Collaborative Approach to Community-based Malaria Prevention in Benin
Improvement Topics: Insecticide-treated nets (ITNs), Intermittent preventive treatment, Malaria case management, Malaria treatment in children, Malaria
Region and Country: Africa, Sub Saharan, Benin
The collaborative aims to contribute to the reduction of child and maternal mortality rates by improving behaviors related to the prevention and treatment of malaria by the community itself. Specifically, the collaborative aims to:
o Increase from 34% to 60% the use of LLIN;
o Promote appropriate management of malaria in households and communities;
o Increase by 40% timely care seeking for complicated malaria among children under five and pregnant women; and
o Strengthen collaboration between health structures and communities through home visits and support to community groups.
o Training of community-based volunteers in community management of malaria and C-IMCI
o Information, education, and communication on malaria prevention and treatment (LLIN utilization, identification of signs of serious malaria)
o Home visits and night visits to reinforce good behaviors
o Home-based treatment of malaria with ACTs
o Establishment of a referral and counter-referral system between CHWs and health facility staff
The key indicators tracked by the Quality Improvement Teams (QITs) in each village were:
o % of children under 5 who slept under a mosquito net the previous night
o % of children under 5 who had a fever within the last 2 weeks and who were treated according to the guidelines
o Number of children under 5 who were referred to a health center through the community referral system
o % of pregnant women who slept under a mosquito net the previous night
o % of children with serious malaria who were brought to a health center within 24 hours
Progress on these indicators was tracked by QIT members through home visits every two months. In addition, the QITs maintained records on home visits, referrals to health facilities for serious malaria, and provision of Coartem to children with malaria.
The collaborative was implemented in 50 villages in the communes of Aplahoué and Djakotomey in the Couffo department of Benin. Benin has a total of 12 departments and 77 communes.
Animators from partner NGOs visit every village at least once a month to coach in teamwork, problem solving and monitoring by the village of progress being made, using indicators and data collection methods feasible for the education level of the team members.
In each village, Quality Improvement Teams (QITs) held bimonthly sessions to report monitoring data and project progress to the community and village assembly. In addition, learning sessions for QITs from different villages were conducted each quarter to collectively share experiences and best practices, thereby encouraging constant improvement in village implementation strategies and overall program effectiveness. Each quarter’s learning session was held in a different QIT’s village to allow the other teams to witness firsthand the innovative methods they had developed. Moreover, by collecting data on common indicators, the teams were able to assess their effectiveness relative to one another, thereby fostering a competitive and entrepreneurial spirit.
o LLIN Utilization. The evaluation found that the project succeeded in improving LLIN utilization among the targeted groups. While QITs conducted unannounced nighttime visits to monitor actual LLIN utilization during project implementation, the final evaluation measured utilization through three proxy criteria: presence of an LLIN which is 1) suspended over the sleeping location, 2) of a recommended brand to ensure quality, and 3) untorn. The percentage of mothers and children under five found to sleep under an LLIN in the 24 hours preceding the survey more than doubled over the project period, increasing from 34% at baseline to 70% at the project’s conclusion. For mothers and their infants zero to 11 months, the percentage utilizing LLINs at the end of the project was even higher at 80%. Moreover, 90% of mothers of infants aged zero to 11 months consistently slept under LLINs during their last pregnancy.
o Appropriate home-based care and treatment. The project’s educational activities and home visits were effective in increasing the provision of appropriate home-based care and treatment of malaria. Home-based care and treatment is considered appropriate if the caregiver of an under-five child suffering from malaria has purchased Coartem and complies with the directed dose according to the age of the child. Over the course of the project, the percentage of children under five who suffered from fever in the two weeks preceding the survey and who received appropriate home-based care and treatment for malaria within 24 hours increased from 25% to 55%, surpassing the target of 40%.
o Early referral to health facilities. One of the effects achieved through the project’s awareness-raising activities was an increase in knowledge of danger signs of malaria and a consequent increase in referral of serious malaria cases to health facilities. From a baseline level of just 19%, the project was able to enable 95% of mothers with children under five to identify at least one sign of serious malaria. As a result, the number of children under five in the project villages who were treated in health centers with serious cases of malaria increased from only 92 in 2006 to more than 200 in 2008. Moreover, over the two years of project implementation, no deaths among pregnant women recorded in the health facilities were due to malaria.
o Creating local responses to identified barriers. As effective solutions to identified barriers were found, they were disseminated among the pilot villages and adapted to suit the circumstances in each locality. For example, in order to provide support to families in need of financial assistance in case of health emergencies, 16 of the project villages set up solidarity funds, fueled by contributions varying from $0.05 to $0.10 per family per month. The pooled funds then remain available to subsidize the transportation of under-five children in the case of serious malaria or other serious health concerns.
o Increasing collaboration between communities and health facilities. Given the limited reach of health facility staff, the use of QITs and CHWs to address awareness and health behaviors at community level was key to the project’s success. Regular home visits allowed QITs to observe household practices, reinforce good behaviors, and address individual barriers; these visits were key to producing results such as increased LLIN utilization among both pregnant women and children. In addition, CHWs were able to provide effective monitoring of sick children during home visits.
