Sharing our Lessons in Malaria

THE MRDT PILOT PROJECT

PS Kenya has been implementing a pilot project in Coast Region that encourages the premise of testing every fever presented before treating. This WHO recommended guideline ensures that people presenting at a health facility with fever are not immediately given Malaria drugs because not all fevers are caused by Malaria. During the last quarter, PS Kenya disseminated their lessons from the pilot project in a meeting that brought together participants from WHO, DFID, the National Malaria Control Program, other NGO partners and private sector players.

According to WHO’s Officer in Charge and Malaria Advisor, Dr. Nathan Bakyaita, the findings of the mRDT(Malaria Rapid Diagnostic Tests) pilot project will be fed into a larger policy framework being developed by the World Health Organization. “The  mRDT project undertaken in 5 African countries, including Kenya by PS Kenya provides important insights that for Malaria Case Management in the private sector,” he added.

Since 2010, the Kenya government has required health workers to handle suspected Malaria cases according to the stipulated case management guidelines. While diagnostic implementation was being carried out at public health facilities, there was not much happening in the private sector before the intervention of the mRDT pilot project. “For us in government, projects like this one are important because ultimately it is in our interest that both public and private sector follow guidelines for suspected Malaria. We thank PS Kenya and its donors: UKAID and UNITAID, and even communities for taking part in this project,” remarked Dr. Waqo Ejersa, the Head at the Kenya National Malaria Program (NMCP).

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Reiterating the importance of intervening in the private sector was Dr. Dorothy Memusi who said that the private sector could no longer be ignored if the overall goal of ensuring that suspected malaria cases are tested before being treated. “When we began this pilot with PS Kenya, we were not sure whether it will work but since so many Kenyans access health services in the private sector, it has proven to be a success and an evidence to our push for universal testing and inclusivity of the private sector,” she said.

Indeed, implementing the project was not easy at the beginning since it involved introducing a new idea to private healthcare providers. For Malingi Mwasambu, the owner of Watamu Community Healthcare, a Tunza clinic; when the project started he was not very responsive to it. “A large number of clients that I tested for malaria with the RDT were negative and I live and work in a malaria endemic region. I concluded the tests did not work,” he said. It was after a meeting with other providers in the project held by PS Kenya that their fears were allayed and their confidence in the RDT grew. “I have to say that the training has helped and also the communications to the community about mRDT. Nowadays, my clients demand the test without me probing for it and the test is making me money,” he added.

The NMCP Head received an award from PS Kenya because of the overwhelming support the department gave during the roll-out of the project. PS Kenya’s Chief Operating Officer Joyce Wanderi-Maina added that although the project had come to a close, PS Kenya’s approach was to drive sustainability through a market facilitation process. “Normally for NGOs, our work involves short-term remedies to problems, just like putting out a fire. It however does not address the issue of underlying causes of the fire. With the mRDT project, we ensured that we address the underlying issues so that demand for mRDT in the private remains even after we are gone. We however hope that we can continue facilitating the market with more funding in future,” she added.

THE CONTINUOUS COMMUNITY NET DISTRIBUTION PROJECT

Malaria in Kenya remains a major public health problem with close to 70% of the population at risk (KMIS 2015). The revised Kenya Malaria Strategy 2009-2018 identifies malaria control interventions especially in scaling up distribution of LLINs through appropriate channels i.e. Mass net distribution every 3 years, routine distribution targeting pregnant mothers and children under 1 year through clinics, and social marketing. Following the mass net distribution of 2011/2012, about 67% households achieved universal coverage; however, sustaining high coverage and use levels is still a challenge. Other complimentary distributions mechanisms are therefore needed to reach the required target levels and sustain them over time.

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Through PMI funding and working with the NMCP, PS Kenya piloted a continuous community net distribution within Samia Sub-county, Busia County. Selection of Samia sub-county was based on the fact that it had functional community health units, beneficiary of the mass net distribution campaign of 2011/2012 and is malaria endemic with a prevalence of above 38% (KMIS 2010). Based on the Kenya Malaria Indicator survey 2015, malaria prevalence in this region has reduced to 27%.

The district was randomly divided into intervention and control sites (sub-locations). The objective of the study was to test the feasibility of sustaining universal coverage achieved during the mass net distribution through community based distribution mechanism. Implementation of the pilot involved a pull driven LLIN distribution mechanism where the need for an LLIN is determined at the household level using community health volunteers.  CHVs then verify the need by visiting the household and upon verification on need for a net, gives a coupon to HH head to redeem the LLIN at the nearest distribution point for free.

These trained CHVs integrated active interpersonal communication to encourage net use at both household level and at small group sessions (SGS). During the pilot period, a total of 28,928 out of the target 29,615 nets were distributed to the target audience within 18 intervention sub locations in Samia sub-county. CHVs saved 4,013 nets that were found viable i.e. still in usable condition or torn but repairable.

Utilizing a community cluster randomized controlled design, data was collected before (at baseline) and after (at follow-up) the roll out of the intervention. A household questionnaire was used to collect quantitative data while a structured qualitative questionnaire was used to assess the feasibility of using community based approaches to distribute the nets.

In August 2016, PS Kenya disseminated the results of this pilot to the Busia county stakeholders who included representatives of the National/County Government, NGO’s, Private sector and the community members. Dr Itur Asoka, who is the Chief of Health in the County, represented the County Minister for Health who was to be the chief guest in the meeting.

The end of project evaluation report showed that net use for the general household had increased from 80% at baseline to 93% at end line. In addition, 85% of respondents indicated confidence to hang a net at end line as compared to 73% at baseline. This is attributed to the interpersonal communication sessions facilitated by the CHVs. Qualitative data showed that the Samia community was very positive about the work of the CHVs.  “Going forward, we aim to use the lessons learnt in this pilot to inform future programs” said Dennis Mwambi, a senior manager at PS Kenya.

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 Another noticeable finding is the immense significance of community health workers who were pivotal in implementing this program, as they ensured that the community was well educated on the importance of using nets and as a result their efforts triggered many to embrace their use. “We have strong leadership and commitment from the county but the key to success was the community health volunteers who have been the cornerstone of the project,” said Dr Anne Musuva, MCH Director at PS Kenya. “We have never seen such a high net coverage level like the way we have seen in Samia, especially on this pilot project,” continued Dr Ann Musuva.

Participants at the meeting adopted the findings vowing to continue to play their part to ensure malaria is eliminated in the county.  “We as a County are very happy with these findings and going forward we promise to take it up to ensure that Malaria is completely neutralized in this County,” said the Busia County Chief of Health Dr Itur Asoka.

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