members to recognize symptoms of malaria and give appropriate early and prompt treatment.
Objectives This study was conducted to assess CCMm in trained Role Model caregivers (RMCs) of under fives in Kaduna state, Nigeria.
1. To assess knowledge of malaria amongst role model caregivers trained in CCMm trained in Kaduna state
2. To assess treatment practices of malaria in CCMm trained role model caregivers in Kaduna state
3. To assess the relationship between knowledge and treatment practices of malaria in CCMm trained role model caregivers in Kaduna state
Methodology • What is the current knowledge of malaria in Community Case Management of malaria trained role model caregivers in Kaduna state?
• What are the malaria treatment practices of CCMm trained role model caregivers in Kaduna state?A descriptive cross sectional survey was conducted in Kaduna state. A sample of 308 RMCs were selected by multistage sampling and interviewed using a standardized questionnaire. The questionnaire had questions on sociodemographics, malaria transmission and treatment. Focus Group Discussions with RMCs were also conducted.
Results Mean age of RMCs was 35.34 years (±8.67). Females were 294(95.5%) and 285(92.5%) were literate. Out of 308, 294 (95.5%) correctly identified malaria was transmitted by mosquitoes. Two hundred and sixty three (85.4%) RMCs had treated a child under five years in the two weeks preceding the survey. Age range of children treated for malaria was 4-59 months, mean 26.9 months (±12.41). Out of 263 children, 232 (88.2%) received the correct dose of antimalarials and 220(84.3%) were treated within 24 hours of onset of symptoms. Level of education and literacy level were not significantly found to affect receiving the correct dose of antimalarials.
Limitations
The baseline knowledge of the trained role model caregivers is not available so change in knowledge cannot be assessed
Conclusion Use of RMCs achieved the 80% treatment target of malaria within 24 hours of onset of symptoms. Continuing training and supervision are necessary for correct dosage to be given. The results would be disseminated to the Kaduna state Malaria Control Program and the Department of Public Health of the Kaduna state Ministry of Health.

Sickle Cell Disease and Intervention preparedness among the Messiria people, Western Sudan.

Author(s) Dina Nagodra1, Oladele Akogun2.
Affiliation(s) 1Department of Voluntary Agencies, Khartoum State Ministry of Health, Omdurman, Sudan, 2Public Health, Parasitology, Common Heritage Foundation, Yola, Nigeria.
Country - ies of focus Sudan
Relevant to the conference tracks Social Determinants and Human Rights
Summary Introduction: An exploratory study of the knowledge and practices of the Messiria people about Sickle Cell Disease (SCD).
Methodology: Ethnographic tools and 401 structured household surveys.
Results: The cited prevalence of SCD is 28% with mortality of 20%. About 90% marry their patrilateral parallel cousin resulting in 48% bearing affected children. The communal treatment burden is US $217,138 per crisis. There is no policy regarding the SCD dilemma in Sudan. Almost 79% would accept prenuptial screening and 69% would decline a marriage offer with the prospective SCD spouse. Conclusion: There is a need to provide the foundation for planning a community-directed genetic counseling and prenuptial screening against SCD.
Background Sickle Cell Disease (SCD) is a very common health problem in Africa. It is associated with hemoglobin disorders which may be reduced by balancing disease management with prevention (or behavior change) programs. Promotion of pre-marital screening in areas where it is highly prevalent and discouraging marriages between sickle cell trait partners is a major prevention strategy for reducing the prevalence of the disease. Sickle Cell Anemia (SCA) is one of the major types of anemia, especially in Western Sudan where it is a major public health concern among the Messiria ethnic group. Parents of such children are resign to their fate and to the frequent hospital admissions with their attendant cost. Although an understanding of local knowledge, beliefs and practices is generally considered important, very little effort has been directed to this aspect of SCD management. The present study is to provide information on the local knowledge, attitude and practices about the SCD situation among the Messiria people of Western Sudan in order to understand the local perception of the problem and burden of the disease as well as preparedness to challenge it. Such understanding will be helpful in developing a locally appropriate and community-sustained intervention strategy.
Objectives The main objective of this study is to apply a mixed research methodology for documenting local perception of the burden of the disease and intervention-seeking practices about Sickle Cell Trait and Sickle Cell Disease in a typical Western Sudan community.
The specific objectives of the study are:
i. To describe and document community knowledge, attitude and practice about and towards the prevention and treatment of Sickle Cell Disease.
ii. To assess the cultural and biological burden of the disease (perceived, empirical, social and economic) at the household, community and government sphere of influence.
iii. To assess community preparedness to participate in preventive approaches towards alleviating the problem of SCD (adoption of preventive Hb electrophoresis technique; and denying marriages with Sickle Cell Trait Partner).
iv. To review and analyze current policy on SCD treatment, prevention and control in the State.
Methodology The study was carried out between June 2012 and February 2013 among eight Messiria communities in Southern Kordofan State, Western Sudan. A mixed methodology combining quantitative household survey with social research techniques was used. A thematic design matrix was developed after critical thinking and brainstorming. This approach would yield measurable indicators and variables, identify the source of information and verify the analysis technique for each of them. The study was designed in three stages with each stage preceding and providing information for the subsequent stage. Data tools prepared and pretested.The study comprised of:
1. Unstructured interviews with Health personnel and local opinion leaders about the problem.
2. Household surveys.
3. In-depth interviews with affected, non - affected, FG discussions
The Messiria population is around 507,000, which could be 4 times more but no documented data is available in Sudan. Therefore; 507,000 constituted the study population and the required sample size was 2488 which was equivalent to 401 households. Systematic stratified random sampling method was used. About 11 rohot (pools of water) camps were included in the study and 5 or 6 different camps may be found around each rahat (pool of water). Every camp around each rahat was included in the study and every odd number of household from Messiria Humr community in a camp was selected in the study. Informed Voluntary Consent was taken from every participant and Ethical Clearance was obtained from the University and Locality department.

Data were analysed in the following manner:
1. Selection and baseline data collection: through observation, in-depth interviews, focus group discussion and structured questionnaires analyzed.
2. Assessing community preparedness towards preventive techniques through structured questionnaires interviews analyzed.
3. Estimating disease burden physically, economically and socially and documenting a policy based on current strategy and anticipated outcomes through in-depth interviews and quantitative data collection and analysis.
These were then used for reviewing the local and government policy about the disease.
The qualitative data collected were transcribed appropriately and written notes in English and Arabic were compared for quality. A coding theme was prepared and analysed manually. Quantitative data was entered in Epidata and analysed through IBM SPSS. Analysis was guided by the research questions and objectives using the indicators.

Results Messiria community is divided into two main divisions, Humr and Zurug. Sickle Cell Anemia (SCA) is locally referred to as aldabas. The social worker perceives that the word aldabas means swelling which is the most obvious sign in children with SCA.
About 79% of Messiria Humr regarded aldabas (swelling of hands and feet commonly observed in children) as the most dreadful of the first three principal community health problems, affecting 49% of households with 5745 aldabas sufferers. The cited prevalence of aldabas is about 28% with male to female ratio of 1:3 (P value 0.000) and mortality of 20%; yet, no policy is established regarding SCD dilemma in Sudan. Nine of every 10 Messiria are married to their paternal uncle’s son or daughter. Culture imposes patrilateral parallel marriage as a means of preserving ancestral kinship and wealth of livestock within the family resulting in 48% bearing one or more children with aldabas. However, only 24% consider aldabas to be hereditary and 89% prefer Government health facilities for treatment. Records indicate that SCD accounted for 441 children hospital admissions per year. Estimation of the exact full cost of care and national economic burden due to SCD in Sudan is unfeasible as no such studies have been done and SCA children may be admitted more than once in a month. The burden of aldabas treatment on the Messiria community is US $217,138 per crisis with a mean of US $135 per admission compelling 27% to sacrifice their education. Care not directly related to SCD is unknown and quite higher if the additional contributions of sickle cell disease associated with reduced quality of life, uncompensated care, lost productivity and premature mortality is considered. Almost 79% would accept prenuptial screening to determine SCD status of their partner, and 69% willing would decline a marriage offer if the prospective spouse is confirmed to be inflicted with SCD or is a carrier.
"There is no any ongoing community effort or Government assistance regarding aldabas affected patients or children. The affected child often named SICKLER is neglected / ignored and never given adequate management and are repeatedly admitted, 3 to 4 times every month. It is very painful to lose 7 children in a family due to SCD. These are very precious babies and they are lost without even having understood the disease properly by the parents." Community Leader Interview.
Conclusion Sickle cell anemia disease or aldabas is regarded as the primary health problem among the Messiria people of Western Sudan with a perceived prevalence of 28% and a health burden of $135/ hospital admission (or communal burden of US$217,138). The disease is so well entrenched within the culture that there is a causation theory, beliefs and practices surrounding it. Although the people do not appreciate the association between the practice of patrilineal marriage and aldabas, 83% would accept prenuptial screening to determine their proposed spouse’ sickle cell status and 69% would decline a marriage offer to a prospective spouse with confirmed sickle cell disease or carrier. Healthy marriage Program (Premarital screening) introduced in 2004 in Saudi Arabia resulted in decreasing consanguineous marriage from being 89.6% in 2004 to 62% in 2007. The average cost of treating one person with Sickle cell Anemia in Sudan is US $2695 whereas screening with Hemoglobin Electrophoresis done prior to marriage may cost around US $7.30. Large differences in estimated approximate cost of treating and preventing SCD in Sudan should open up a way for Control and Prevention Programme for SCD similar to Healthy Marriage Programme. The fact that 92%, particularly youths and adults, were eager to participate in community intervention against the disease provides a unique opportunity to commence a community-driven approach to awareness-raising, prenuptial screening and counseling among the Messiria. Community directed intervention (CDI) approaches (made popular by the African programme for onchocerciasis control (APOC) and currently used for the increasing access to culturally appropriate intervention services) are most likely to change the current status of sickle cell disease among the Messiria if introduced at the earliest possibility. The CDI approach that has been made popular in the control of Malaria in nomads in Nigeria can be adopted to control SCD in nomads in Sudan.
In the absence of SCD Policy a Control or Prevention Programme (CDI) can be approached to optimise results with prolonged sustainability.

Irregular migration: malaria re-introduction in elimination settings.

Author(s) Kolitha Wickramage1, Sharika Peiris 2.
Affiliation(s) 1Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka, 2Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Infectious Diseases
Summary Irregular migration in the form of human smuggling and human trafficking is recognized as a global public health issue. Beyond the criminality and human rights abuse, irregular migration plays an important, but often forgotten, pathway for malaria re-introduction. We describe 32 cases of Plasmodium falciparum that were detected in 534 irregular migrants returning to Sri Lanka via failed human smuggling routes from West Africa in 2012, who contributed to the largest burden of imported cases in Sri Lanka which had entered elimination phase. Active surveillance of the growing numbers of irregular migrant flows becomes an important strategy as Sri Lanka advances towards goals of malaria elimination.
Background Sri Lanka is heralded as a ‘success story’ for malaria control in Asia having succeeded in reducing malaria cases
by 99.9% since 1999 and is aiming to eliminate the disease entirely by 2014. Since the end of the protracted civil conflict in 2009, there have been an unprecedented number of migrants leaving Sri Lanka to countries such as Australia, Canada and the UK via ‘irregular migration’ routes. An irregular migrant is defined as someone who, owing to illegal entry or the expiry of his or her visa, lacks legal status in a transit or host country. Irregular migration takes many forms, ranging from human smuggling to trafficking of persons for purpose of exploitation. Globally, the numbers of undocumented cases have increased despite spending on enforcement measures at the major destination countries.
Objectives This report focuses on a migrant flow of major importance for malaria importation that, until recently, has received little attention from public health authorities.
Methodology From the end of 2011, local and international law enforcement authorities intercepted people-smuggling operations from Sri Lanka to Canada across nine West African nations: Togo, Benin, Guinea, Sierra Leone, Mali, Ghana, Senegal, and Mauritania. In close coordination and partnership with the Governments of Sri Lanka, Canada and West African nations, IOM assisted these irregular migrants who were intercepted or detained, and returned to their place of origin. From January to December 2012, all irregular migrants returning from West African countries were subjected to malaria screening upon arrival at the Bandaranayke International Airport (BIA) in Sri Lanka. Screening was conducted on site using the rapid diagnostic test kit CareStart™ Malaria HRP2/PLDH, with 98% sensitivity and 97.5% specificity for Plasmodium falciparum, and microscopic examination of blood smears, collected at the airport and performed at the national reference laboratory. Health personnel from the airport medical unit, Anti-Malaria Campaign (AMC) and IOM officials were involved in facilitating the on-arrival screening process. Under a directive from the Anti-Malaria Campaign, repeat RDTs were carried out for all returnees at the district level within one week of their arrival at home destination. This intensive follow-up was carried out with the collaborative efforts of both the AMC and IOM field staff.
Results Of the total number of returnees screened (n=534), 32 were positive for P. falciparum. Nearly two thirds (n=19) were identified at the point of entry at the BIA and 13 during district level follow-up. The total number of malaria cases from irregular migration routes accounted for 76% (32/42) of the total number of P. falciparum cases detected in Sri Lanka in 2012. This route contributed to 46% (32/70) of the total number of imported malaria cases in the same year. Imported cases overtook indigenously acquired cases of malaria for the first time in Sri Lankan in 2012, contributing to three-quarters of the total malaria burden (70/93). The largest number of irregular migrants (n=17) had returned to Jaffna district which has the highest API of >0.2 to 0.3 in comparison to other districts in Sri Lanka.
Conclusion Malaria incidence in returnees from source countries has proven to be a sensitive predictor of malaria risk, particularly where there is sub-national transmission. The fact that the largest number of migrants returned to districts with the highest API indexes reported nationally is also significant. Re-introduction and risk of spreading the parasites occurs when there is a long-term return into areas of endemicity with presence and prevalence of the mosquito vector. For this reasons the close follow up and monitoring performed by the AMC and IOM field based teams is an important strategy. Unlike other categories of inbound migrants, such as tourists, who may also import malaria to the country, returning Sri Lankan citizens from endemic areas are more likely to be exposed to mosquito bites and hence are more likely to contribute to the spread of malaria upon return to their homes within locally endemic regions. Other inbound migration categories include: returning Sri Lankan labour migrant workers, Sri Lankan armed forces personnel from UN peace keeping missions, and returning students. The attack rate for malaria in this migrant group using irregular modes of travel is considerably high (sixty cases per 1,000) when compared to the risk of contracting malaria for regular travellers returning from West Africa at three per 1,000. For the migrants themselves, their ‘illegal’ status and clandestine nature of movements enhanced health vulnerability, including having little or no access to health care in transit countries.

Partnership with Ministries of Health for Improved Malaria Programme Management in Southwestern Nigeria

Author(s) Olusimbo Ige1, Taiwo Ladipo2, Veronica Iyamabo3
Affiliation(s) 1Program management, Malaria Action Program for States, Ibadan, Nigeria, 2Primary Health Care and Disease Control, Oyo State Ministry of Health, Ibadan, Nigeria, 3Program Management, USAID/MAPS, Abuja, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary The MAPS project has been working with the Ministry of Health using a holistic capacity building approach to build capacity of health managers in malaria programme management to ensure an effective and coordinated malaria program. State officials now have a more accurate overview of performance, through proper planning and implementation assessment with skills, in order to work towards harmonisation, improved resource allocation and effectiveness. With greater attention to supply chain management, the flow of malaria commodities has improved and health managers within the States now have the technical and managerial skills to implement the state operational plan for malaria control.
What challenges does your project address and why is it of importance? Several strategic interventions for malaria control have been implemented in Nigeria since the launch of the Roll Back Malaria Initiative. However, progress towards set targets has been slow and the National Malaria Strategic Plan has recognized the need to strengthen program management at all levels to achieve the desired impact. This implies that effective implementation and enhanced efficiency can only be achieved through collective gap analysis, planning, technical and managerial coordination. The National strategy recognizes programme management capacity building as a cross-cutting issue that transcends each and every one of the National and State program outputs based on rapid appraisal of malaria control programme. Consequent to this assessment, a capacity building training package was developed with the National Malaria Control Programme to address program management using a standard set of training materials appropriate for Nigeria and consistent with national policies. This is expected to ensure that all involved in the management of malaria control at Federal, State, LGA or service delivery points understand their roles and responsibilities to improve program management and service delivery.
How have you addressed these challenges? Do you see a solution? In response to the management challenges identified in the state, the USAID funded Malaria Action Program for State (MAPS) instituted a 4 year project to support health managers at the health facility, local and state government levels in malaria programme management. The project approach was, in providing technical assistance to the State Ministry of Health(SMoH) and State Malaria Control Programme (SMCP), to facilitate the development of a State-led, costed, holistic operational plan for malaria control. The plans set out to articulate State priorities and formed the basis of a rapid scale up of interventions to achieve the ambitious targets for malaria control as articulated in the Federal Ministry of Health’s “Road Map for Malaria Control in Nigeria 2009 – 2013. This included supporting SMoH to harmonize efforts of donors and funding agencies around State plans, and providing direct support to the delivery of effective malaria prevention and treatment through the public and private sectors. In addition to operational planning support, MAPS supported the State to develop a Capacity building/Training Plan and integrated supportive supervision/On-the-Job Capacity Building implementation plans.
A significant percentage of the interventions for malaria control are driven by various partners and funding agencies who are inter-dependent. The State was supported to develop state specific plans in a participatory process involving stakeholders at all levels. While the State ensured synergy of strategies across sectors and partners to prevent duplication and ensure equitable distribution of activities across the State, partners helped build individual and team capacity through in-depth training events, coaching and mentoring. State trainers were drawn from the state officers who remained within the health system and participated in integrated supportive supervision and on the job capacity building of trainees. The efficiency and effectiveness of existing institutional structures and line systems such as procurement and supply chain management, health management information system and coordination frameworks were strengthened through process optimization and improvements in functionality and relationships. The MAPS project supported Government in its leadership role by seconding an experienced programme manager to work from the ministry of health to help strengthen management skills of the SMCP team.
How do you know whether you have made a difference? The State has successfully progressed from a vertical project mode to a horizontal state malaria program mode with the commitment and buy-in of the key players supporting malaria control efforts in the State. The first Annual Operational Plan performance review revealed that overall programme performance was 59%. Achievement of planned activities for health systems strengthening was 73.7%, malaria prevention 71.4%, advocacy, communication and social mobilization 64.3% and malaria diagnosis and treatment 61.1%. Lowest performance was in monitoring and evaluation at 33.3% and procurement of prophylactic drugs for pregnant women 0%. Proxy indicators to assess state perfomance relative to national targets showed that the number of women who received two doses of malaria prophylaxis in pregnancy increased from 23.9% at baseline to 50% thorough the engagement of the private sector. Functional village development committees increased from 25% to 46.7% as a result of intense community mobilization activities. Percentage of state malaria budget released increased from 24.2% to 81.5% which is ascribed to successful budget justification and advocacy for greater funding. Timely health facilities reporting and complete data increased marginally from 50%-59.4% due to staff shortage and the need for service providers to double as data clerks. Stock out of malaria commodities reduced from 100% to 79% mostly due to better quantification and commodity supply by partners. Regular supervisory visits are conducted by the state and local government with on the job capacity building to enhance performance in service delivery and internal management and administration.
Have you or the project mobilized others and if so, who, why and how? A wide range of stakeholders and key players are involved in Nigeria’s efforts to ensure an effective malaria control program. These include public and private providers of care, the donor community, civil society organizations and the community. The state was supported to put in place systems, through which these interrelated, or interdependent components work together efficiently and effectively. Village development committees were mobilised to support primary health facilities through local resource mobilization, awareness creation and monitoring leakage of malaria commodities. Heads of primary health care departments of the local government were trained to provide supportive supervision and on the job capacity building to improve performance at service delivery points. Technical and logistic support was provided for the multisectoral malaria technical working group to address implementation challenges. Partners activities were coordinated through regular partners meetings to ensure that partners did not diverge from the state plan. The capacity of the SMCP teams was enhanced for internal coordination of activities and to provide the desired leadership for all key players to work together in a synergistic manner.
When your donor funding runs out how will your idea continue to live? MAPS’ capacity building efforts recognize sustainability planning as an integral part of its planning process. There are inbuilt mechanisms for exit that ensure that gains achieved are not only sustained but improved upon. For this reason all aspects of the program activities take into cognizance the vital role of stakeholder participation and ownership across the program outputs. As much as possible, every opportunity to provide technical assistance to the State malaria programme team was through hands-on support and on the job capacity building with activities deliberately designed to enhance stakeholder inclusion, participation, buy-in and ownership. Capacity of the SMCP has been built for resource mobilisation, advocacy, communication and social mobilization, coordination of key players in malaria control and engagement with private providers. The increasing percentage of malaria control activites are state funded. It is anticipated that the program shall continue to support the hand over process of continuous improvement for capacity building in the short run through technical assistance and hand holding as SMCP coordination and technical capacity improves. The active involvement of the personnel from SMCP in the planning and implementation of program activities, such as the program management training roll out, and other technical areas will provide the opportunity for 'learning by doing' with a resultant rise in confidence levels of key health staff and the establishment of a pool of technical resources at State and local government levels. This state technical resource pool is likely to sustain the current effort outside the geographical scope and lifetime of the program.

Strengthening Referral Linkages for Malaria in Nigeria.

Author(s) Chinazo Ujuju1, Ernest Nwokolo2, Jennifer Anyanti3, Chinwoke Isiguzo 4, Onoriode Ezire 5, Ifeanyi Udoye6, Wellington Oyibo7
Affiliation(s) Research and Evaluation Division, Society for Family Health, Abuja, Nigeria, Global Fund Malaria project, Society for Family Health, Abuja, Nigeria, Technical Services, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, Research and Evaluation, Society for Family Health, Abuja, Nigeria, College of Medicine , University of Lagos, Lagos, Nigeria, 8
Country - ies of focus Nigeria
Relevant to the conference tracks Education and Research
Summary Lack of referral linkage from PPMVs to health facility may have contributed to increased mortality due to the home management of malaria illnesses. This study showed that of the 461 clients who were tested for malaria at PPMV outlet, 88 tested positive while 365 who tested negative were referred to a nearby health facility for further diagnosis and treatment. Only 18 referral cards were retrieved from health facilities. There is a need to integrate PPMVs into the national referral system to ensure appropriate treatment for severe malaria, other febrile infections and reduce morbidity and mortality due to home management of illnesses.
Background In Nigeria malaria remains a major cause of morbidity and mortality among children under 5 years of age. Most of the early treatments of fever and malaria occur through self medication with anti malarial bought over the counter from drug vendors. The Nigerian health system provides for three tiers of health care: primary, secondary and tertiary. The primary health centers should be the point of first contact for patients from where they are referred to other levels of health care. This is far from reality as Private Patent Medicine Vendors (PPMVs) found across Nigeria are the first point of call for malaria treatment. Global malaria initiatives highlight the potential role of PPMVs in improving access to early effective malaria treatment. Parasitological diagnosis before administration of anti-malarial treatment has recently been recommended by WHO for everyone presenting with symptoms compatible with malaria at all level of the health system.
Objectives In Nigeria, more than half of household members sought treatment for fever at PPMV shops. Anecdotal evidence suggests that PPMVs do not refer clients to the health facility. There is a need to explore whether PPMVs would actually refer clients who accessed the malaria rapid diagnostic test (RDT) from their outlet to a health facility. This study was conducted to determine whether PPMVs referred clients who visited their outlet for malaria diagnosis to a health facility.
Methodology A cross-sectional pilot study to explore RDT feasibility and use was conducted in six states (Adamawa, Cross River, Enugu, Lagos, Kaduna and F.C.T) of Nigeria, each representing a geo-political zone of the country. About 20 registered PPMVs were selected from each of the selected states. Multi-stage purposive sampling was used to select the state and the PPMVs that participated in the study. These outlets were grouped into clusters of 6 per state. Two days of curriculum based training was conducted for the selected PPMVs. Nurses and laboratory personnel were recruited to monitor the PPMVs as they conducted the malaria RDT. The RDT test was conducted for clients aged 18 years and above after obtaining informed consent to participate in the study. Clients who tested negative were referred to a higher health facility identified within the cluster for further diagnosis and treatment, while those who tested positive for malaria were offered a full course of medicine according to Nigerian malaria treatment guidelines. During the study, referral was tracked in two states; Kaduna and Lagos state. Ethical clearance was obtained from the National Health Research and Ethics Committee prior to commencing the study. Data generated from the study was entered and verified using data management software, CSPro 2.6. The data was subsequently imported into SPSS (version 18) for statistical analysis. Descriptive statistics were used and data for the two states where referrals were tracked were analysed for this paper. Socio economic status of the respondents was calculated based on reported household’s ownership of consumer goods, dwelling characteristics, source of drinking water and sanitation facilities. To construct the index, each asset was assigned a weight (factor score) generated through principal component analysis, which was divided into quintiles from one (lowest) to five (highest).
Results 461 clients who visited PPMV outlet in Kaduna and Lagos received malaria RDT as confirmatory diagnosis of their illness. The proportion of males in the population was slightly higher (58%) than the proportion of females (42%). More than half (69%) of the respondents were married. There was variation in the educational attainment of respondents who participated in the survey. While about 48% had attained a secondary level of education, about one in four (23%) of the respondents had attained a higher level of education. A higher proportion of respondents were aged between 25-34 years (36%) and ranked as average socio economic status (26%). The reported symptoms experienced by most of the respondents can be associated with malaria illness. These symptoms include fever (55%), headache (77%), joint pains (54%), tiredness (39%), bitter taste (27%) and poor appetite (25%). About 88 clients tested positive for malaria while 365 who tested negative were referred to a nearby health facility for further diagnosis and treatment. A few visited the health facility for further diagnosis and treatment and 18 referral cards were retrieved from the health facilities.
Conclusion There is a need to integrate PPMVs into the national referral system and strengthening referral of client from drug store outlets to a higher quality of care. There is a need to implement malaria RDT among PPMVs and ensure that this group of health workers is trained and their activities monitored effectively to ensure proper management of malaria illness at the community level. It would also provide avenue for PPMVs to refer febrile clients who tested negative to malaria RDT to a health facility for further diagnosis and treatment. It would reduce the possibility of parasitic resistance as a result of repeated home treatment of unconfirmed malaria cases. Hence, this would increase clinical effectiveness of recommended drug regimen, Artemisinin-based Combination Therapies (ACTs). It would strengthen the referral linkages for treatment of severe malaria, treatment for other febrile infections and ultimately reduce the morbidity and mortality due to home management of illnesses.

The use of Insecticide Treated Nets among Pregnant Women in Nigeria.

Author(s) Martina Ezeama1, Felix Ezeamah2
Affiliation(s) 1Nursing science, Imo State University Owerri Nigeria, 2Private Practictioner, Ndukwu Hospital Amaifeke Orlu Imo State , Owerri, Nigeria,
Country - ies of focus Nigeria
Relevant to the conference tracks Education and Research
Summary The study was carried out to determine factors militating against utilization of insecticide treated nets by pregnant women. This was based on the background of the study which reflected low usage of ITNS by pregnant women in the study setting. A total 201 pregnant women were interviewed using questionnaire. Overall results showed that majority were aware of the insecticide treated net but usage was low. Most respondents reported experiencing excessive heat under net and were afraid of the chemical used in producing the net. Findings suggest the need for an intensive public enlightenment campaign to dispel fear of chemicals used in treating the ITNs and heat produced by ITNs to encourage use among pregnant women.
Background Malaria infestation during pregnancy has been associated with persistent high maternal and childhood morbidity and mortality among pregnant women especially in Nigeria were malaria is highly endemic. Malaria accounts for 11% of maternal death, 70% of morbidity in pregnant women and is responsible for 63% of all clinic attendances in Nigeria. It causes 25% of infant mortality and 30% of all childhood deaths. Malaria during pregnancy accounts for up to 15% of maternal anemia and 5-14% of low birth weight (Safe motherhood fact sheet 19). As a result the World Health Organization (WHO) launched Roll Back Malaria (RBM) initiative in 1998 with a major focus on the prevention & management of malaria during pregnancy by using insecticide treated nets (ITNs) among other measures. Although malaria is preventable, easily treated and curable, it assumes a deadly dimension when it occurs in pregnancy and it is not promptly managed.
Objectives The broad objective of this study was to determine factors militating against the utilization of insecticide treated net among pregnant women attending the antenatal clinics (ANC) in a tertiary health facility in Imo State Nigeria. Other objectives include:
 To determine the level of awareness of insecticide treated nets among pregnant women.
 Ascertain the frequency of the use of insecticide treated nets among pregnant women.
 Determine the measures that promote the use of ITNs by pregnant women.
 Determine the influence of socio-demographic characteristics of pregnant women towards the use of insecticide treated nets.
Methodology The study was descriptive in nature and because of its focus on the clinics within the teaching hospital, was a case study of the factors militating against the utilization of insecticide treated net among pregnant women attending antenatal care in teaching hospital Orlu, Imo State Nigeria. In the course of clinical experience at the antenatal clinic (ANC) and community posting, the researcher noticed that the usage of insecticide treated nets (ITNs) among pregnant women is still not encouraging despite awareness being created about the importance of this cost-effective and efficient method of malaria prevention and control.
The researcher conducted a study to ascertain the level of usage of insecticide treated mosquito nets (ITNs) among pregnant women attending antenatal (ANC) in Imo state teaching hospital and also the factors militating usage by asking the following questions:
 What is the level of awareness of insecticide treated nets among pregnant women.
 To what extent are insecticide treated nets used by pregnant women.
 What are the factors influencing the use of insecticide treated nets among pregnant women.
 What are the measures that could promote the use of insecticide treated nets by pregnant women.
 What is the influence of socio-demographic characteristics of the respondents towards the use of insecticide treated nets. The study was approved by the hospital Human Research Ethic Committee and informed consent was obtained from the patients. The sample size used was based on a simple proportion and prevalence of 13% from previous study. Data were collected on a pretested research administered structured questionnaire and analyzed using SPSS version 16 statistical software. Information collected included socio-demographic data, level of awareness and usage of ITNs, factors militating against usage and measures that could promote the use of ITNs by pregnant women. Descriptive statistics was obtained for quantitative variables while frequencies and percentages were used to present categorical variables. Chi Square statistical tests were carried out where applicable with the level of significance set at p < 0.05.
Results A total of 201 pregnant women were interviewed. Their ages ranged between 18 and 50 years with mean of 27% years. The majority 191(95%) were married, 150 (74.6%) had attained tertiary education and 137(68.2%) were multigravida while 64(31.8%) primigravida, 155(77.1%) were aware that insecticide treated nets (ITNs) could prevent malaria in pregnancy, but less than half 91(45.39%) of them were using ITNs. Their major source of information about ITN's was at the ANC. 71(35.3%) of pregnant women were in possession of ITNs. Constraints to the use of ITNs were 98(48.8%) and included not using ITNs because of the heat they experienced under the ITNs, 64(31.8%) reported fear of the chemicals used in treating the net, 24(11.9%) indicated non-availability of ITNs and 17(8.5%) lacked knowledge on how to install the nets. Measures to increase the use of ITNs by respondents included: the majority 91(45.3%) indicated the increase in ITNs awareness campaign, 74(36.8%) increase availability of nets, and 46(22.9%) indicated the need for increased education on how to install the net. There was no statistical significance between marital status (P=0731, Parity (P=0.538), level of education (P=0.269) and usage of ITNs.
Conclusion Although there was a high awareness about ITNs, the use of ITNs was low. Experiences of excessive heat and fear of the chemical used in treating the nets are major constraints. Intensive public enlightenment to dispel misconception about fear of the chemical used in treating the net, excessive heat and availability of ITNs may encourage the use of ITNs among pregnant women. The study is significant as it has pointed out factors that militate against the use insecticide treated nets by pregnant women. This study will equip health personals or care providers with more knowledge on how to create more awareness to the populace on the use of ITNs and will also help government and policy makers through supplying the populace with enough ITNs thereby reducing high mortality and morbidity rate. It is recommended that the major challenges of low usage such as fear of chemicals, excessive heat and inadequate supply be seriously addressed to encourage the use of insecticide treated nets by pregnant women to prevent malaria during pregnancy.

Alternative Approaches to New Drug Development: Two R&D Initiatives

Author(s): Philippe Desjeux1, Bernard Pécoul2
Affiliation(s): 1Senior Programme Officer for Disease Control, iOWH, San Francisco, CA, USA, 2Executive Director, Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
Summary (max 100 words): Philippe Desjeux: The illnesses of invisible people usually stay invisible. This statement is reflective of the limited attempts to develop new treatment regimens for neglected diseases. Most of these diseases are preventable or curable, but often strike poor and marginalized people living in remote rural areas. Development of effective, safe and affordable drugs for neglected diseases is an urgent need. Many of the available drugs are not adequate: they are either toxic, difficult to administer or too expensive. Therefore, investment in drug research and development for neglected diseases is crucial to bridge the gap between the pharmaceutical R&D model and the unique requirements of the global health field, where the traditional market system does not work. Meeting the challenge: The Institute for OneWorld Health (iOWH) is the first non-profit pharmaceutical company in the USA, formed to address the 10/90 gap in health R&D. Our mission is to develop safe, effective and affordable new medicines for people with infectious diseases in the developing world. OneWorld Health’s core competencies lie in pharmaceutical product development. Our in-house teams identify development leads through partnerships with industry and universities. Together, iOWH works to optimize existing drug candidates, complete preclinical and clinical investigation needs, secure quality manufacturing of developed products, and obtain the necessary regulatory approvals to bring the product to the beneficiaries. Concurrently, iOWH collaborates to devise product delivery and access strategies with relevant stakeholders, which include governments, donors, and international NGOs. These Public-Private Partnerships (PPPs) allow for a more rapid development of new drugs by utilizing complementary skills and resources. iOWH’s current pipeline includes programmes for visceral leishmaniasis (VL), malaria, and diarrheal disease. Paromomycin, for the treatment of VL, is currently the most advanced pharmaceutical product for iOWH. After the completion of a Phase III clinical trial in Bihar, India, for paromomycin, iOWH has submitted the dossier for regulatory approval in India. iOWH’s product selection criteria is designed to meet the needs of the poor in the developing world. In addition to customary selection criteria such as scientific merit, probability of success, clinical and regulatory developmental path, iOWH examines the unmet medical needs in the developing world, cost-of-goods, and mechanisms of delivery, including the endemic country’s infrastructure. These criteria allow us to devise products that will be both appropriate for communities with high disease burden and affordable and accessible to the population in a manner which is sustainable. Conclusions: iOWH strives to provide a flexible and innovative vehicle to engage both the pharmaceutical and biotech industries, as well as public health organizations in global health product development. Through partnerships and collaborations, by adhering to the highest ethical standards for clinical research, and by utilizing the scientific and manufacturing capacity of the developing world, OneWorld Health can deliver affordable and effective new medicines where they are needed most.Bernard Pécoul: The majority world shoulders a disproportionate burden of disease and has few drugs with which to respond to this challenge. In 2005, Africa, Asia (excluding China)- Pacific, and Latin America, which housed 63 per cent of the world?s population, had a mere 11.7 per cent share of the world's $602 billion pharmaceutical market. This stark disparity is echoed in the dearth of research funding dedicated to the diseases prevalent in developing regions. Over the past 30 years, only 21 of the 1,556 new chemical entities marketed between 1975 and 2004 were for tropical diseases and tuberculosis. Millions continue to suffer from diseases such as tuberculosis, malaria, leishmaniasis, sleeping sickness, and Chagas disease. Regrettably, these diseases target impoverished populations with immune systems already weakened by hunger and other diseases. If patients are to have any hope of survival they urgently need new, more effective treatments for these diseases, as the few available drugs are compromised by poor efficacy, toxicity, long courses of treatment, parenteral administration and resistance to the parasite.
Meeting challenges: The Drugs for Neglected Diseases Initiative (DNDi), a not-for-profit drug R&D initiative, is seeking to research and develop new drugs for these neglected diseases. Existing treatments for these diseases are often inadequate and ineffective and patients need new medicines urgently. Founded by a group of 5 renowned medical research organizations including the Indian Council for Medical Research, the Oswaldo Cruz Foundation from Brazil, the Kenya Medical Research Institute, the Ministry of Health of Malaysia, and the Pasteur Institute, as well as the WHO’s Special Programme for Research and Training in Tropical Diseases, and Médecins sans Frontières (MSF), DNDi presents an alternative approach to drug development. It facilitates north-south and south-south collaboration, capacity building, and knowledge sharing among researchers, scientists, industry, and governments.
Conclusion (max 400 words): DNDi's current portfolio of 20 projects focuses on discovery and development projects for malaria, leishmaniasis, sleeping sickness, and Chagas disease. Its alternative approach will make new drugs available for the treatment of neglected diseases within the next decade. It is already on the road to success with its two fixed-dose artesunate-based combination therapies scheduled to be delivered to patients by the end of 2006.

Public Responsibility in Research and Development Partnerships

Author(s): Bernard Pécoul1
Affiliation(s): 1Executive Director, Drugs for Neglected Diseases Initiative, Geneva, Switzerland
Key issues: A fatal imbalance exists in the investment in new drugs for neglected diseases, such as sleeping sickness and leishmaniasis, versus diseases prevalent in wealthy countries. From 1975 to 2004, of the 1,556 new drugs marketed only 21 just over one percent were for infectious tropical diseases and tuberculosis, in spite of the huge need. So, not only are the poor in developing countries disproportionately suffering from curable diseases, but their needs are woefully unmet by the existing model of drug development.
Meeting challenges: This disparity is now widely acknowledged and is being addressed by new research as well as new initiatives. Several research initiatives have been set up in the last 5 years to address this issue, e.g., the Drugs for Neglected Diseases Initiative (DNDi), Medicines for Malaria Venture, and TB Alliance. The challenge here lies in procuring full financial and political support from governments so that the initiatives can achieve their goals of developing and delivering desperately needed, new, effective, needs-oriented medicines to neglected patients. Currently, only 16% of funding for these initiatives comes from governments, while almost 80% comes from philanthropic organisations. This is unsustainable. The importance of public responsibility in providing equitable access to these health tools is an essential part of DNDi’s message as a not-for-profit research organisation that works in close collaboration with public and private partners in both developing and developed countries. The need for increased public support of essential innovation for neglected diseases is a growing global concern. Governments are being urged to lose no more time in supporting new funding mechanisms for neglected disease research and development and to create a favourable environment to stimulate R&D. A handful of Innovative Developing Countries such as India, South Africa, Brazil, etc. are becoming more proactive in the field of drug R&D. Yet innovation in drug discovery for neglected diseases remains a critical gap.
Conclusion (max 400 words): This message has recently gained ground at the WHA 2006, which voted to adopt a resolution to establish a global strategy and a plan of action directed at public health, innovation and essential health research. These are positive steps towards addressing the greater problem of R&D for neglected diseases. Much more remains to be done.

Working in Partnership to Improve Child Survival: Red Cross Support to the Ministry of Health During the Mali Integrated Campaign

Author(s): M. M. Erskine1, D. Adama*2, J. Peat1, O. I. Toure3
Affiliation(s): 1Health and Care Department, International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland, 2Governance Committee, Mali Red Cross Society, 3Ministry of Health, Bamako, Mali
Keywords:

Child survival, Mali, Ministry of Health, Red Cross, integration, vaccination, malaria, civil society, partnership

Background:

In 2007, the Malian Ministry of Health worked with its financial and technical partners to plan and implement one of the largest child survival campaigns to date. The Mali Child Survival campaign targeted over 2.8 million children under the age of five throughout the country. In one week, children received vaccination against measles and polio, supplementation with vitamin A, deworming treatment and long-lasting insecticide treated nets for malaria prevention. Together, the integrated package addresses a number of diseases that contribute to a high disease burden among African children.  A central part of the campaign planning was the communications and social mobilization strategy, to ensure that all segments of society were informed and motivated to promote and participate in the activities. One organization that played an important role was the Mali Red Cross Society, which trained 2,500 volunteers in six regions of the country. The partnership between the Malian Ministry of Health and the Malian Red Cross is an example of how civil society organizations can play a supportive role to improve healthcare delivery. The Malian Red Cross continues to play this auxiliary role for community- and household-based promotion of routine health services to work towards sustaining the high coverage rates attained during the integrated campaign.

Summary/Objectives:

The objectives of the Integrated Child Survival campaign in Mali were to reach more than 95% of children with measles vaccination and more than 80% of children with all other interventions. Additional objectives included ensuring adequate social mobilization to persuade caretakers of the importance of the campaign, undertaking micro-planning for logistics and management of all campaign supplies and implementing an effective system for monitoring and supervision during the week of activities. The campaign will be evaluated in late January/early February using PDA technology.

Results:

Results for this presentation are divided into two components, one related to process and the other related to impact. In terms of process, a strong collaboration and cooperation existed amongst partners, with the Ministry of Health leading and coordinating all activities. Strong relationships with civil society organizations, including the Mali Red Cross, allowed for successful mobilization of parents and organization of sites for the child survival campaign. The role of the Red Cross as a civil society organization is highlighted here to emphasize the need for community-based volunteers to ensure that the most vulnerable, and the most resistant, households receive these necessary interventions. In terms of impact, data were collected daily during the seven days of campaign activities and information was relayed from the health centre level to the national level through telephones, computers and radios. The results of the campaign indicate that all objectives set at the outset of the campaign were not only reached but also exceeded. A cluster survey, using PDA technology, will be used to confirm the daily tally results from health facilities with household level data regarding under fives and their participation in the campaign.

Lessons learned:

The Mali Integrated Child Survival campaign was an enormous undertaking for the country. The importance of partnership, at both international and national levels, is highlighted as a major reason for the success of the initiative. Within the vast country, the contribution of community-based organizations is central, as demonstrated by the role of the Red Cross in mobilizing caretakers before, during and after the campaign. The importance of ongoing messaging to parents to ensure that health facilities are accessed for routine vaccination services, and to contribute to positive behaviour change at the household and community level, are retained as major lessons for sustaining achievements.