Primary health care in rural Malawi – A qualitative assessment exploring the relevance of the community-directed interventions approach

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Study Justification:
– The study aimed to assess the implementation of Primary Health Care (PHC) in rural Malawi and explore the relevance of the community-directed interventions approach.
– PHC is a strategy endorsed for equitable access to basic health care, but its implementation remains sub-optimal in many Sub-Saharan African countries.
– The study focused on two rural districts in Malawi that had not previously used the community-directed treatment with ivermectin (CDTi) approach.
– The goal was to understand the challenges and opportunities in implementing PHC in these districts and determine the added value of community participation.
Highlights:
– The study found that there is a functional PHC system in place in the two study districts, but implementation is faced with challenges related to accessibility of services and shortage of resources.
– Health service providers and consumers emphasized the importance of community participation to strengthen PHC, particularly in areas such as provision of insecticide-treated bed nets, home case management for malaria, management of diarrheal diseases, treatment of schistosomiasis, and provision of food supplements against malnutrition.
– The study suggests that intensified community participation based on the community-directed interventions (CDI) approach can increase accessibility of vital interventions at the community level.
Recommendations:
– Strengthen community participation in PHC by implementing the CDI approach in areas without prior experience with CDTi.
– Prioritize interventions such as provision of insecticide-treated bed nets, home case management for malaria, management of diarrheal diseases, treatment of schistosomiasis, and provision of food supplements against malnutrition.
– Address challenges related to accessibility of services and shortage of resources to improve the implementation of PHC.
Key Role Players:
– Ministry of Health officials at national and district levels, including the Director of Preventive Health Services, Chief PHC Officer, District Health Officers, District Nursing Officers, and District Environmental Health Officers.
– Representatives from partner organizations such as the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Management Sciences for Health (MSH), Catholic Development Commission (Cadecom), and Africare.
– Health service providers at health center level, including in-charges or their representatives.
– Community leaders and members from the target villages.
Cost Items for Planning Recommendations:
– Training and capacity building for health service providers and community leaders on the CDI approach and specific interventions.
– Procurement and distribution of insecticide-treated bed nets, diagnostic and treatment supplies for malaria, diarrheal diseases, and schistosomiasis, and food supplements for malnutrition.
– Infrastructure improvements to enhance accessibility of services, such as construction or renovation of health facilities.
– Monitoring and evaluation activities to assess the impact of the CDI approach and ensure the effectiveness of interventions.
– Communication and awareness campaigns to engage and educate the community about the importance of PHC and community participation.
Note: The actual cost of implementing the recommendations would depend on various factors and would need to be determined through a detailed budgeting process.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because the study used qualitative methods to collect data from multiple sources, including key informant interviews, focus group discussions, and in-depth interviews. The study involved a diverse range of participants, including health officials, community leaders, and community members. The findings indicate that there is a functional primary health care system in place in the study districts, but implementation is faced with challenges related to accessibility of services and shortage of resources. The study suggests that community participation based on the community-directed interventions approach can be a realistic means to increase accessibility of certain vital interventions at the community level. To improve the evidence, the study could have included a larger sample size and conducted a quantitative analysis to complement the qualitative findings.

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.

Based on the information provided, it seems that the study focused on exploring the relevance of community-directed interventions (CDI) in improving primary health care (PHC) and access to maternal health services in rural Malawi. Here are some potential innovations that could be considered to improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that travel to remote areas can help bring maternal health services closer to communities that have limited access to healthcare facilities.

2. Telemedicine: Using telecommunication technology, such as video conferencing or mobile apps, to connect pregnant women in rural areas with healthcare professionals can provide them with access to prenatal care and guidance.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in their communities can help bridge the gap in access to maternal health services.

4. Community-based health financing: Establishing community-based health financing schemes, such as community health insurance or savings groups, can help ensure that pregnant women have the financial means to access maternal health services.

5. Maternal waiting homes: Building maternal waiting homes near healthcare facilities can provide a safe and comfortable place for pregnant women to stay before and after delivery, especially for those who live far away from the nearest healthcare facility.

6. Transportation support: Providing transportation support, such as ambulances or vouchers for transportation services, can help pregnant women in remote areas reach healthcare facilities in a timely manner for prenatal care, delivery, and postnatal care.

7. Health education and awareness campaigns: Conducting health education and awareness campaigns in rural communities to promote the importance of prenatal care, skilled birth attendance, and postnatal care can help increase demand for maternal health services.

These are just a few potential innovations that could be considered to improve access to maternal health based on the information provided. It is important to note that the feasibility and effectiveness of these innovations would need to be further assessed and tailored to the specific context of rural Malawi.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health in rural Malawi is to implement the community-directed interventions (CDI) approach. The study found that community participation based on the CDI approach can increase accessibility to vital interventions at the community level. This approach involves engaging community members in the provision of insecticide-treated bed nets, home case management for malaria, management of diarrheal diseases, treatment of schistosomiasis, and provision of food supplements against malnutrition. By involving the community in these interventions, access to maternal health services can be improved, particularly in areas where the CDI approach has not been previously implemented. This recommendation is based on the findings of the study conducted in two rural districts of Malawi and is aligned with the principles of Primary Health Care (PHC) strategy.
AI Innovations Methodology
Based on the provided information, it seems that the study focused on assessing the relevance of community-directed interventions (CDI) in improving primary health care (PHC) in rural areas of Malawi. The study aimed to explore the perspectives of health service providers and beneficiaries on existing PHC practices and the potential of community participation to strengthen PHC.

To improve access to maternal health, here are some potential recommendations based on the study findings:

1. Intensify community participation: The study suggests that community participation, based on the CDI approach, can be a realistic means to increase accessibility to vital interventions at the community level. This approach can be extended to include maternal health services, such as antenatal care, skilled birth attendance, and postnatal care.

2. Provision of insecticide-treated bed nets: The study highlights the importance of community participation in the provision of insecticide-treated bed nets. This intervention can help prevent malaria, which poses a significant risk to pregnant women and their unborn babies.

3. Home case management for malaria: Strengthening community participation in the management of malaria cases at home can improve access to timely treatment for pregnant women in remote areas where health facilities may be far away.

4. Management of diarrheal diseases: Community participation can be leveraged to improve the management of diarrheal diseases, which can have severe consequences for pregnant women and their infants. This can include community education on prevention, early recognition of symptoms, and appropriate treatment.

5. Treatment of schistosomiasis: Schistosomiasis, a parasitic infection, can have adverse effects on maternal health. Community participation can be utilized to increase awareness, prevention, and treatment of schistosomiasis in pregnant women.

6. Provision of food supplements against malnutrition: Malnutrition during pregnancy can lead to adverse maternal and fetal outcomes. Community participation can be harnessed to ensure the provision of food supplements to pregnant women in areas with high malnutrition rates.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Collect data on the current status of maternal health access in the target areas, including indicators such as antenatal care coverage, skilled birth attendance, postnatal care utilization, and maternal mortality rates.

2. Define simulation parameters: Determine the specific variables and indicators that will be used to measure the impact of the recommendations. For example, the increase in community participation, the number of insecticide-treated bed nets distributed, the percentage of households practicing home case management for malaria, etc.

3. Model development: Develop a simulation model that incorporates the baseline data and the defined parameters. This model should simulate the potential impact of the recommendations on the selected indicators of maternal health access.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the simulation model. This involves testing the model with different scenarios and varying the input parameters to understand the range of potential outcomes.

5. Impact assessment: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. This can include quantifying the expected increase in antenatal care coverage, skilled birth attendance, or reduction in maternal mortality rates.

6. Policy recommendations: Based on the simulation results, provide evidence-based policy recommendations to stakeholders, such as the Ministry of Health, NGOs, and community leaders, on how to implement the identified recommendations to improve access to maternal health.

It is important to note that the above methodology is a general outline and may need to be adapted based on the specific context and available data.

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