PMI Impact Malaria
This year, we’re approaching World Malaria Day with a vivid and shared understanding of the catastrophic impact that infectious diseases can have on our world. As we remain committed to defeating malaria—one of the world’s oldest and most devastating diseases—COVID-19 is a reminder that emerging infectious diseases pose a serious challenge in our work to end malaria.
Recognizing the burden of malaria in sub-Saharan Africa and the region’s fragile health infrastructure, the World Health Organization (WHO) has stressed that “ensuring access to core malaria prevention measures is an important strategy for reducing the strain on health systems.” PMI Impact Malaria, the global service delivery project of the U.S. President’s Malaria Initiative (PMI), supports the prevention of malaria infection, illness, and death through strengthening malaria service delivery—particularly medicine-based prevention for young children and pregnant women, the two populations most vulnerable to malaria.
The COVID-19 pandemic has underscored the crucial role of health care providers and community health volunteers in preventing and responding to the human toll of infectious diseases. To help advance the capacity of health workers and volunteers to provide robust malaria services, we collaborate closely with national malaria programs to improve the access, quality, and efficiency of malaria service delivery.
In 2019, we worked with national malaria programs on their seasonal malaria chemoprevention (SMC) campaigns to prevent malaria in about 3.7 million children. As malaria season nears in sub-Saharan Africa and challenges from COVID-19 threaten the region, PMI Impact Malaria is proud to be supporting the planning and implementation of SMC campaigns 2020 to continue to protect millions of children from malaria.
What does our work of malaria service delivery look like on-the-ground?
During this time when we’re so aware that public health connects us all, I want to especially thank you for your partnership in working to end malaria. I look forward to continuing to tell stories of the human impact of our work and, increasingly, sharing our country-driven results and lessons learned to advance malaria service delivery. Thank you for your interest and support.
PMI Impact Malaria is led by Population Services International (PSI) in partnership with Jhpiego, Medical Care Development International (MCDI), and UCSF.
Both photos credited to Mwangi Kirubi, PMI Impact Malaria
A scenic view of Lake Victoria welcomes you to the township of Sindo, in Kenya’s southwest corner. Colorful wooden fishing boats line the shore as groups gather to negotiate the sale of fish.
Women clean dishes while keeping a watchful eye on their children playing in the shallow water. Other women balance buckets of fish on their head as they depart for the market. It’s 7 a.m. and the bay has been a flurry of activity for three hours already.
The journey to this part of Kenya is long. Here in Suba sub-county, the road network is rugged and the only way to access Suba’s six islands is by boat.
Suba has a beautiful landscape but also, unfortunately, a very high incidence of malaria—a disease which, if not prevented and promptly treated, often leads to death and is a leading killer of children and pregnant women in this region.
Health Care that’s a Boat Ride Away
To access health care services from any of the six islands, residents must take a boat to the mainland. This can be costly and often impractical.
To create a stronger link between communities and malaria health care services—in Suba sub-county but also in other areas of the country—Kenya’s national malaria program has been working with county health management teams to train community health volunteers (CHVs) and community health assistants (CHAs).
Through these trainings funded by PMI Impact Malaria, the Kenyan government has enhanced the capacity of 268 CHVs and 28 CHAs to identify and address signs of malaria.
A Man on a Mission
“I noticed that my neighbors had very little information on illnesses common to our region, such as malaria,” Eric says. “The issue of access to basic health care was also very limiting, especially for pregnant women and mothers with young children.”
Eric felt strongly that he could be a link between his community and the information they needed to make informed health choices and adopt positive health-seeking behavior.
As a trained CHV, he taught families about the symptoms and dangers of malaria and explained the importance of sleeping under an insecticide-treated bed net. He mapped out homes with young children and pregnant women and embarked on a door-to-door campaign.
He discovered that out of the six women who were pregnant at the time, only one was attending antenatal visits. Antenatal care is crucial for preventing malaria in pregnancy because it’s during these visits with a health care provider that women receive a bed net and take anti-malaria pills.
To help convince his clients to attend monthly pregnancy visits, Eric reached out to the women as well as their spouses. “I knew that in order to succeed, I also needed to involve the men from the beginning,” he recounts.
Eric went a step further and registered all children under five years of age and expectant mothers at the Nyamrisra health facility, for follow up. This is the only health facility accessible to residents of Kibuogi island. Looking back, Eric is proud of how far his village has come. All the expectant mothers have started receiving the recommended doses of anti-malaria medication.
Asked why he keeps doing what he does, Eric says simply, “It’s for my people. I love my community and I want to help people in my village. I want to connect them with information so that they can know what is available to them. I am empowered and so I want to empower others.”
Written by Catherine Ndungu, PMI Impact Malaria (IM) Kenya. Contributions from Alexander Kaluoch and Moses Kidi, Jhpiego; and Anne Bulchis, IM Communications Manager.
All photos credited to Catherine Ndungu, PMI Impact Malaria.
A version of this story appeared as a blog post on the U.S. President's Malaria Initiative's website.
A warm, energetic hum seems to follow Amichia Solange as she goes about her day providing guidance, listening to heartbeats, administering medication with clean water, transitioning from one patient to the next, and sharing goodbye hugs as women head out the door.
At Mouyassue Rural Health Center in Cote d’Ivoire, Amichia is one half of the indispensable duo that provides medical care to women throughout all stages of pregnancy. Amichia and her colleague, the two midwives at the health center, together see more than 400 pregnant women a year.
What these pregnant women learn from Amichia, if they don’t already know, is that malaria infection in pregnancy is a major threat to their lives and the health of their babies.
Pregnant women are particularly vulnerable to malaria when they become infected because pregnancy reduces a woman’s immunity, increasing the risk of illness, severe anemia, and death. For the fetus, maternal malaria increases the risk of miscarriage, stillbirth, premature delivery, and low birth weight—a leading cause of child mortality. Last year, an estimated 11 million pregnant women in sub-Saharan Africa—29 percent of all pregnancies—were infected with malaria.
This reality is hugely consequential for women in Cote d’Ivoire because every single person in the country—a population of about 24 million people—is at risk of malaria throughout the entire year, with spikes of malaria transmission during the rainy season.
Fortunately, there are proven ways to protect pregnant women from malaria. One of Amichia’s patients, Boni Awa, learned of her heightened risk several years ago when she was pregnant with her first child. Now a mother of three, Boni gave birth to a healthy baby a month ago after attending routine antenatal (ANC) visits where she received preventive malaria care that helped keep her malaria-free throughout her pregnancy.
Boni prevented malaria during pregnancy by sleeping under an insecticide-treated bed net (ITN) every single night and taking antimalaria pills during three ANC visits with Amichia. The pills are part of a full therapeutic course, known as intermittent preventive treatment of malaria in pregnancy (IPTp), that is given to pregnant women at routine ANC visits, regardless of whether the woman is infected with malaria.
The World Health Organization (WHO) recommends IPTp in areas with moderate to high malaria transmission in Africa. In line with these recommendations, Cote d’Ivoire’s national guidelines state that all pregnant women should receive at least three doses of preventive treatment during pregnancy, with each dose given at least one month apart.
Through funds from PMI Impact Malaria, Boni received IPTp and an ITN for free.
When asked about her observations of preventing malaria in pregnancy among her patients, Amichia’s response is forthright. “I’ve noticed a decrease in malaria among women who adhere to my advice: those who come for monthly visits during pregnancy, take the malaria prevention pills, and use ITNs at home. My main challenge is getting women to come to the health center early in their pregnancies.”
In 2018, 54 percent of pregnant women at Mouyassue Rural Health Center received three or more IPTp doses during pregnancy. This year, in an effort to reach more pregnant women, the health center is doubling down on guidance and counseling that emphasizes the importance of on-time IPTp. During Boni’s most recent visit, for example, Amichia pointed out that Boni can play a key role in educating her female friends and relatives about the importance of this intervention.
To continue building capacity in providing malaria services, Amichia recently attended a PMI Impact Malaria-supported training for health providers run by Cote d’Ivoire’s national malaria control program. During this training, Amichia and her fellow participants were reminded of the need to give all eligible pregnant women IPTp during ANC visits, and also guided on steps to follow if the stock of medication is low or unavailable.
Among 36 African countries that reported on IPTp coverage levels in 2018, an estimated 31 percent of eligible pregnant women received the recommended three or more doses of IPTp, compared with 22 percent in 2017 and two percent in 2010, indicating considerable improvement in country uptake of this intervention.
With continued support, clear guidelines in countries, strong training and mentoring of health providers, and the antimalaria drugs available at health facilities, more pregnant women like Boni will be reached each year with this lifesaving intervention.
Sources: WHO World Malaria Report 2019, PMI, and PMI Impact Malaria
Header Photo Caption: Midwife Amichia Solange and her patient Boni Awa smile together outside Mouyassue Rural Health Center in Cote d’Ivoire. Credit: Mwangi Kirubi, PMI Impact Malaria
Written by Anne Bulchis, PMI Impact Malaria Communications Manager, and Kathryn Malhotra and Jacques N'dri Kouakou, PMI Impact Malaria Technical Advisors
A version of this story appeared as a blog post on USAID's Medium channel.
The miracle of birth and the making of mothers has long fascinated Jenifer Adjei. Now an accomplished midwife at the Oda District Hospital in Ghana, Jenifer helps expectant and new parents plan for and cope with the arrival of their babies.
Through her work, Jenifer has become all too familiar with the adverse effects of malaria in Ghana—especially malaria in pregnancy (MIP). While Ghana has made substantial gains in driving down malaria, with malaria-attributable death declining from 19% in 2010 to 1.5% in 2018, the disease still kills far too many Ghanaians.
Prior to treating malaria, the World Health Organization (WHO) recommends confirmation of malaria by either microscopy or a rapid diagnostic test (RDT). Despite subscribing to WHO’s framework for scaling up malaria diagnostic testing, treatment, and surveillance, the reports from health facilities in Ghana indicate low health worker adherence to malaria testing before treatment.
Jenifer recounts times at her hospital where patients with fevers were treated with antimalarials often without any testing—a practice that increases the risk of antimalarial resistance and fetal loss among pregnant women, and also contributes to drug wastage.
To improve malaria service delivery, PMI Impact Malaria (IM) has supported Ghana’s National Malaria Control Program (NMCP) and Regional Health Administration (RHA) in organizing health facility-based malaria case management trainings for health workers. To determine which facilities were most in need of immediate trainings, IM collaborated with the RHA to prioritize districts and facilities with adverse malaria indicators—ultimately selecting 10 high burden facilities per region.
The training curriculum included the treatment of severe and uncomplicated malaria and MIP, using a quality improvement model that emphasizes the uptake of knowledge and the corresponding behavior change that should result. During the training, Jenifer and her hospital team identified non-testing of uncomplicated malaria before treatment as a challenge—with up to 60% of suspected uncomplicated malaria cases not tested before treatment. Three months after the training, presumptive treatment had dropped to zero.
Today, every patient at Oda District Hospital who shows signs of malaria undergoes microscopy or RDT before treatment. Jenifer has observed that conducting RDTs before treatment has significantly reduced patient wait times and pressure on laboratories. According to her, ‘‘It’s also improving the quality of care and our antimalarial medicines are now used rationally.”
Jenifer is just one of over 1,200 health workers in 37 high burden health facilities across Ghana who has benefitted from the malaria case management training. To continue advancing universal testing of suspected malaria cases, this year IM is supporting the NMCP to scale up on-site training and supportive supervision to 17,475 health workers in 2,140 health facilities. In light of these efforts, 2020 should be a remarkable year for improving the quality and efficiency of malaria diagnosis and treatment in Ghana.
Written by Emmanuel Attramah, Knowledge and Communications Officer, PMI Impact Malaria (IM) Ghana. Contributions from Amos Asiedu, Surveillance, Monitoring and Evaluation Advisor, IM Ghana; Pius Affipunguh, Regional Technical Advisor, IM Ghana; Eric LaFary, Peace Core Volunteer; and Anne Bulchis, IM Communications Manager.
Data Source: Ghana Health Service District Health Information Management System
Header Photo Credit: Emmanuel Attramah for PMI Impact Malaria. Caption: Jenifer Adjei, midwife-in-charge at Ghana’s Oda District Hospital, tests a patient for malaria using a rapid diagnostic test (RDT).
PMI Impact Malaria is led by Population Services International (PSI) in partnership with Jhpiego, Medical Care Development International (MCDI), and the Malaria Elimination Initiative (MEI) at UC San Francisco.
Kakamega, Kenya — Nineteen-year-old Jane* delivered a full-term baby in a health facility near her home without complications. When the new mother was discharged a day later, there was no hint of any problem. She was happy to go home and care for her newborn.
However, six hours later, Jane spiked a fever. She experienced convulsions and confusion, and was refusing to breastfeed.
Jane’s family rushed her back to the health facility, where a clinician mistakenly diagnosed her with postpartum pre-eclampsia—a rare condition characterized by high blood pressure and excess protein in the urine, which, like severe malaria, can cause convulsions. Jane lost consciousness and immediately was referred to Kakamega County Teaching and Referral Hospital for specialized treatment. She was admitted to the intensive care unit due to her altered consciousness and put on oxygen.
Clinicians there suspected that Jane had developed severe malaria. They quickly ordered a malaria microscopy test. Sure enough, Jane tested positive for malaria and immediately received treatment for severe malaria, using Kenya’s recommended regimen of IV artesunate. These clinicians had recently participated in a refresher course on the diagnosis and treatment of severe malaria, run by Kenya’s National Malaria Control Program (NMCP) and supported by PMI Impact Malaria (IM).
Dr. Erick Anyira, the consultant doctor who saw Jane and is a trainer of trainers with NMCP/IM, felt there was a strong link between the recent training and how well Jane’s case was managed. According to him, “Were it not for the severe malaria training, Jane’s case could have been missed and would have been another funeral.”
During Jane’s hospitalization, treatment with IV artesunate led to her full recovery. She regained consciousness on the second day and was discharged a few days later to rejoin her newborn baby.
Timely diagnosis and treatment of severe malaria are critical to fighting malaria, saving lives, and ultimately achieving malaria elimination. To date, IM has supported Kenya’s NMCP in training and mentoring 84 clinicians on the identification and treatment of severe malaria.
But a lack of national data on severe malaria and malaria deaths has complicated Kenya’s fight against this mosquito-borne disease that, although preventable and curable, globally killed an estimated 405,000 in 2018 (WHO).
IM has focused its resources in Kenya on supporting the NMCP to close this gap by enhancing the availability of data on malaria in its focus counties. A training in late 2019 prompted the review and documentation of inpatient malaria data in the western Kenya counties of Kakamega, Bungoma, Busia, and Vihiga. In a three-month period following the training, 12 health facilities recorded more than 5,000 admissions and more than 600 deaths related to malaria. The findings: Malaria accounted for one-quarter of all hospital-related admissions in the four counties, and 12 of every 100 people admitted were likely to die from malaria.
Because accurate data lead to timely decisions and ultimately strengthen the quality of health services, IM is supporting Kenya’s NMCP to take positive action in communities and in the context of outpatient visits and inpatient stays, while also ensuring that community health workers are able to identify and refer severe cases of malaria to appropriate health centers.
Without a doubt, Jane and her family can attest to the personal impact that this important work has already had on strengthening malaria service delivery in Kenya.
*Not her real name.
Written by Justus Nondi and Catherine Ndungu. Contributions from Dr. Willis Akhwale, Chief of Party for PMI Impact Malaria in Kenya, and Anne Bulchis, PMI Impact Malaria Communications Manager.
Header Photo Credit: Mwangi Kirubi for PMI Impact Malaria. Caption: Emily Atieno Achieng at Ahero County Hospital in Kisumu, Kenya.
Drocas Dako knows how to multitask. During Mali’s seasonal malaria chemoprevention (SMC) campaign, she’s out the door by 7 a.m. to distribute free pills that protect children from malaria. She goes from one household to the next, the whole time with her baby on her back.
At one of the first homes, Drocas is welcomed with friendly greetings and chatter as she and the household’s grandmother, Assitar, collect the young children and sit down together in the shade of a nearby tree.
Thinking back to the training she received from a nurse at the closest health clinic, Drocas administers the pills to a 4-year old boy, Alou, and speaks kindly as she reminds Assitar of the importance of checking off on Alou’s SMC card that the second and third doses were indeed given later at home.
That afternoon, Drocas emerges from visiting another household in the Segou region and makes a mark with chalk next to the home’s door to signal that she has visited the house and distributed medicine, as is the custom during SMC campaigns. Drocas managed to reach all six of the eligible children living there.
During the first campaign in July, Drocas reminded Assitar and other caregivers that she would be back almost exactly one month later to administer another dose, and would return again in both September and October.
For young children in Mali and other countries across the Sahel region of Africa, Drocas’ work is lifesaving. SMC is a campaign-style intervention that involves giving an antimalarial medicine at monthly intervals for a maximum of four months during the rainy season when malaria transmission spikes.
SMC has been shown to dramatically reduce malaria cases and deaths in children under 5 years of age, which is the most vulnerable age group affected by malaria. In 2017, according to the World Health Organization, they accounted for about 60 percent of all malaria deaths worldwide. That same year, an estimated 15.7 million children were protected through SMC campaigns, but 13.6 million children who could have benefited from SMC were not reached. Insufficient funding is one of the most common reasons that countries cite to explain this coverage gap.
Through the generosity of the American people, the U.S. President’s Malaria Initiative (PMI) has supported nine countries this year in their efforts to prevent childhood malaria through SMC from July to October. With PMI support, it is expected that about 5 million children will be reached this season.
PMI Impact Malaria has been working with national malaria control programs in Cameroon, Mali, and Niger to support their SMC campaigns and will have reached an estimated 3.7 million children altogether. Here is a snapshot of three children who are benefitting right now from SMC in each of those countries:
Farida, age 3, lives with her parents and two siblings in Niger. Thanks to PMI Impact Malaria's support of Niger’s SMC campaign, Farida has had the chance to take free pills every month until the rainy season is over. Farida was one of 534,389 children in Niger’s Dosso Region who received antimalarial medicine during August’s SMC cycle. Her mother said, “I want her to receive this prevention because I know malaria can kill her.”
Community health worker Fatimatou Ibrahim administers malaria prevention pills to Ruth, age 4, who is so excited to attend school for the first time with her older brother and sister. In July, she was one of nearly 1.6 million children who received free pills during Cameroon’s SMC cycle in the North and Far North regions. The pill should keep Ruth from getting malaria so she can go to school and learn.
Karotumay holds her son, Bedy, age 2, and the card that shows he just received an antimalarial through Mali’s SMC campaign. As a mother of six, she knows the importance of protecting children from malaria. “When children get malaria, they vomit and have such a bad fever that they can convulse and die. It’s very serious and treatment at the health center can be very expensive,” says Karotumay. “In the past, Bedy’s older sister and brothers received SMC to prevent malaria. I know it works.”
Supporting SMC is one hugely impactful way that PMI Impact Malaria is working with countries to fight malaria and save children’s lives. Read more about SMC and PMI Impact Malaria's support in this August 2019 blog post: Preventing Childhood Malaria through Seasonal Malaria Chemoprevention (SMC): Three Big Lessons.
Written by Anne Bulchis, PMI Impact Malaria Communications Manager. Contributions from Kathryn Malhotra and Yves-Marie Bernard, PMI Impact Malaria Technical Advisors.
Sources: World Health Organization—Malaria Key Facts and SMC
Header Photo Credit: PMI Impact Malaria. Caption: A community health worker administers antimalarial medicine to a child during the first cycle of Mali's seasonal malaria chemoprevention (SMC) campaign in July.
Children under five years of age are the most vulnerable group affected by malaria. In 2017, they accounted for about 60% of all malaria deaths worldwide. Fortunately, there are proven ways to prevent malaria in this population. One is seasonal malaria chemoprevention (SMC)—a campaign style public health intervention to prevent and treat malaria infection in young children living in the Sahel region of Africa. SMC involves giving an antimalarial medicine at monthly intervals for a maximum of four months during the rainy season when malaria incidence dramatically increases. The World Health Organization (WHO) has recommended SMC since 2012. (For those unfamiliar with SMC, learn more here: https://www.pmi.gov/how-we-work/technical-areas/seasonal-malaria-chemoprevention.)
This year, PMI Impact Malaria (IM) has been supporting National Malaria Control Programs (NMCPs) in Cameroon, Mali, and Niger in their work to plan and implement SMC campaigns. Cameroon held its second SMC cycle from August 1-5 and both Mali and Niger are running their second cycles this week. Within these three countries, SMC in IM’s target intervention areas will reach an estimated 3.7 million children altogether. Simply put, this intervention will save the lives of many children.
Because SMC is resource-intensive with children’s lives at stake, it’s imperative that countries consistently improve their delivery of the intervention. IM works closely with NMCPs to support them in this endeavor. Together, we think about how to improve access, efficiency, and quality through these three overarching questions:
In getting ready for this year’s campaigns, our IM teams in Cameroon, Mali, and Niger reflected on what the NMCPs and other partners did in previous years. This review of past campaigns through coordination meetings, discussions, and analyses of reports and data allowed IM and NMCPs to get up to speed on lessons learned and use these to strengthen planning for 2019 campaigns. Here are the three big lessons that have helped to plan for SMC success:
The early bird catches the worm
It’s vitally important to start planning early. Really early—almost a full year ahead of the campaign. With the seasonality of rainfall determining when SMC can be most impactful, the NMCP must work backwards and ensure that all key steps can be carried out in plenty of time ahead of the campaign. (See the key activities and timeline mapped out in the graphic below.) Planning early involves thinking carefully about competing priorities because the district health teams supporting the campaign also work on a wide variety of other health areas. If strategic planning doesn’t happen in advance, these teams could be pulled into other health activities when the campaign needs them most.
It’s crucial that the NMCP work with district health teams and implementing partners, such as IM, to identify any gaps and come up with solutions far in advance of the campaign. One area that benefits from significant attention during the “microplanning and validation” stage is data. Key elements for a successful campaign include a map of data flow, identification of entry points where data quality can be enhanced, a robust data analysis framework, and a plan to ensure there will be enough staff to handle data entry, management, and analysis—both during and after the campaign. Teams must anticipate potential weak points in the data flow (which could lead to poor quality of data) and develop a coherent data quality plan at the community, district, regional, and national levels to mitigate the possibility of these weak links and ensure that data will be processed in a timely manner.
All hands on deck
SMC success is impossible without a workforce that is sufficient in size and well trained. We know from all campaign style activities that it takes a huge collection of actors to make it all happen. The NMCP must be able to readily recruit SMC staff that can mobilize communities, deliver the intervention, and supervise and troubleshoot in communities and at the district level.
In planning for the campaigns that started in July across all three countries, IM closely supported NMCPs in training hundreds of community level distributors—most often community health workers—who go door-to-door during each campaign cycle to administer antimalarial medication. In addition, IM recruited a small group of temporary district-based SMC staff who have been working hand-in-hand with IM team members and NMCPs to ensure a successful campaign. One of their most significant tasks is conducting supervision visits. During these visits, temporary SMC staff follow up with community level distributors to help ensure that distributors are following through on all the practices they were trained in—for example, sharing information about SMC in an effective way so that families are clear on how the campaign will benefit their children.
In Mali, temporary SMC consultants work at the district level to respond to immediate technical and operational needs during SMC implementation. According to Dr. Beh Kamate, IM Technical Advisor in Mali, the SMC consultants are crucial because “they provide a strong linkage between the district and community distribution activities, enhance quality assurance, and work alongside national health providers to review SMC data reporting.”
It takes a village
Communities need to know what to expect. For this reason, community mobilization campaigns must be both highly visible and targeted. For some communities this means using radio promotions to get out key messages. In others, the most effective messengers are community mobilizers (i.e., town criers) who remind young children’s caregivers that SMC is coming soon. Trusted faith leaders also play an important role in getting out the message. NMCPs have been working to ensure that everyone involved is aware of the value of SMC as a lifesaving intervention and understands the importance of taking all three doses of antimalarial medication during each of the four campaign waves.
Cameroon, Mali, and Niger all launched their SMC campaigns in July and will conduct four cycles in total, finishing in October. NMCPs in these countries have built their SMC planning and implementation upon a solid foundation of past SMC campaigns, enabling them to carry out this vital intervention better than ever before. IM is partnering with these three countries to look more deeply at what’s working well, what isn’t, and why—while also helping the NMCPs to distill and apply cross-country learnings. We look forward to taking you along on our journey through SMC as we share the impact of this lifesaving intervention on children and families in Cameroon, Mali, and Niger!
Written by Kathryn Malhotra, PMI Impact Malaria Technical Advisor, and Anne Bulchis, PMI Impact Malaria Communications Manager. Contributions from Tabitha Kibuka, PMI Impact Malaria M&E Advisor, and Gladys Tetteh, Malaria Director at Jhpiego and Malaria Technical Leader with PMI Impact Malaria.
Header Photo Credit: Natalie Hendler for PMI Impact Malaria. Caption: Community health worker Fatimatou Ibrahim administers antimalarial medicine during the second cycle of Cameroon’s SMC campaign in August 2019.
Almost half the world’s population is at risk of malaria. Pregnant women are particularly vulnerable to the disease when they become infected because pregnancy reduces a woman’s immunity, increasing the risk of illness, severe anemia, and death. For the fetus, maternal malaria increases the risk of miscarriage, stillbirth, premature delivery, and low birth weight—a leading cause of child mortality.
Globally, malaria in pregnancy (MIP) contributes to about 10,000 maternal deaths and up to 200,000 newborn deaths each year. The World Health Organization (WHO) and the U.S. President’s Malaria Initiative (PMI) agree that MIP is a significant global health problem that has been neglected for too long. In Africa, 30 million women living in malaria-endemic areas become pregnant each year. As PMI’s flagship global service delivery project, PMI Impact Malaria is supporting numerous sub-Saharan African countries in their efforts to combat MIP.
Following WHO guidelines, PMI Impact Malaria supports a three-pronged approach to the prevention and management of MIP:
WHO updated its IPTp guidelines in 2012 to recommend providing the medicine sulfadoxine-pyrimethamine (SP) at every scheduled antenatal care (ANC) visit after the first trimester, with doses administered at least one month apart until delivery.
In Sierra Leone, where the entire estimated population of 6.5 million is vulnerable to malaria, PMI Impact Malaria is working with the National Malaria Control Program (NMCP) and the Directorate of Reproductive and Child Health (DRCH) to improve the quality and accessibility of the three-pronged approach through ANC facilities and in communities. Despite progress achieved in recent years, key indicators show that health providers in the country are struggling to follow MIP guidelines.
While three-quarters of pregnant women in Sierra Leone attend at least four ANC visits, IPTp administration falls after the first visit and drops dramatically after that (1st dose: 96% of women; 2nd dose: 69%; and 3rd dose: 27%). Other critical roadblocks are also apparent. These include:
To tackle these challenges, PMI Impact Malaria is supporting the NMCP and the DRCH to reinvigorate Sierra Leone’s MIP Technical Working Group (TWG), creating a structure to coordinate stakeholder efforts, advocate for funds and strategic prioritization, monitor progress towards targets, and strengthen national integration and collaboration across all levels of the health system. The MIP TWG consists of government directorates, academic institutions, civil society, international donors, implementing organizations, and other key stakeholders.
The Working Group is heavily focused on ensuring that all guideline, policy, job aid, and strategy documents pertaining to MIP and ANC at the national level are aligned with WHO recommendations. This includes reviewing and updating supportive supervision checklists to reflect the latest guidance, including the Outreach, Training and Supportive Supervision Plus (OTSS+) MIP checklist. PMI Impact Malaria created this tool using country learnings to improve provider performance through quality supportive supervision at the facility level.
Another avenue for reduced malaria burden comes from the fact that Sierra Leone is one of the only PMI focus countries that promotes IPTp through traditional birth attendants (TBAs) at the community level. The MIP TWG will coordinate centrally to ensure maximum uptake of IPTp by pregnant women through the country’s 1,888 TBAs.
Many other countries in sub-Saharan Africa are doubling down on activities to better prevent and manage MIP, which includes experimenting with service delivery outside of just ANC visits. PMI Impact Malaria will collaborate with Sierra Leone’s NMCP to share best practices and lessons learned from the country’s renewed focus on advancing MIP activities. Broader knowledge of Sierra Leone’s experience enhances cross-country and global learning which will help to keep greater numbers of women and infants safe and healthy from the burden of malaria.
Written by Keith Esch, PMI Impact Malaria Technical Advisor; Kwabena Larbi, PMI Impact Malaria Sierra Leone Chief of Party; and Kumba Wani Lahai, MIP Focal Point from Sierra Leone’s NMCP. Contributions from Gladys Tetteh, Malaria Director at Jhpiego and technical leader with PMI Impact Malaria.
Sources: WHO, U.S. President's Malaria Initiative Technical Guidance (Feb 2017), Sierra Leone Multiple Indicator Cluster Survey (2017)
Photography credit: Mwangi Kirubi for PMI Impact Malaria, Kenya, 2018.
Malaria is a major public health problem in Niger. It is the country’s primary cause of illness and accounts for half of all recorded deaths. While the entire population of Niger is at risk of malaria, children are especially vulnerable when they become infected because they have little to no immunity to the disease. In Niger, children under five years of age account for about 62 percent of the burden of malaria and 75 percent of malaria-related deaths. The country’s national malaria control program (NMCP) supports a number of prevention strategies, including seasonal malaria chemoprevention (SMC) to reduce childhood deaths from malaria.
SMC was a centerpiece of discussions during U.S. Ambassador to Niger Eric P. Whitaker’s June 19-21 visit to the Tahoua Region. When stopping by the Regional Hospital Centre, Founkoye and Kofan Tahoua Integrated Health Centers, and the National Office of Pharmaceuticals and Chemicals Warehouse, Ambassador Whitaker spoke with a variety of health care providers and health officials. Through these converations, he developed a strong understanding of the state of malaria control and prevention in the region and became familiar with the impact that the U.S. President’s Malaria Initiative (PMI) has had in Tahoua.
All stakeholders present cited the NMCP’s SMC campaign last year as an effective strategy that reduced childhood malaria mortality in 2018. PMI supported SMC in Niger through PMI Impact Malaria and, for the last several months, PMI Impact Malaria has been working closely with the NMCP to plan for Niger's upcoming SMC campaign. The first of the four campaign waves is scheduled to start on July 29. With that topic at hand, the people of Niger thanked the contribution of the American people and also expressed their wish that the U.S. continue to support efforts to end malaria in the region.
On Ambassador Whitaker’s three-day U.S. Embassy mission in Tahoua, he was accompanied by Ms. Els Mathieu, Activity Manager for PMI in Niger, and the Director of the American Cultural Center in Niger. Supporters included the Governor of the Tahoua Region, representatives of Niger’s Ministry of Heath, the country representative for Population Services International (PSI) in Niger, and the Chief of Party for PMI Impact Malaria in Niger.
Written by Koko Daniel, PMI Impact Malaria Niger Chief of Party, and Maman Badamassi, Niger NMCP Community Activity Manager
Source: PMI’s Niger page
Photography credit: PMI Impact Malaria Niger for both photos
Today, World Malaria Day, is a time for all of us to recognize and reflect on our collective action and achievements in the fight to end malaria, especially over the last year.
As the flagship global service delivery project of the U.S. President’s Malaria Initiative (PMI), PMI Impact Malaria stands with the RBM Partnership to End Malaria and other partner organizations in promoting “Zero Malaria Starts With Me” – a grassroots campaign that aims to keep malaria high on the political agenda, mobilize resources, and empower communities to take ownership of malaria prevention and care.
We understand that progress against malaria has stalled and so we affirm WHO’s view that “urgent action is needed to get the global response to malaria back on track – and ownership of the challenge lies in the hands of countries most affected by malaria.” PMI Impact Malaria lives and breathes this.
We support national malaria control programs in PMI focus countries as they fight malaria and save lives by strengthening diagnosis, treatment, and drug-based prevention, particularly for children and pregnant women. As our project enters its second year, we are implementing, learning, sharing best practices and lessons learned, and, ultimately, advancing malaria service delivery.
I invite you to learn with us by exploring where our project has been and where we are going:
Thank you for your time, support, and partnership as we work together to accelerate progress towards a malaria-free world.
Senior Project Director, PMI Impact Malaria
Photography credit: Mwangi Kirubi for PMI Impact Malaria, Kenya, 2018
February 2019 saw PMI Impact Malaria celebrate its first official year as the U.S. President’s Malaria Initiative’s (PMI) flagship global service delivery project. As of today, World Malaria Day 2019, we are running offices and implementing activities in ten countries, with more coming on board all the time.
Following a delayed start, PMI Impact Malaria (IM) kicked off in April 2018. With the end of MalariaCare and the pending completion of the Maternal and Child Survival Program (MCSP), many PMI focus countries were experiencing a gap in service delivery support for malaria case management and the prevention and treatment of malaria in pregnancy (MIP). With no time to lose, a tiny but growing IM headquarters (HQ) team sprang into action to fill those gaps by collaborating with National Malaria Control Programs (NMCPs) and maternal and child health divisions of Ministries of Health (MOH) to design and implement prioritized activities. One year and a few months later, we are in various stages of carrying out key on-the-ground activities, including revising and updating national malaria control strategies and guidelines, conducting baseline assessments, developing trainings for facility-based and community-based health workers, and microplanning for seasonal malaria chemoprevention (SMC) campaigns. This list goes on, all happening on a daily basis.
The lessons learned during project start-up are fresh in our minds. These are the top five strategies we used to get this global health project up and running:
Building on solid foundations
From the outset, IM understood that we were not starting from scratch. With the crucial support of PMI and other global malaria partners such as the Global Fund, UNICEF, and the Bill & Melinda Gates Foundation, the NMCPs in our focus countries have achieved remarkable progress in driving down the burden of malaria. Members of the IM consortium have the advantage of having been a part of previous PMI-funded service delivery projects, and therefore were able to bring the technical expertise, institutional memory, and established relationships into this new contract.
For malaria service delivery in each country, IM has worked with NMCPs to dig under the surface to identify the systems already in place, understand key strengths and challenges, and recognize the opportunities that exist to push the needle further in bringing these countries towards malaria elimination.
We have built our country offices based on IM consortium partners who already had a country presence and relationships on the ground. For example, in Mali, PSI had supported the NMCP under the MalariaCare project to address malaria case management. They have been able to recruit the technical experts who successfully led those previous interventions and can take them to the next level, while utilizing PSI’s existing offices in Bamako as well as the Mopti region to quickly establish a robust program.
Listening and learning
While IM has drawn on lessons from the past, we have been intentional about not just replicating previous projects. During start-up, IM took the time to listen and learn from our in-country counterparts. In most countries, we started off by conducting scoping visits of 1-2 weeks. During these visits, IM held conversations with NMCPs and other MOH stakeholders from national to district level; met with nurses, midwives, and clinical officers at health facilities; went into communities to speak with community health workers; and talked with technicians in laboratories. IM staff also met with key stakeholders, including PMI, other partners working on malaria in-country, and multiple governmental counterparts.
Following these exchanges, we emerged with an understanding of not just what the needs were, but also a clear picture of the different channels available to meet those needs. For example, in Cote d’Ivoire, the NMCP expressed a pressing need to reinvigorate and accelerate their community-based malaria case management. IM collaborated with the NCMP, the Department of Community Health, UNICEF, and other community partners to re-mobilize 545 community health workers from four districts within the first six months of implementation. These workers are leading community-based malaria prevention and treatment services as IM continues to scale-up in additional districts.
Maintaining a “can do” philosophy
During start-up, there was so much to accomplish in a condensed period of time. At HQ and in countries, we needed to find office space, recruit and hire staff, procure basic office equipment, create templates for everything, and develop detailed annual work plans and budgets for our core activities and each country. While our team was energized by working on a new project, we also experienced times when we felt overwhelmed and impatient. But we supported each other during these moments and maintained a teamwide “can do” philosophy throughout this first year. We critically thought through all of the project’s needs, and then prioritized and tackled them.
For example, Niger’s NMCP needed IM to support the roll out of their annual seasonal malaria chemoprevention (SMC) campaign in the regions of Dosso and Tahoua approximately one month before the campaign. Despite the lack of staff and other logistical challenges, IM realized the critical importance of ensuring that a successful campaign took place. With funding from PMI and help from PSI staff in Niger, we were able to make it happen. Borrowing staff from other projects, bringing in technical assistance from HQ, and working closely with the NMCP to execute detailed plans, IM was able to reach 90% or more of the targeted number of children during each of the four rounds of the campaign. The flexibility and agility that IM displayed in Niger is being translated to our other programs globally as we continually take the approach that we “can do” it!
Finding the right people for the job
At IM, the number one criterion for all employees—whether they are Chiefs of Party, Technical Advisors, M&E Officers, Finance Managers, Administrative Assistants, or Drivers—is a passion for the elimination of malaria in the countries where we are working. In some of our countries, like Ghana and Mali, IM was fortunate to recruit staff who had previous experience with the PMI-funded MalariaCare project. But in other countries, especially those new to PMI, there were few candidates who had previous experience working on malaria service delivery projects.
IM developed numerous job descriptions to meet the varying needs for each country and then actively recruited candidates through open advertisements and wide dissemination of opportunities via country-level networks. IM HQ and consortium partner staff conducted a rigorous interview process to identify high quality managers and technical advisors who not only met the required qualifications, but also embodied the dedication and drive that will lead the project to success. Between July-December 2018, IM recruited and onboarded more than 50 new staff.
Establishing clear systems and processes
Managing a complex and multi-faceted global health project with multiple consortium partners requires the creation, socialization, and utilization of clear systems and processes that enable each of us to carry out our work as effectively as possible. At HQ we focused extensively during the start-up period on thinking through these processes in order to efficiently deliver project interventions while staying compliant with the IM contract. We have developed checklists, templates, guidance documents, roles and responsibility matrices, and more. Results of these processes include work plan, budget and reporting templates, travel request and approval checklists, procurement guidance, new hire and biodata review checklists, and many, many trackers and project guidance briefs. While these systems will continue to evolve as the project grows, they helped enormously to set the stage for clarity in how to “get things done.”
Overall, the start-up period of any global health project is an incredibly and unavoidably hectic time. But IM’s shared vision for open communication among all partners, finding efficiency and innovation within regulations, and dedication to quality service delivery has set the stage for continued success in the months and years to come.
Written by Natalie Hendler, PMI Impact Malaria Country Operations Director
PMI Impact Malaria is led by Population Services International (PSI) in partnership with Jhpiego, Medical Care Development International (MCDI), and the Malaria Elimination Initiative (MEI) at UC San Francisco. The group photo is from our 2018 IMPACT global meeting.
Countries in West and Central Africa are increasingly decentralizing resources and decision-making for health as part of a sustainable strategy to improve health system quality and efficiency. In Cote d’Ivoire, decentralization is part of the Ministry of Health’s (MoH) new strategic approach and is reflected in the country’s malaria planning and programming. One recent example is the National Malaria Control Program’s (NMCP) launch of a program that embeds malaria technical advisors within regional MoH offices. Each Regional Technical Advisor (TA) is based in one regional office and responsible for two regions, traveling frequently to work on malaria activities around both regions.
To help ensure a strong start, a group of stakeholders held a three-day workshop at the end of November 2018 for the launch of the new Regional TA program. Participants included the NMCP, the National Maternal and Child Health Program (PNSME), the Division on Community Health (DSC), the U.S. President’s Malaria Initiative (PMI) country office in Cote d’Ivoire, PMI Impact Malaria, other PMI implementing partners—including Breakthrough Action, Human Resources for Health 2030 (HRH2030), Integrated Health Supply Chain-Technical Assistance (IHSC-TA), and MEASURE Evaluation—UNICEF, Save the Children, and the ten new TAs.
Government stakeholders and PMI partners presented different sessions to the TAs, which covered the objectives of the TA role and key malaria technical areas, including diagnosis and treatment, malaria in pregnancy, severe malaria, stock management, and data quality. The TAs (pictured below) were given their site placements at the end of the workshop and have been in their assigned regions since then.
One of the new TAs, Dr. Hans Bahibo, explained that he is enthusiastic about his new role because he thinks the regional model will address many of the operational challenges that he experienced while working as a monitoring and evaluation specialist with the NMCP. According to Dr. Bahibo, “these difficulties limit the ability of the NMCP to achieve the objectives set in its strategic plan for the fight against malaria.” He feels strongly that the role of TAs in providing technical and operational support will be very useful for the NMCP and “there is no doubt that it will allow for improvement of national malaria control indicators.”
TAs were first tasked with supporting the rollout of a training for community health workers and a training of trainers, both centered on a new integrated community case management (iCCM) package. The daily work and activities of the TAs varies based on the needs of the regions and districts they cover, but they each play an important role in working to ensure that malaria services are accessible and high quality. The TAs receive ongoing coaching and mentoring from the NMCP and PMI Impact Malaria and participate in quarterly meetings to discuss activity updates and new initiatives for the TAs to work on.
Cote d’Ivoire’s Regional TA program is an important resource to strengthen capacity and coordination at the regional level and beyond, both across the country and in the PMI intervention districts. The lessons learned from this program will be useful from region-to-region and will inform the programming and activities of other national health systems. Stay tuned as we learn more!
Written by Kathryn Malhotra and Silue Mamadou, PMI Impact Malaria Technical Advisors
Photography credits from top to bottom: Benjamin Schilling for the first photo; PMI Impact Malaria Cote d'Ivoire for the second photo.
Ricki Orford is PMI Impact Malaria’s Senior Project Director, responsible for guiding the strategic, technical, and operational direction and delivery of the project. He brings 20 years of malaria expertise to the team. Among other experiences, Ricki worked with the World Health Organization (WHO) to provide technical support to national malaria control programs in southern Africa, led Population Service International’s (PSI) in-country Malawi team and programming, and most recently served as PSI’s Director of Malaria, Child Survival and Sanitation.
Read on to learn more about PMI Impact Malaria and hear Ricki’s perspective on the project’s role in the global fight to end malaria.
This project you’re leading, PMI Impact Malaria, is funded by the U.S. President’s Malaria Initiative (PMI) to “advance malaria service delivery.” What does that mean in practice?
All our project activities, whether taking place in countries or at the global level, are driven by our mission to save lives and reduce illness from malaria by strengthening diagnosis, treatment, and drug-based prevention. We’re focused on the populations that are most at risk, which translates to children and pregnant women in countries with a high malaria burden. To achieve our mission, we focus our work mainly around three key intervention areas: malaria in pregnancy (MiP), seasonal malaria chemoprevention (SMC), and the diagnosis and treatment of malaria.
The U.S. President’s Malaria Initiative (PMI) supports 27 countries across Africa and Asia and we currently are working closely with 12 of them. The national malaria control programs (NMCPs) in these countries lead on-the-ground activities while our team provides implementation support and technical assistance to the NMCP on behalf of PMI. We’re helping NMCPs tackle malaria service delivery challenges by working to:
We’re also focused on supporting global malaria technical leadership by harnessing our teams’ expertise across several key global malaria technical working groups. Through that involvement and our longstanding relationships with NMCPs, our team is strengthening the linkage of global dialogue with country experiences to improve malaria service delivery and accelerate the translation of country learning into international practice.
With the backdrop of the global malaria landscape, why is the focus and timing of this project so relevant?
Unfortunately, it’s clear that global progress in the fight to end malaria has stalled. The most recent World Malaria Report showed that, for the second consecutive year, cases are rising. In 2017, approximately 70% of all malaria cases (151 million) and deaths (274,000) were concentrated in 11 countries: 10 in Africa (Burkina Faso, Cameroon, DRC, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and Tanzania) and India.
To boost progress in these highest burden countries, WHO has developed a new “high burden to high impact” approach based on four key pillars:
PMI Impact Malaria is currently active in almost half of these countries and is well positioned to support WHO’s new strategy through our country-led programming and data driven approaches to achieving results, generating evidence, and distilling lessons learned. We understand that our project’s work is needed now more than ever.
A core function of public health is preventing disease. Could you tell me about a malaria prevention activity that PMI Impact Malaria is supporting?
Malaria threatens the lives of billions of people around the world and accounts for more than 400,000 deaths every year, the majority of whom are children under five. One of our project’s key interventions, Seasonal Malaria Chemoprevention (SMC), is specifically designed to prevent and treat malaria in young children. SMC involves giving an antimalarial medicine made up of two components, sulphadoxine pyrimethamine (SP) and amodiaquine (AQ), at monthly intervals for a maximum of four months during the rainy season when malaria incidence dramatically increases. The goal is twofold: 1) treat any existing malaria infections; and 2) prevent malaria by maintaining protective drug concentrations in the blood for the entire transmission season.
According to WHO, in 2017 an estimated 15.7 million children were protected through SMC campaigns, but 13.6 million children who could have benefited from this intervention were not reached. Two of the most common reasons for the coverage gap reported by countries include insufficient resource allocation and delayed disbursements of funding, which hinder the ability of countries to plan and procure medicines in time for the malaria transmission season.
Our team is currently working with NMCPs in Cameroon, Mali, and Niger to help address these and other challenges and will support this work again in these same countries in 2020, with the addition of Ghana (and potentially other countries, as well). We are also working with partners at the global level to advocate for additional resources to close this funding gap.
Based on project activities so far, do you have an example that would help someone understand how your team provides support to NMCPs as they lead work on-the-ground?
PMI Impact Malaria supports NMCPs in carrying out their malaria service delivery work more efficiently and effectively. An early example of this is the implementation support that we provided to the Niger NMCP’s 2018 SMC campaign in the regions of Dosso and Tahoua.
Our project was just getting up and running in Niger and had not yet hired in-country staff, but we recognized the time sensitive nature of SMC campaign work. Thanks to funding from PMI, we recruited substantial help from the PSI staff in Niger and worked closely with them and the NMCP to develop a budget and work plan, secure transportation for community health workers, and arrange for delivery of commodities from districts to health centers and from health centers to SMC teams. We also coordinated extensively with the NMCP to align procedures with the microplans for each region and ensure timely preparation before each SMC campaign wave.
Through our rapid mobilization of staff and resources, our team was able to help the NMCP cover two key regions during a critical malaria transmission season. The campaign resulted in a total of about a million treatment doses administered, with each of the four campaign waves reaching 90% or more of the targeted number of children. In collaboration with the NMCP, we are currently compiling lessons learned and will share these broadly to help improve future campaigns in Niger and inform the planning of SMC campaigns in other countries.
So, using this example, you can see that we promote more efficient and effective programming by “getting into the weeds” with each country, but we also do it by providing our countries with the knowledge and insights that we gain through our cross-national and global work.
How does your team stay focused on those who benefit from your project’s work and ultimately are the reason why PMI Impact Malaria exists in the first place?
With PSI leading the project (in partnership with Jhpiego, Medical Care Development International, and the Malaria Elimination Initiative (MEI) at UCSF), we employ PSI’s human-centered design approach when thinking about our malaria service delivery interventions. To help us with this, we orient all our work around “Sara”—the name we use to represent a woman of childbearing age who is striving to keep herself and her family healthy in the face of constant obstacles to affordable, high quality, respectful health care. At PMI Impact Malaria, we’re working as a team with PMI and partners to support NMCPs in enabling those most at risk to protect themselves and their families from illness and death caused by malaria.
You grew up in a small town in England, right? What prompted your earliest awareness of malaria and how did you go from that to making it the focus of your career?
During university I was fortunate enough to take part in a year-long internship with WHO in Zimbabwe. This was a life-changing experience, funded by the British government and in partnership with WHO’s emergency and humanitarian affairs program. I focused on emergency management of natural and manmade disasters and epidemics, but of course it was impossible to live and work in southern Africa without developing an understanding of malaria and its human toll, unfortunately.
When the internship ended and I returned to the UK to finish my degree, I stayed connected with WHO colleagues who later put me in touch with a new team that was coming together to reinvigorate malaria control efforts in southern Africa. They saw an opportunity to apply my training in emergency management to the role of managing malaria prevention and control efforts during malaria epidemics and acute and complex emergencies.
Working to end malaria is such a meaningful challenge and I’m still incredibly grateful to the Southern Africa Malaria Control (SAMC) team for their willingness to invest in me. Individual team members and NMCP managers welcomed me into their programs, taught me so much, and were patient with my youth and limited experience. That was my introduction and, well, the rest is history!
Written by Anne Bulchis, PMI Impact Malaria Communications Manager
Photography credits from top to bottom: Mwangi Kirubi, Kenya, 2018 for the first and third photos; Elisabeth Soumaye Djinari, Niger, 2018 for the second photo.
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