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Background: Primary Health Care (PHC) is a strategy endorsed for attaining equitable access to basic health care including treatment and prevention of endemic diseases. Thirty four years later, its implementation remains sub-optimal in most Sub-Saharan African countries that access to health interventions is still a major challenge for a large proportion of the rural population. Community-directed treatment with ivermectin (CDTi) and community-directed interventions (CDI) are participatory approaches to strengthen health care at community level. Both approaches are based on values and principles associated with PHC. The CDI approach has successfully been used to improve the delivery of interventions in areas that have previously used CDTi. However, little is known about the added value of community participation in areas without prior experience with CDTi. This study aimed at assessing PHC in two rural Malawian districts without CDTi experience with a view to explore the relevance of the CDI approach. We examined health service providers’ and beneficiaries’ perceptions on existing PHC practices, and their perspectives on official priorities and strategies to strengthen PHC. Methods. We conducted 27 key informant interviews with health officials and partners at national, district and health centre levels; 32 focus group discussions with community members and in-depth interviews with 32 community members and 32 community leaders. Additionally, official PHC related documents were reviewed. Results: The findings show that there is a functional PHC system in place in the two study districts, though its implementation is faced with various challenges related to accessibility of services and shortage of resources. Health service providers and consumers shared perceptions on the importance of intensifying community participation to strengthen PHC, particularly within the areas of provision of insecticide treated bed nets, home case management for malaria, management of diarrhoeal diseases, treatment of schistosomiasis and provision of food supplements against malnutrition. Conclusion: Our study indicates that intensified community participation based on the CDI approach can be considered as a realistic means to increase accessibility of certain vital interventions at community level. © 2012 Makaula et al.
The study was carried out in 2010 as part of a larger multi-country study involving Cameroon, Kenya, Malawi, Nigeria and Uganda. In Malawi, the study was carried out in two rural districts of Mangochi in the south and Mzimba in the north (Figure (Figure1)1) where the CDTi strategy for onchocerciasis control has not been applied. Districts were selected based on comparative socio-economic, demographic and health indicators (Table (Table1).1). The selection process involved consultations with key Ministry of Health officers, including the Director of Preventive Health Services, the Chief PHC Officer, and District Health Management Team (DHMT) members in the target districts. From an exhaustive list of functioning health centres located in the two target districts, four health centres per district were randomly selected. Subsequently, from the catchment areas of each of the targeted health centres, four villages were randomly selected (Table (Table22). Map of Malawi showing the two study districts in red. The dots show the main cities of Lilongwe and Blantyre. The location of Malawi in Africa is shown in the inset. Comparative socio-economic, demographic and health indicators for the two study districts and for Malawi as a whole Sources: *Malawi Census Report, 2008; **Malawi Demographic and Health Survey, 2004; ***District Social Economic Profiles for Mangochi and Mzimba, 2003; +A Joint Programme of Works, 2004 &++Malawi Poverty Reduction Strategy Paper, 2002. Summary of randomly selected health centres and villages involved in the study At national level the Director of Preventive Health Services and the Chief PHC Officer in the Ministry of Health participated in the study. In addition, two representatives from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) participated after being identified by the Director of Preventive Health Services as PHC financial and technical partners. At district level, the study involved selected members of DHMT namely, the District Health Officers, District Nursing Officers and District Environmental Health Officers, Programme Coordinators of PHC, malaria, schistosomiasis and HIV and AIDS. Representatives of some of the development partners of the DHMT, namely Management Sciences for Health (MSH), Catholic Development Commission (Cadecom) and Africare also participated. At health facility level, mostly the in-charges or their representatives who were available on the days of the visit also participated. At community level all community leaders of the 32 target villages participated in the study. In addition, we purposely selected different groups of respondents from each village, namely men, women, boys and girls, to obtain a diverse community representation and a detailed impression of community perceptions. Ten community members available during the time of the visit were invited to participate in a focus group discussion (FGD). At the end of each FGD session, one participant was randomly selected for a further in-depth interview (IDI). The study employed qualitative methods to collect data. Key informant interviews (KII) were carried out with the officials at national, district and health centre levels as well as with health services delivery partners at national and district levels. FGDs were carried out with the different homogenous groups of community members such as men, women, boys and girls; one FGD involving ten participants was conducted for each of the groups in each of the target villages. Lastly, in every village IDIs were carried out with a community leader and a randomly selected community member. A summary of the data collected using each of the applied methods is shown in Table Table33. Summary of type and quantity of data collected at national level and for both target districts combined Topics covered during KIIs with health officers and their implementation partners at national and district levels included the nature of PHC elements being implemented at health centre and community levels, priority health issues at community level, health services and their mode of delivery at health centre and community levels, PHC coverage at district level and identification of partner organisations actively involved in PHC. The topics explored using FGD and IDI at health centre and community levels were: perceptions and attitudes of health service providers and consumers towards PHC, role of gender, minority and different socio-political groups, community participation and contribution in health activities, and perceived challenges, opportunities and synergies in PHC delivery. All tools used at community level were translated to local languages of Chewa, Yao and Tumbuka prior to use. Trained research assistants (4 males and 4 females) conversant with the local languages carried out the data collection. Except during the individual interviews the research assistants worked in pairs where one facilitated the discussion and the other took notes and tape recorded the discussions. Document reviews were carried at national, district and health centre levels. Some of the documents accessed and reviewed during the study were the Malawi Poverty Reduction Strategy Paper, the Health Sector Wide Approach (SWAp) 2004–2010, Malawi 2004 Demographic and Health Survey, Malawi 2008 Census Report, District Socio-Economic Plans, and Annual Reports. These documents were reviewed in order to get an insight on the national prescription of PHC policy, priority health issues, strategy for delivery of PHC services, effectiveness of the existing PHC interventions, identification of partner organisations involved in PHC, availability of resources for PHC and the challenges, and opportunities and synergies of PHC interventions. Health facility checklists developed during a workshop organised by the multi-country study group in 2008 were used to ascertain the availability of selected vital equipment such as refrigerators, scales, sphygmomanometers and stethoscopes. All interviews and FGDs data collected were transcribed and processed using standard word processing software. A computer-assisted qualitative content analysis of the data using Atlas-Ti software was conducted to ensure a standardized and comparable analysis and interpretation of the qualitative data across the study sites. Review of documents made reference to eight key elements of PHC in order to assess the effectiveness and level of implementation of PHC policies and activities. The eight PHC elements are as follows: 1) education concerning prevailing health problems and the methods of preventing and controlling them; 2) promotion of food supply and proper nutrition; 3) adequate supply of safe water and basic sanitation; 4) maternal and child health care, including family planning; 5) immunization against major infectious diseases; 6) prevention and control of locally endemic diseases; 7) appropriate treatment of common diseases and injuries; and 8) provision of essential drugs [2]. Ethical clearance was sought and granted from both the WHO Ethics Review Committee (WHOERC) and the Malawi’s National Health Sciences Research Committee (NHSRC) (NHSRC Approval # 628). Prior to all interviews and discussions oral informed consent was obtained from the participants. The study participants were informed that their involvement in the study was voluntary. The informed consent information sheets administered at community level were translated to local languages.
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