Strengthening primary health care at district-level in Malawi – Determining the coverage, costs and benefits of community-directed interventions

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Study Justification:
– The study aimed to assess the effectiveness of the Community-Directed Interventions (CDI) approach in strengthening primary health care (PHC) services at the district level in Malawi.
– Limited knowledge was available about the added value of CDI for areas without previous experience in Community-Directed Treatment with ivermectin (CDTi).
– The study sought to determine how best to use the CDI approach to strengthen locally identified PHC services.
Study Highlights:
– The study involved a comparative intervention carried out over 12 months, with four health centers and 16 villages assigned to either a conventional PHC approach or a PHC/CDI approach.
– The CDI approach included home management of malaria, distribution of long-lasting insecticide-treated nets, vitamin A distribution, and treatment of schistosomiasis.
– The study found that implementing the CDI approach at the community level alongside PHC services was feasible and acceptable to health professionals, implementers, and beneficiaries.
– Significant increases in intervention component coverage were observed for long-lasting insecticide-treated nets among children under 5 years and pregnant women.
– Increases were also observed for home management of malaria, vitamin A distribution among children under 5 years, and treatment against schistosomiasis, but these were not statistically significant.
– Implementation of the CDI approach was more costly in CDI areas compared to PHC areas, with health center costs and transport being the most expensive.
Recommendations for Lay Reader and Policy Maker:
– The CDI approach is an effective means to increase accessibility of vital services at the community level, thereby strengthening the delivery of PHC services.
– The CDI approach can complement regular PHC efforts and should be considered for implementation in areas without previous experience in CDTi.
– Key intervention components to consider include home management of malaria, distribution of long-lasting insecticide-treated nets, vitamin A distribution, and treatment of schistosomiasis.
– It is important to adapt the CDI approach to local contexts for successful implementation.
– Further research and evaluation are needed to assess the long-term impact and sustainability of the CDI approach.
Key Role Players:
– District Environmental Health Officer
– District Community Health Nurse
– Coordinators for malaria, Neglected Tropical Diseases (NTD), and diarrhea
– Medical Assistants or Nurses in charge at health centers
– Senior Health Surveillance Assistants
– Community-based volunteers/implementers
– Implementation partner organizations (Icelandic International Aid Agency and Amref Health Africa)
Cost Items for Planning Recommendations:
– Training and supervision of district-based health professionals
– Training and supervision of health center-based professionals
– Training and support for community-based CDI implementers
– Procurement and distribution of intervention components (e.g., insecticide-treated nets, vitamin A)
– Transportation costs for delivering services
– Monitoring and evaluation activities
– Research and data collection expenses
Please note that the above information is a summary of the study and may not include all details. For a comprehensive understanding, it is recommended to refer to the original publication in BMC Health Services Research, Volume 19, No. 1, Year 2019.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are areas for improvement. The study design is a comparative intervention study, which provides some level of evidence. The study collected both quantitative and qualitative data, which adds to the strength of the evidence. However, the abstract does not provide specific details about the sample size or the statistical methods used for analysis, which could affect the reliability of the findings. To improve the strength of the evidence, the authors should provide more information about the sample size, statistical methods, and any potential limitations of the study.

Background: Community-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level. Methods: This was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components. Results: Implementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation. Conclusion: The CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts. Trial registration: The study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921.

Malawi is a country in Sub-Saharan Africa with a 2018 population size of 17,563,749 people and 28 districts organized into three regions: northern, central and southern [21]. The study was carried out in Mangochi, one of the 12 districts in the southern region of Malawi. The district is situated on the southern end of Lake Malawi (Fig. 1) and has a total population of 1,148,611 [21]. The district is mainly inhabited by people of Yao and Chewa ethnicities, while Islam (72%) and Christianity (28%) are the most practiced religions. Agriculture, fishing and microbusiness enterprising are the main economic activities of people in the district. Adult literacy is 49%, access to safe water supply is 73%, maternal mortality rate is 400 per 100,000 and the infant mortality rate is 169 per 1,000 [22]. Map of Malawi showing locations of Mangochi District (in red), Lake Malawi (in blue), major cities of Mzuzu, Lilongwe and Blantyre and the location of Malawi in Africa (red in the inset) (Source: Authors’ own map [20]) The study was designed as a controlled implementation study to run for 1 year. The assumption was that the district received what they needed in terms of information, materials, drugs and other supplies to allow them to satisfactorily implement EHP/PHC services in rural settings and that the study supported the district processes through a CDI based approach. In total, four health centres and 16 villages were involved in the study. Equal numbers of health centres along with their corresponding villages were randomly assigned to either the intervention or control arm of the study (Table 1). List of the involved health centres and villages in Mangochi District according to their assigned study arms 1. Saiti Tiputipu 2. Kamangazula 3. Kansiya 4. Binali 5. Kwitunji 6. Mponda 7. Sokole 8. Kasanga 1. Makunula 2. Nankamwa 3. Chimwaza 4. Mtendere 5. Itimu 6. Matenganya 7. Mbalula 8. Meso The support rendered included EHP/PHC/CDI training and supervision of district-based health professionals, health centre-based professionals attached to two health centres and community based volunteers/implementers in eight villages in the intervention arm of the study; no such training and supervision support was provided in the two health centres and eight villages involved in the control arm. For the intervention arm, the EHP/PHC/CDI approach was implemented mainly at community level on top of ongoing regular EHP/PHC activities at health centre levels in the same arm thereby complementing rather than replacing the regular health service delivery. In the control arm, the regular EHP/PHC system continued to operate at the health centre level without any EHP/PHC/CDI approach being implemented at community level. By applying these approaches, we expected to assess if CDI could strengthen ongoing EHP/PHC efforts in Mangochi District. Both the EHP/PHC and EHP/PHC/CDI strategies were implemented and evaluated over a period of 12 months. The research team identified an intervention package that was agreed with the communities and health care providers during the formative phase based on their priority health issues in the setting [20]. To be properly guided on existing policies regarding the implementation of the EHP/PHC/CDI approach at community level the final choice of intervention components also depended on consultations with key health personnel and other professional stakeholders. The following intervention components were finally included in the study: (i) home management of malaria (HMM) and fever to children under 5 years of age, (ii) distribution of long lasting insecticide treated nets (LLIN) to children under 5 years of age and pregnant women, (iii) vitamin A distribution to children under 5 years of age and (iv) treatment of urinary schistosomiasis using Praziquantel (PZQ) for those above 5 years of age. The study involved a total of five district-based officers consisting of the District Environmental Health Officer, District Community Health Nurse, and three Coordinators for malaria, Neglected Tropical Diseases (NTD) and diarrhoea. These were incorporated into the study as trainers and supervisors after being briefed and trained by the research team on the overall aims of the study, principles and processes of the CDI approach, and on available intervention components of the study. In turn the five district-based officers identified and provided training for two health centre based health workers, who were either a Medical Assistant or a Nurse in charge, and two Senior Health Surveillance Assistants from the two participating health centres under the intervention arm of the study to serve as trainers and later as supervisors for community based CDI implementers. The two health centre based staff in turn engaged their respective villages through community meetings from where 32 community based volunteers (one volunteer per each of the four intervention components in each of the eight intervention villages) were identified, trained and assigned roles as CDI implementers of the selected interventions. At every stage at health centre and community levels, both the research and district teams participated in the trainings as observers to ensure adherence to the study protocol. These health centre based staff later continued to supervise and support CDI implementers in their respective villages throughout the implementation period. No briefing and training were offered out to the staff from the corresponding two health centres and eight villages participating in the control arm of the study. Two implementation partner organizations involved in delivery of health services at district level, Icelandic International Aid Agency (ICEIDA) and Amref Health Africa (AHA) were identified and consulted at the beginning of the study. During the implementation of the CDI process at community level, the health services, implementation partners and the community played the following roles: The study employed a mixed-method approach to data collection focusing on quantitative data for coverage and cost estimates during baseline and follow-up, and qualitative data for assessing intervention benefits and evaluating processes. Data were collected at district, health centre and village levels in the intervention and control arms of the study. Research assistants collected the necessary data for the study from the involved health professionals, implementation partners, CDI implementers and beneficiaries using 19 data collection instruments previously used by the research group in a 2008 multi-country study [13]. An additional file shows the instruments that were used during data collection [see Additional file 1]. The instruments consisted of survey questionnaires administered to household heads or representatives at community level for determining intervention coverage, and questionnaires administered to relevant health programme coordinators at district level, in-charges at health centres, and leaders at community level, for determining intervention costs. Moreover, Health Management Information System (HMIS) records were reviewed to establish the burden of disease and coverage data at district, health centre and village levels using checklists; Interview guides were used to conduct in-depth interviews with professionals at district and health centre levels, implementation partners at district level and CDI implementers at community level about their perceptions on benefits and critical factors. Finally, focus group discussion guides were used to conduct group interviews with beneficiaries about their perceptions on using the CDI approach. Using these tools data were collected in both intervention and control areas before (baseline) and after (follow-up) introducing the intervention. All the proceedings of the key informant in-depth interviews and focus group discussions were recorded using digital audio recorders. Table 2 summarizes the methods, purposes, sources and quantities of data collected in the study. Methods, purposes, sources and amount of data collected in the study Quantitative data collected through survey questionnaires and checklists were processed and analyzed using statistical software Epi Info™ version 7.2.1. Analysis involved calculation of percentages, tabulations and frequencies to estimate coverage of individual intervention components. Furthermore, statistical significance tests using Chi Square were performed on differences in delta values (i.e. differences between baseline and follow-up) for each intervention component between intervention and control groups. The analyses of costs and benefits data were carried out using the following procedures: Qualitative data consisted of textual and audio data, including transcripts of key informant in-depth interviews, transcripts of focus group discussions, field notes on observations and other intervention-specific insights, notes and reports from meetings. Transcripts were translated into English and were entered in the computer using standard word processing software. A computer-assisted qualitative content analyses of the data using Atlas-Ti 8, a qualitative data analysis software programme (GmbH 2016) were conducted. Data were analyzed using open coding to come up with cross-classification and retrieval of categories of texts by theme.

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide pregnant women and new mothers with access to important health information, appointment reminders, and emergency services.

2. Telemedicine: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls, reducing the need for travel and improving access to medical advice.

3. Community Health Workers: Train and deploy community health workers who can provide basic prenatal care, education, and support to pregnant women in underserved areas.

4. Transportation Solutions: Develop transportation solutions, such as ambulances or community transport systems, to ensure that pregnant women have access to timely and safe transportation to healthcare facilities during emergencies or for regular check-ups.

5. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with financial assistance to cover the costs of prenatal care, delivery, and postnatal care, making healthcare services more affordable and accessible.

6. Maternal Health Clinics: Establish dedicated maternal health clinics in underserved areas, staffed with skilled healthcare professionals who can provide comprehensive prenatal, delivery, and postnatal care.

7. Health Education Programs: Develop and implement health education programs that focus on maternal health, targeting both women and their families to increase awareness and knowledge about the importance of prenatal care and safe delivery practices.

8. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve access to maternal health services through joint initiatives, resource sharing, and capacity building.

9. Maternal Health Hotlines: Set up toll-free hotlines staffed by trained healthcare professionals who can provide information, counseling, and referrals to pregnant women seeking guidance or assistance.

10. Maternal Health Monitoring Systems: Implement digital health solutions that enable real-time monitoring of maternal health indicators, allowing healthcare providers to identify high-risk pregnancies and intervene early to prevent complications.

These innovations have the potential to improve access to maternal health services, reduce maternal mortality rates, and ensure better health outcomes for both mothers and their babies.
AI Innovations Description
The recommendation to improve access to maternal health in Malawi is to strengthen primary health care at the district level through the implementation of Community-Directed Interventions (CDI). CDI is a participatory approach that delivers essential healthcare services at the community level, based on the principles of Primary Health Care (PHC). This approach has been successful in areas that have previously used Community-Directed Treatment with ivermectin (CDTi), but its effectiveness in areas without CDTi experience is not well-known.

The study conducted in Mangochi District, Malawi, assessed the feasibility and acceptability of implementing the CDI approach to strengthen locally identified PHC services at the district level. The study involved four health centers and 16 villages, which were randomly assigned to either a conventional Essential Health Package (EHP)/PHC approach at the health center level or an EHP/PHC/CDI approach at the community level in addition to EHP/PHC at the health center level.

The intervention components included home management of malaria (HMM), distribution of long-lasting insecticide-treated nets (LLIN) to children under 5 years of age and pregnant women, distribution of vitamin A to children under 5 years of age, and treatment of urinary schistosomiasis using Praziquantel (PZQ) for those above 5 years of age. The study found that the EHP/PHC/CDI approach was feasible and acceptable to health professionals, implementers, and beneficiaries. There were statistically significant increases in intervention component coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age, and treatment against schistosomiasis, but these increases were not statistically significant.

However, it is important to note that the implementation of the EHP/PHC/CDI approach was more costly in CDI areas compared to EHP/PHC areas, with the highest costs accrued at the health center level. The study identified critical factors that need to be considered and adapted to local contexts for successful implementation.

In conclusion, the CDI approach is an effective means to increase accessibility to vital maternal health services at the community level, thereby strengthening the delivery of EHP/PHC services. It can complement regular EHP/PHC efforts and improve access to maternal health in Malawi.
AI Innovations Methodology
Based on the provided information, the study titled “Strengthening primary health care at district-level in Malawi – Determining the coverage, costs and benefits of community-directed interventions” aimed to assess the effectiveness of the Community-Directed Interventions (CDI) approach in improving access to essential healthcare services at the community level in Malawi. The study compared the outcomes of two strategies: 1) a conventional Essential Health Package (EHP)/Primary Health Care (PHC) approach at health center level, and 2) an EHP/PHC/CDI approach at the community level in addition to EHP/PHC at health center level.

The methodology used in the study involved a comparative intervention design, carried out over a period of 12 months. Four health centers and 16 villages were randomly assigned to either the intervention or control arm. The intervention arm implemented the EHP/PHC/CDI approach at the community level, while the control arm continued with regular EHP/PHC services at the health center level without the CDI approach.

Data collection included both quantitative and qualitative methods. Quantitative data was collected through survey questionnaires administered to household heads or representatives at the community level to determine intervention coverage, and questionnaires administered to relevant health program coordinators at district level, in-charges at health centers, and community leaders to determine intervention costs. Health Management Information System (HMIS) records were also reviewed. Statistical analysis was performed to calculate percentages, tabulations, frequencies, and to test for statistical significance using Chi Square.

Qualitative data was collected through in-depth interviews with health professionals, implementers, and beneficiaries, as well as focus group discussions. The data was analyzed using computer-assisted qualitative content analysis software.

The study found that the EHP/PHC/CDI approach at the community level was feasible and acceptable, and resulted in statistically significant increases in intervention component coverage for long-lasting insecticide-treated nets (LLIN) among children under 5 years of age and pregnant women. Increases were also observed for home management of malaria (HMM), vitamin A distribution, and treatment against schistosomiasis, although these increases were not statistically significant. The study also identified critical factors for successful implementation.

In summary, the study used a comparative intervention design to assess the effectiveness of the CDI approach in improving access to essential healthcare services at the community level in Malawi. The methodology involved quantitative data collection for coverage and cost estimates, as well as qualitative data collection for assessing intervention benefits and evaluating processes. The findings highlighted the feasibility and acceptability of the CDI approach and its potential to complement regular EHP/PHC efforts.

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