Menu
Menu
Menu
Menu
The Government of Malawi (GoM) initiated activities to deliver treatment of common childhood illnesses (suspected pneumonia, fever/suspected malaria, and diarrhea) in the community in 2008. The service providers are Health Surveillance Assistants (HSAs), and they are posted nationwide to serve communities at a ratio of 1 to 1, 000 population. The GoM targeted the establishment of 3, 452 village health clinics (VHCs) in hard-to-reach areas by 2011. By September of 2011, 3, 296 HSAs had received training in integrated case management of childhood illness, and 2, 709 VHCs were functional. An assessment has shown that HSAs are able to treat sick children with quality similar to the quality provided in fixed facilities. Monitoring data also suggest that communities are using the sick child services. We summarize factors that have facilitated the scale up of integrated community case management of children in Malawi and address challenges, such as ensuring a steady supply of medicines and supportive supervision. Copyright © 2012 by The American Society of Tropical Medicine and Hygiene.
This paper provides an overview of the implementation of CCM in Malawi, summarizing information from multiple data sources. The main sources of data were program records and Health Management Information System (HMIS) reports from the Integrated Management of Childhood Illness (IMCI) unit in the Ministry of Health (MOH), and they included statistics on the number of HSAs trained, the number of village health clinics (VHCs) established, the proportion of target areas reached, and the number of treatments provided by month. These data are compiled by the MOH from monthly reports provided by trained HSAs and reported through health facilities and the district health office on a monthly basis. The density of HSAs per 1,000 population (based on the Malawi 2009 census estimates of district population)13 and the ratio of functional VHCs per hard-to-reach area (as identified by the MOH) were calculated in Microsoft Excel. We also include the results of additional assessments conducted for an external evaluation of maternal and child health programming in Malawi led by the Institute for International Programs at Johns Hopkins University (IIP-JHU) and the Malawi National Statistics Office (NSO), here referred to as the Independent Evaluation Team (IET). In 2009, the IET conducted an assessment of the quality of care provided by HSAs through direct observation and reexamination by a gold-standard clinician.14 The assessment also included measurement of caregiver satisfaction with CCM services through a client exit interview and qualitative investigation of health workers perceptions of the CCM program.14,15 The assessment was conducted in six districts that were strong in early implementation, and results are not representative of all districts during that period, which had variable implementation. The IET collected follow-up data on implementation strength in 2011 through a telephone survey of a random sample of CCM-trained HSAs in one district.16 HSAs are community-based health workers recruited and salaried by the Malawi MOH. This cadre of worker was established for smallpox vaccination in the 1960s and continued to serve evolving needs of the health system, including response to cholera outbreaks during the 1970s and 1980s and environmental health education and population surveillance in the 1990s. With a grant from the Global Fund in 2008, the government doubled the size of the HSA workforce to over 10,000 HSAs, each serving approximately 1,000 people, for the delivery of community-based interventions. The minimum education level for HSAs is a junior certificate (grade 10), and all HSAs follow a 10-week basic training to learn the core set of tasks for which they are responsible (not including iCCM). Their remuneration is based on the government’s civil service salary scale and equivalent to the remuneration of a first-level clerical staff. The current job description includes (1) promotion of hygiene and sanitation, (2) provision of health education, (3) home visitation and maintenance of community registers, (4) conducting community assessments, including public facility inspection, (5) disease surveillance, (6) conducting outreach clinics, including immunization, and (7) conducting VHCs to provide iCCM services. Additionally, selected HSAs are also involved in diverse activities, such as distribution and administration of contraception, treatment of tuberculosis, and voluntary counseling and testing for HIV. Many HSAs are young and male. They do not always originate from the communities that they serve and may not reside in their catchment area. The WHO/UNICEF training materials on caring for the sick child in the community are a simplified version of the IMCI guidelines for first-level health workers and focus on the major causes of death among children under age 5 years.17 CBHWs learn to identify and treat uncomplicated cases of suspected pneumonia, fever (presumed malaria), and diarrhea and identify and refer children with danger signs, severe malnutrition, or other problems that they have not been trained to treat. A job aid, known as the Sick Child Recording Form (SCRF), specifies the algorithms for assessment and classification of the sick child’s signs and symptoms, and it guides CBHWs on selection of treatment with an antibiotic, antimalarial, and/or oral rehydration salt (ORS) and zinc tablet (Panel 1). The SCRF serves as the basis for training and can serve as a main reference tool when providing services in the community. Sick child recording form job aid with iCCM guidelines. Provision of iCCM requires minimal medicines and equipment. In addition to the four essential medicines listed, CBHWs also learn to use a rapid diagnostic test (RDT) to assess for malaria and a mid-upper arm circumference (MUAC) strap to assess for severe acute malnutrition. A timer to count respiratory rate is desirable but not mandatory. The initial iCCM training is 6 days and includes seven clinical practice sessions, two sessions in inpatient facilities to practice recognition of danger signs and five sessions in outpatient facilities to practice the entire process of assessment and treatment or referral. A follow-up visit to the CBHW by an experienced facilitator within 4–6 weeks of training is strongly recommended for additional skills reinforcement; also, regular supervision that includes observation of clinical practice is recommended. The Malawi MOH IMCI unit adopted the materials included in caring for the sick child in the community in June of 2008 after a demonstration course. Minimal adaptations were made to the clinical content (i.e., the inclusion of palmar pallor as a danger sign and management of eye infections). Use of RDT to assess for malaria was not part of the initial version of the WHO/UNICEF generic materials and hence, was not included in the adaptation. It was decided that the implementation strategy would target HSAs in hard-to-reach areas based on (1) distance to the nearest health facility of 8 km or more or (2) difficult access because of geographical terrain or natural barriers. Using these criteria, district management teams (DHMTs) identified 3,452 hard-to-reach areas. Targeting the hard-to reach areas, DHMTs, under the guidance of the district IMCI coordinator, became responsible for establishing community-based child health services. Establishment involved conducting community orientation and HSA training, providing medicines and supplies, supervision, and monitoring. HSAs are provided a drug box after training, and they replenish medicines from the nearest health center. They use a register based on the SCRF to record the care provided to children that they see. They send standard reporting forms to the health facility monthly, from which summary reports are sent to the DHMT and the national IMCI unit. Village health committees support and safeguard the work of an HSA. For example, the committee contributes to managing the medicine supply by holding a key for the HSA’s drug box; the drug box has double locks, and a committee member must assist the HSA in opening the box on the day of the VHC. HSAs, in principle, conduct VHCs to provide curative care on scheduled days of the week, taking into consideration their other responsibilities and tasks. By the end of 2010, all districts in Malawi had adopted the policy of iCCM, focusing on the establishment of VHCs by iCCM-trained HSAs in hard-to reach areas. As of September of 2011, 3,296 HSAs had received iCCM training, and 2,709 (or 79%) were providing services, hence managing functional VHCs. The iCCM approach was being implemented in all districts, with 13 of 28 districts having coverage of more than two HSAs per 10,000 total population (Figure 1A). All but 2 districts had reached 50% coverage of the targeted hard-to-reach areas, and 17 districts had reached coverage of 76% or more (Figure 1B). District coverage of iCCM-trained HSAs (A) by population and (B) in hard-to-reach areas. A quality of care assessment undertaken in 2009 (described below) included a review of HSA registers to assess routine use of iCCM services in six districts with early implementation.14 Of 131 HSAs surveyed, 102 HSAs had complete registers for the month of September of 2009 and had documented seeing a median number of 41 sick children per month (interquartile range of 19–73 visits per month). The central IMCI unit established a system to monitor use of iCCM services in 2009. For the period of October of 2010 to September of 2011, on average, 68% of functional VHCs submitted monthly reports. Figure 2 summarizes the numbers of treatments given and referrals made at those VHCs per 1,000 children ages 0–4 years in all districts. To reflect the national policy of VHCs in hard-to-reach areas, an analysis of the average monthly number of treatments by VHCs was also done for one district with a high level of monthly reporting by HSAs. Figure 3 shows the average monthly number of treatments and referrals at VHCs in Phalombe district in the period of January to December of 2011. Each VHC treated an average of 41.3 children for fever (presumed malaria), an average of 20.6 children for presumptive pneumonia, and an average of 11.6 children for diarrhea each month. On average, two children were referred every month. The predominance of fever treatments may be partially explained by the national policy of presumptive treatment of fever for malaria. Monthly average number of treatments given and referrals made at VHCs per 1,000 population ages 0–4 years in all districts from October of 2010 to September of 2011. Monthly average number of treatments given and referrals made at VHCs in Phalombe district per health clinic from January to December of 2011. In late 2009, IIP-JHU, MOH, and WHO conducted an early assessment of the quality of iCCM services provided in the community by HSAs; the full methodology and results are described elsewhere. Briefly, the assessment was carried out in six districts that had made progress in implementation as of September of 2009. Table 1 presents selected results from directly observed consultations with sick children for common illnesses (signs of pneumonia, fever/malaria, and diarrhea) and danger signs compared with a clinician trained as a master iCCM trainer. The proportion of sick children receiving correct assessment, classification, and treatment of common illnesses was similar to the proportion observed in previous studies.18,19 Just over one-half of children requiring referral were referred appropriately. An analysis of common errors in clinical steps reported elsewhere provides additional insight into the factors affecting the performance. For example, only 37% of children were assessed correctly for all four physical danger signs. The survey also assessed caregiver satisfaction through an exit interview, in which 97% of caregivers reported to have found the services excellent (34%) or good (63%) and 99% reported that they would visit the HSA again for a child’s illness. Qualitative interviews indicated that both program managers and HSAs positively received the program.15 HSAs reported increased feelings of usefulness and respect in the community, although they also perceived their workload to have increased with iCCM.15 Selected results from the quality of care assessment of HSAs providing community case management services for common child illnesses in Malawi in October and November of 2009 The assessment found that supervision and drug supply in the first year were less than optimal. Less than 40% of HSAs included in the sample had received an iCCM-specific supervisory visit in the previous 3 months, and only 16% received a visit that included clinical observation of case management. Although the sample was drawn only from HSAs having received initial drug stocks, only 69% of VHCs manned by HSAs had all three primary treatments (cotrimoxizole, antimalarials like lumefantrine-artemether [LA], and ORS) on the day of the visit.14 A telephone survey conducted by the Malawi NSO and IIP-JHU in coordination with the MOH between March and April of 2011 in the Balaka district found that, among 49 iCCM-trained HSAs, 74% had received a medicine box, 71% had treated sick children in the previous 3 months, and 67% had treated sick children in the previous 7 days. The proportion of HSAs with an uninterrupted stock in the previous 3 months was 11% for ORS, 40% for LA, and 82% for cotrimoxazole16; 53% of HSAs had received supervision in the previous 3 months, 29% of HSAs had supervision at their VHC, and 40% of HSAs reported receiving iCCM-specific supervision with reinforcement of clinical practices in the health center or at their VHC.16 Although this survey was restricted to one district in Malawi’s central region, the high levels of CCM activity among trained HSAs who received their drug boxes are consistent with the use reports of Phalombe district included in Figure 2.
N/A
