According to a study conducted by Plan Benin in the Couffo and Atacora districts in 2006, malaria was found to be the principle cause of morbidity and mortality among infants and pregnant women. In the Couffo district, malaria was found to be the most frequent infection occurring in children under-five (39 percent). In addition, the Africare study found that 34.7 and 35.3 percent of children and mothers sleep under bed nets impregnated with insecticide, respectively. The same study also found that the majority of women’s groups, men, youth, local leaders, and Health Center Management Committees (HCMC) do not recognize the symptoms common to malaria. For example, very few focus groups mentioned convulsions as a serious symptom of malaria. Moreover, in Couffo, 86 percent of mothers seek counseling and treatment in their homes rather than seeking care and support in a health facility. Mothers were found to only seek care outside of their homes if they think that they require better medications or if the expected results from home-based treatment are slow to manifest. Due to the limited human resources for health, the one health agent (the average coverage per village) located at the periphery of villages is unable to respond to the health needs of all the children in the villages. As a result, it is essential that community members themselves play an intermediary role, i.e., form the bridge between the health center and the community to promote key practices. Those community actors constitute a critical piece of the system, also responsible for assisting mothers and caretakers in the process of sustaining those behaviors.
Was a pilot – using the approach at community level to address the problem of malaria Area encompasses 11 health centers and a population of ~30,000
Training of community-based volunteers in community management of malaria and C-IMCI
Measured through home visits by the QITs – bimonthly Quarterly monitoring by monitoring committees Also, each QIT kept a record book to document home visits, referral of serious malaria cases, and provision of Coartem
Many levels of supervision, support, and sharing: QITs Each team was made up of diverse social strata of the community—CHWs, mothers of children, opinion leaders, members of the Health Center Management Committees (HCMCs), traditional healers, and members of the children’s village committees for development (CVCD). In each village, Quality Improvement Teams (QITs) held bimonthly sessions to report monitoring data and project progress to the community and village assembly. Inter-QITs Learning sessions for QITs from different villages were conducted each quarter to collectively share experiences and best practices, thereby encouraging constant improvement in village implementation strategies and overall program effectiveness. Each quarter’s learning session was held in a different QIT’s village to allow the other teams to witness firsthand the innovative methods they had developed. Moreover, by collecting data on common indicators, the teams were able to assess their effectiveness relative to one another, thereby fostering a competitive and entrepreneurial spirit. Coaching – Animators Animators from partner NGOs visit every village at least once a month to coach in teamwork, problem solving and monitoring by the village of progress being made, using indicators and data collection methods feasible for the education level of the team members. Coaching – Heath district staff The coaching team of the health district AD&D has provided technical support to the CHWs through training and monitoring. The health agents at the peripheral level played a semi-supervisory role for the CHWs and facilitated community referrals and counter-referrals for serious malaria cases detected at the community-level. Advisory committee An advisory committee whose members have been meeting quarterly for monitoring purposes and to make recommendations to the project implementation team as part of the process of continuous improvement, and to report interim results. The advisory committee is made up of representatives from the national and international NGOs, children from the CVDCs, health agents from the HSD, health districts covered by the project, and staff from the project municipalities. Advisory role – Plan Benin Plan Benin’s technical team (Health advisor and coordinator and the project coordinator) played an advisory role to the QIT through formative supervision, conducting capacity building and regular refresher sessions, etc.
Results are from the end of the pilot phase – March/April 2009, data from 19 pilot villages The final evaluation measured utilization through three proxy criteria: presence of an LLIN which is 1) suspended over the sleeping location, 2) of a recommended brand to ensure quality, and 3) untorn. Significant improvements in LLIN utilization were achieved: The percentage of mothers and children under five found to sleep under an LLIN in the 24 hours preceding the survey more than doubled over the project period, increasing from 34% at baseline to 70% at the project’s conclusion. For mothers and their infants zero to 11 months, the percentage utilizing LLINs at the end of the project was even higher at 80%. Moreover, 90% of mothers of infants aged zero to 11 months consistently slept under LLINs during their last pregnancy. The positive outcomes were likely due to the awareness activities organized in the communities during the weighing sessions and in the maternity hospitals during antenatal consultations. Additionally, the QITs, which conduct unannounced night visits to households to make sure that LLINs are used, have contributed to better practices by reinforcing behaviors and addressing individual barriers. However, there is still a gap between knowledge and access and utilization. Although 95% of mothers of children under 5 possess bed nets, and an equal percentage are aware of the importance of using bed nets to prevent malaria, only 70% (of their children) slept under a bed net the previous night. Two reasons for non-use of bed nets in the households that possessed bed nets were related to heat and the nets being considered dirty.
Home-based care and management is considered appropriate if the mother of a child aged under-five suffering from malaria has purchased Coartem and complies with the directed dose according to the age of the child. The evaluation found that the percentage of children under-five that suffered from fever two weeks preceding the survey and who were appropriately treated for malaria within 24 hours at home, increased from 25 percent to 55 percent (target rate – 40 percent) . Seventy five percent of mothers of children under-five reported having purchased Coartem for their child. Twenty percent indicated that they had not accurately followed the dosage directions provided by the CHWs (i.e., they did not did not administer the directed dose within 24 hours after the onset of fever and for three days). The results can be attributed to: awareness and capacity building activities Plan Benin coordinated with suppliers and the MoH to have Coartem made available to CHWs for distribution in the project villages Although the project achieved its objective related to the proper home-based care and management of fever, the following areas still need to be improved: Coartem provision to the CHWs; the care and management of children within 24 hours after the onset of fever; and compliance with the directed dosage according to the age of the child. In addition, CHWs should enhance the monitoring of mothers whose children suffer from malaria through daily home visits during the three days of treatment to ensure proper measures are being taken.
The project focused on improving knowledge of danger signs (refusal of eating or sucking, vomiting, unconsciousness or lethargy, and convulsions) in order to facilitate early referral of serious malaria. Based on the data collected through questionnaires, 95 percent of mothers with children under-five identified at least one sign of serious malaria, which increased from 19 percent at baseline . Due to this improved knowledge: 20 percent of children who suffered from fever within the last two weeks preceding the survey and displayed one of the serious signs were referred by their mothers through a CHW to the nearest health center for appropriate care. More children under-five were brought by their mothers to the health centers with serious cases of malaria. The health centers in the project villages treated more than 200 children under-five in 2008, which climbed from 100 in 2007 and only 92 in 2006 at baseline. However, clearly, knowledge (to encompass all major danger signs) and early referral (to surpass 20%) still need to be improved.
To comply with the new strategy for the management of primary and secondary prevention of malaria during pregnancy, the project built the capacities of maternity hospitals through the training of service deliverers on IPTp and the provision of Sulfadoxine Pyrimethamina (SP – an IPTp medication). According to the strategy’s protocols, women are to receive at least two doses of SP during antenatal care visits. The women are then to ingest them in the presence of the midwife/care provider who can verify that they were taken. In the project villages, 40 percent of mothers with infants benefitted from IPTp over their last pregnancy. However, the percentage of pregnant women with supervised SP intake (40 percent) remains considerably lower than the percentage receiving antenatal care visits (85 percent). During the two years of project implementation, an average of 66 pregnant women consulted health centers every year for malaria, compared to 92 in 2006 (before the project started up). This result shows, as a proxy, that the frequency of malaria cases during pregnancy decreased significantly in health centers. This is largely due to the malarial preventative treatment (i.e., IPTp) provided to pregnant women. In addition, over the two years of project implementation, no deaths recorded in the health facilities among pregnant women were due to malaria . The following interventions also contributed to reduction in the number of malaria cases among pregnant women: Awareness sessions for information or for recalling pregnant women about malaria prevention and treatment; Home visits and monitoring conducted by the CHW for pregnant women; and Training on the serious signs of malaria conducted at the community level and at the maternity hospital during antenatal care sessions. The project has placed a particular emphasis on recognizing the signs of malaria (headaches, stiffness, fever, asthenia) so that pregnant women are able to seek timely early referrals.
Home visits provided individual contacts through which household practices could be observed, positive behaviors could be reinforced, and individual barriers could be addressed. Regular home visits were an enabling factor to secure consent for night visits for LLIN control in households. For example, acknowledging that transportation and financial means serve as two significant barriers to seeking health care for malaria, communities worked together to create solidarity funds and transportation agreements to remove this barrier. As effective solutions such as these were found, they were disseminated among the pilot villages and adapted to suit the circumstances in each locality. Holding one QIT member in each hamlet accountable for their tasks has facilitated the social mobilization and the diffusion of messages. Ensures that someone is driving the QITs Given the limited reach of health facility staff, the use of QITs and CHWs to address awareness and health behaviors at community level was key to the project’s success. Referrals made by CHWs for children suffering from serious malaria to seek care at the nearest health center. Counter-referrals were weaker. The integration of health education activities during LLIN distribution sessions has facilitated women’s access to the antenatal care messages. Solidarity funds: Community funds to subsidize early referral to a health facility While knowledge was a major barrier to early referral of severe malaria cases to health facilities, affordability and accessibility were also major hindrances for many families. In order to provide support to families in need of financial assistance in case of health emergencies, 16 of the project villages set up solidarity funds, fueled by contributions varying from $0.05 to $0.10 per family per month. The pooled funds then remain available to subsidize the transportation of under-five children in the case of serious malaria or other health complications. When a CHW refers a child to a health facility for treatment, the CHW contacts the solidarity fund treasurer for transportation fees. In the absence of the treasurer, the CHW makes the necessary arrangements with a village motorcycle owner who will take the child to the health center. In each of the three villages (Dekandji, Koyohoué, and Avégodo) where there is no solidarity petty cash fund, a driver has been identified to provide transportation free of charge; they are always available to transport a sick child. The solidarity fund in some villages also helps parents cover expenses for consultation and treatment. With these support systems in place, parents no longer have to worry about how to get their sick children to the health facility for treatment.
According to the results of the assessment, aside from the technical support provided to the CHWs by the coaching team in the health zone for AD&D, the CHWs and other members of the QITs did not benefit from monitoring or supervision from government health agents at the district or community levels. Chief nurses and matrons in health centers stated that this was due to the fact that they were overworked (each has a workload of 20,000 patients) within their coverage zone. Also, there was a lack of motivation or incentive to engage in monitoring and supervision. They agreed that strong planning and integration of activities were effective mechanisms for allowing them to conduct monthly supervisions of the QIT. The practice of health facility workers making counter-referrals to CHWs should be further expanded to ensure proper follow up of serious malaria cases after discharge. Barriers to the use of intermittent preventive treatment for malaria during pregnancy (IPTp) have been identified but still require further work to be addressed. Sensitize women on the importance of eating before going for an antenatal care visit. Sensitize more husbands in the care and management of pregnant women. Advocate to the MoH for a part of the profit from bed net, Coartem, and IPTp sales to be used for community funding. Efforts have not been self sustaining
The methodology fostered an entrepreneurial spirit that led to continuous improvements and shared learning between QITs on improving malaria-related behaviors and practices in the community. Two main strategies contributed to this success: increased collaboration between communities and health facilities, and community learning and problem solving.
Chang collaborative approach
Collaborative Approach to Community-based Malaria Prevention in Benin Judy Chang | Plan International USA CORE Group Fall Meeting September 15, 2010
Plan International <ul><li>A child-centered, community development organization with over 70 years of experience </li></ul><ul><li>Benefits approximately 15 million people in 48 developing countries in Asia, Africa and the Americas </li></ul><ul><li>Began operating in Benin in 1994 </li></ul><ul><li>Works in 754 villages in Benin, covering the domains of health, water and sanitation, education, household food security, and child rights </li></ul>
Background – Malaria in Benin <ul><li>A principle cause of morbidity and mortality among infants and pregnant women </li></ul><ul><li>Utilization of ITNs is low (34%) </li></ul><ul><li>Very few mothers (~14%) seek care and treatment from health facilities for their children </li></ul><ul><li>Limited human resources for health – average of one health agent per village </li></ul>
Plan’s Improvement Collaborative <ul><li>Dates: April 2007-June 2009 </li></ul><ul><li>Coverage: 50 villages in the communes of Aplahoué and Djakotomey in the Couffo department of Benin </li></ul><ul><li>Improvement topics: Malaria—LLINs, malaria case management, malaria treatment in children and pregnant women, IPTp </li></ul>
Goal and objectives <ul><li>Goal: To contribute to the reduction of child and maternal mortality rates by improving behaviors related to the prevention and treatment of malaria by the community itself </li></ul><ul><li>Objectives: </li></ul><ul><ul><li>Increase from 34% to 60% the use of LLIN </li></ul></ul><ul><ul><li>Promote appropriate management of malaria in households and communities </li></ul></ul><ul><ul><li>Increase by 40% timely care seeking for complicated malaria among children under five and pregnant women </li></ul></ul><ul><ul><li>Strengthen collaboration between health structures and communities through home visits and support to community groups. </li></ul></ul>
Implementation package <ul><ul><li>Establishment and training of Quality Improvement Teams (QITs) </li></ul></ul><ul><ul><li>Information, education, and communication on malaria prevention and treatment (LLIN utilization, identification of signs of serious malaria) </li></ul></ul><ul><ul><li>Home visits and night visits to reinforce good behaviors </li></ul></ul><ul><ul><li>Home-based treatment of malaria with ACTs </li></ul></ul><ul><ul><li>Establishment of a referral and counter-referral system between CHWs and health facility staff </li></ul></ul>
Measurement <ul><li>Key indicators monitored by QITs: </li></ul><ul><ul><li>% of children under 5 who slept under a mosquito net the previous night </li></ul></ul><ul><ul><li>% of children under 5 who had a fever within the last 2 weeks and who were treated according to the guidelines </li></ul></ul><ul><ul><li>Number of children under 5 who were referred to a health center through the community referral system </li></ul></ul><ul><ul><li>% of pregnant women who slept under a mosquito net the previous night </li></ul></ul><ul><ul><li>% of children with serious malaria who were brought to a health center within 24 hours </li></ul></ul>
Coaching, learning, and communication among teams Activity Purpose Frequency QIT meetings <ul><li>Report monitoring data and project progress </li></ul>Bimonthly Inter-village learning sessions for QITs <ul><li>Share innovative methods developed </li></ul><ul><li>Assess each QIT’s effectiveness relative to one another </li></ul>Quarterly Coaching by animators from partner NGOs <ul><li>Improve QITs’ teamwork, problem solving, and monitoring of progress </li></ul>Monthly Advisory Committee supervision and meetings <ul><li>Monitor project activities </li></ul><ul><li>Make recommendations to project implementation team </li></ul>Quarterly
Results – Home care and management of fever Target: 40%
Results – Early referral of serious malaria Target: 40%
Results – IPTp <ul><li>40% of pregnant women received IPTp </li></ul><ul><li>Malaria consultations among pregnant women at health centers decreased from 92 to 66 per year </li></ul><ul><li>No malaria-related deaths were recorded among pregnant women </li></ul>
Best practices <ul><li>Conducting home visits and night visits </li></ul><ul><li>Creating local responses to identified barriers </li></ul><ul><li>Establishing accountability of QIT members </li></ul><ul><li>Increasing collaboration between communities and health facilities </li></ul>
Challenges <ul><li>Engaging health facility staff in supervision and coaching of QITs </li></ul><ul><li>Counter-referrals </li></ul><ul><li>IPTp </li></ul><ul><li>Sustained support and scale up </li></ul>
Conclusions <ul><li>The project was successful in creating a favorable environment for sustained behavior changes </li></ul><ul><ul><li>Development of entrepreneurial spirit and shared learning among QIT members </li></ul></ul><ul><ul><li>Increased ownership of community health </li></ul></ul>
The preceding slides were presented at the CORE Group 2010 Fall Meeting Washington, DC To see similar presentations, please visit: www.coregroup.org/resources/meetingreports