Moving malaria in pregnancy programs from neglect to priority: experience from Malawi, Senegal, and Zambia

Integration of Programs and Services

After the 2000 Abuja Summit, all 3 countries successfully brought together malaria control and reproductive health policy makers and program implementers, through malaria or MIP-specific working groups, to institute MIP policies and interventions. In line with WHO recommendations, the countries successfully integrated MIP interventions into a platform of ANC services at the facility level—a key step in reaching the current levels of coverage.

Since this initial rollout, however, political will has waned or been diverted elsewhere, and while services at the facility level remain integrated, national-level coordination and planning has become disjointed. At the time of data collection, MIP working groups in Malawi and Zambia were reported to be dissolved or inactive, not due to a conscious decision of stakeholders but due to competing health priorities. The Malawi NMCP did, however, have a MIP focal point person on staff who reportedly intended to revitalize the link between the NMCP and the Reproductive Health Unit (RHU). Zambia had been seeking funding for a MIP focal point person but, at the time of this writing, had yet to succeed. In Zambia, a lack of human resources in the Ministry of Health was reported to be a major constraint in cross-sector coordination. The RHU and the NMCP confirmed that although representatives of the other unit are invited to participate in joint annual planning, mutual participation in the planning process has been minimal for the last several years because there are not enough staff to attend each other's meetings. This reportedly resulted in the shifting of MIP funds to other priority areas of malaria implementation.

In Senegal, one interviewee noted:

… national-level integration may be less effective because coordination of national activities is not routine … and the level of joint planning [between the NRHP and NMCP] is low.

This lack of coordination negatively affects program components, including training capacity, supervision, and availability of commodities. In Malawi and Senegal, lack of coordination has resulted in parallel, duplicative MIP trainings, conducted independently by different groups for the same health care providers. At the time of this article, a focused antenatal care (FANC) working group had been created in Zambia to address issues in MIP programming; however, the group has struggled to accomplish tasks because the RHU, NMCP, and implementing partners have limited funding and staff to support MIP and FANC.

• Download figure
• Open in new tab
• Download powerpoint

In Malawi, a pregnant woman receives intermittent preventive treatment for malaria at an antenatal care visit.

Policy Processes

All 3 countries have malaria policies in place that reflect WHO MIP guidance. In Senegal and Zambia, national reproductive health and malaria control policies and guidelines have been harmonized through strong leadership by the NMCPs and commitment from partners to support the process. Dissemination of national guidelines in both Senegal and Zambia has been widespread. In Zambia, specifically, the NMCP conducted case management updates to reorient providers, addressing issues such as the correct use of SP, and, at the time of data collection, planned to distribute revised treatment guidelines with a memorandum to district-level staff for dissemination to providers.

In Malawi, there are inconsistencies between reproductive health and malaria guidelines. For example, the national reproductive health service delivery guidelines stipulate IPTp provision at defined week intervals, while the national malaria guidelines stipulate IPTp provision following quickening and giving at least 3 doses 1 month apart. The Malawi reproductive health guidelines also stipulate that providers should not administer SP after 36 weeks gestation, while the malaria guidelines note no such limitation. Providers may provide different care depending on which set of national guidelines they refer to. What providers actually practice in all 3 countries is unknown as documentation of findings during supervision visits was not available.

Commodities

Sulfadoxine-pyrimethamine: In each of the 3 countries, WHO-recommended medicines for malaria treatment for pregnant women and for IPTp are approved and available through ANC clinics. However, stockouts of SP at ANC clinics were frequent due to central-level stockouts and ineffective distribution systems. This problem was further exacerbated by the irrational use of SP (based on key informant interviews) to treat malaria cases in the general population, whereas SP should be reserved for preventing malaria in pregnant women. In Zambia, although NMCP partners routinely provided the Ministry of Health with early warnings of impending stockouts of SP, stockouts persisted. This happened in 2009, when one implementing partner had to shift US$50,000 meant for rapid diagnostic tests to procure an emergency stock of SP.

One stakeholder interviewed in Zambia described the situation:

Sometimes you go to a clinic and they are stocked out of SP and they say it is because there isn't any at the district. Then, you go to the district and find it. Sometimes, they are stocked out at the district, but you find it at the central level.

In Malawi and Senegal, stakeholders described similar issues with persistent SP stockouts. Stakeholders cited problems at all levels of the logistics management system for commodities, including quantification, ordering of drugs in a timely manner, tendering, receipt, storage, and distribution.

Insecticide-treated bed nets: In the 3 countries, distribution of nets to pregnant women free of charge at ANC clinics is considered an effective mechanism for increasing usage among pregnant women and for incentivizing ANC attendance. Nevertheless, as with SP, facilities often experienced ITN stockouts due to procurement shortfalls, central-level stockouts, and disjointed distribution systems.

In Malawi, it was reported that ITNs were frequently, but not always, available in ANC clinics. Facility supplies were based on estimated target populations rather than consumption, but recent changes from a single- to a multi-distributor system led to increased stockouts. At the time of data collection, all 3 countries were planning to implement universal ITN coverage campaigns, aimed at increasing net usage by the general population, and supplemental efforts targeting pregnant women and children under 5 years of age.

• Download figure
• Open in new tab
• Download powerpoint

In Zambia, a counselor educates community members at an antenatal care clinic about use of insecticide-treated bed nets.

Quality Assurance

Due to lack of funding and competing responsibilities among Ministry of Health staff, comprehensive quality assurance systems were not currently functioning in any of the 3 countries. While MIP clinical performance standards had been developed in each of the countries, application of these standards was inconsistent. In large part, each country relies on routine supervision from national, provincial, or district-level supervisors; however, due to lack of human resources and logistical and financial constraints, these visits were not consistently conducted. In 2006, Zambia developed an integrated reproductive health tool composed of reproductive health standards that included MIP (for example, group and individual education on MIP, ITN use, and IPTp uptake). Provincial-level Ministry of Health staff were oriented to this tool with the intention that training would cascade down to district- and facility-level staff. At the time of data collection, it was unknown if district-level orientations had been completed and, according to stakeholder reports, the tool was not in widespread use.

Although Malawi has designed an integrated tool for quarterly supervision visits that targets infection prevention, MIP, reproductive health, and prevention of mother-to-child transmission of HIV, these visits were occurring infrequently. In Malawi, one interviewee mentioned:

Donors place more emphasis on “number of persons trained” in program-reporting indicators than on the number supervised or the impact of training those persons, with program design following suit.

In Senegal, the program review revealed that 31% of health facilities did not receive any kind of supervision.

Lack of supervision has negative implications for consistent delivery of quality services for pregnant women as well as the general population. This can contribute to SP stockouts as well as to increased morbidity and mortality from improperly treated non-malarial fevers. For example, in Malawi and Zambia, stakeholders reported that SP was often used by providers to treat fevers in men, children, and non-pregnant women; in Zambia, SP was given when rapid diagnostic tests were negative; and in Malawi, SP was given when there were stockouts of artemisinin-based combination therapies (ACTs).

Capacity Building

Malawi, Senegal, and Zambia have all updated in-service training and preservice education materials with MIP content. This positions each country to focus training on evidence-based updates and maintenance of critical MIP competencies. However, as noted previously under the integration findings, at the time of data collection, there was a need to harmonize efforts further to avoid redundancies in training, both between preservice education and in-service training and within in-service training courses.

In Malawi, the RHU and NMCP were implementing parallel in-service training events. As one interviewee pointed out:

Where is the rocket science in MIP? We present focused ANC like it's something new, but it's the same thing [health care providers] have been doing.

Human resource shortages are a major challenge in all 3 countries and affect access to quality of care. Zambia was 28,000 health professionals short of its Ministry of Health staffing targets. In Malawi, interviewed stakeholders said many providers were over-diagnosing malaria because of high client loads (implying not enough trained staff), lack of time or skills for proper clinical diagnosis, and the propensity for providers and clients alike to presume all fevers are malaria.

Community Engagement

All 3 countries were actively supporting community involvement to enhance and engender community education and mobilization. In Malawi, community groups (for example, village health committees and health surveillance assistants) actively partnered with health facilities to raise awareness in communities about health issues, including MIP; to refer women to ANC; and to identify key health problems in the community.

In Zambia, community groups (for example, neighborhood health committees and safe motherhood action groups) were trained to sensitize communities about a range of maternal health topics in order to promote healthy behaviors and improve care seeking, including for MIP. Although one program follow-up report noted increased ANC attendance in the year since the community program was implemented, no improvements were seen in IPTp coverage due to frequent SP stockouts and poor recordkeeping. At the time of data collection, support for community involvement was not consistent, and more strategies were required to adequately involve communities and foster links between communities and facilities in a sustainable way.

Although there is little documentation and assessment of these community-focused efforts, qualitative feedback suggests they were effective. For example, in Senegal, stakeholders attributed improved ITN use among pregnant women to the USAID-supported “Community Action against Malaria and Tuberculosis” program and in Malawi, to community involvement.

Monitoring and Evaluation

MIP indicators are generally tracked through a variety of sources in malaria-endemic countries, including: (1) periodic household surveys, such as Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and Malaria Indicator Surveys; (2) the routine national HMIS; and (3) sentinel site surveillance systems (now less common). In the 3 countries, health facilities routinely collected and reported data on IPTp uptake by dose during ANC services through the HMIS, which aggregates data into national coverage indicators. However, the WHO-recommended MIP indicators on “percentage of ANC staff trained in the control of MIP in the past 12 months” and “percentage of screened pregnant women with severe anemia in the third trimester, by gravidity”²² were notably missing from national data sources in all 3 countries, although data on anemia are recorded in some form at the facility level, most frequently in client records.

ITN indicators have been effectively integrated into the HMIS in Senegal but were absent from the HMIS in Malawi and Zambia. Instead, such information was collected on parallel, program-specific reporting forms. HMIS data quality in Malawi and Zambia was reported to be weak by key informants, but Zambia was making strides to train district medical offices and health facility staff in data management. Prior to data collection, Senegal had taken significant steps, including hiring of new staff and establishment of a web-based data management system, to improve data completeness, timeliness, and reliability.

While SP stockouts were reported to be a significant inhibiting factor for MIP programs, data on stock levels were not routinely made available to reproductive health and malaria control stakeholders. Additionally, at the time of data collection, no countries were reporting national data on MIP incidence or treatment—crucial indicators for measuring the effectiveness of MIP interventions.

Financing

All 3 national governments commit some funds to MIP programming but still rely heavily on donor support. The Senegalese and Zambian governments were providing funding for SP, with central-level shortages reportedly due more to poor quantification of necessary medicines than to lack of funding. For ITNs, the 3 countries relied entirely on donors, primarily the Global Fund and PMI, which has proved insufficient to cover all pregnant women. While the “Sector-Wide Approach”—a resource allocation system that pools all health sector resources from all sources and allocates funds based on need—had been effective in Malawi for coordinating donor support, lack of accountability of funds provided directly to the government limited contributions to the basket fund. Delays in receipt of Global Fund monies in Malawi and Zambia further hindered program implementation. Across sub-Saharan African countries, funding to support malaria programming has increased since 2004; however, the currently available funding is far below the estimated US$5.1 billion required each year to reach universal coverage of interventions. In 2012, the global total of international and domestic funding for malaria was US$2.5 billion—less than half of what is needed.²⁷

Limitations

The country case studies were limited to secondary data gathered through the desk review process, as well as qualitative data collected through in-depth interviews among key stakeholders at the national level. Due to time and resource constraints, the country case studies did not generally include interviews with key stakeholders at the regional, district, or facility levels. In Malawi, one District Medical Director was interviewed. Hence, the case studies present a limited but comprehensive picture of MIP prevention and control programming at the national level. Also, since the case studies only targeted better-performing countries, it is not possible to compare the findings to lower-performing countries that could reveal new insights to existing challenges in MIP programming.

Further, while the review is meant to focus on MIP comprehensively, the focus is primarily on IPTp uptake and ITN use and does not address case management in detail, because very little information about case management of pregnant women was found at the country level.