PMI Impact Malaria
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.
Sources: WHO, U.S. President's Malaria Initiative Technical Guidance (Feb 2017), Sierra Leone Multiple Indicator Cluster Survey (2017)
Author info: 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.
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.
Source: PMI’s Niger page
Author info: Koko Daniel, PMI Impact Malaria Niger Chief of Party; Maman Badamassi, Niger NMCP Community Activity Manager.
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.
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!
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!
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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