This post is part of a blog series on Malaria in Pregnancy. To view the entire series, click here.
Throughout sub-Saharan Africa, malaria in pregnancy (MIP) programs are at a crossroads. While many countries have made important strides in achieving their broader goals, most countries are still far from achieving the Roll Back Malaria (RBM) Initiative or the US President’s Malaria Initiative (PMI) (80% to 85%respectively) for intermittent preventive treatment in pregnancy (IPTp), and insecticide-treated bed net (ITN) coverage among pregnant women. Case management, the third prong of malaria in pregnancy programs is often forgotten in the implementation of country MIP programs. As countries continue scale-up of MIP interventions, there are successful practices and lessons learned that should be reviewed and applied to help countries accelerate MIP programming and achieve country scale up.
Recognizing that there are critical lessons to bring to light, USAID’s flagship Maternal Child Health Integrated Program (MCHIP), with funding from the President’s Malaria Initiative, conducted country case studies from 2009-2011 to gain a more detailed understanding of MIP programming in three countries: Malawi, Senegal and Zambia. The case studies were compiled using a desk review of secondary data sources, followed by stakeholder interviews designed to gain insights into successes, remaining challenges and a way forward.
The case studies reviewed eight key areas of MIP programming- policy, integration, commodities, capacity development, quality improvement, community engagement, monitoring and evaluation and finance. The case studies revealed key insights to MIP programming including what’s working and what remains to be addressed. For each of the eight program areas, in summary, the case studies revealed:
1. Policy- While each of the three countries has malaria policies in place that reflect the World Health Organization guidance, there exists inconsistencies between malaria and reproductive health policies in Malawi, which has resulted in duplicative training efforts.
2. Integration- Services are integrated at antenatal care (ANC) in each of the three countries, however, national level planning and coordination between reproductive health and malaria programs is not always regular, which impacts program implementation.
3. Commodities- While each country reported availability of both medicines for pregnant women and bed-nets, there were stock-outs of these commodities at antenatal care clinics- across countries.
4. Capacity Development- All three countries updated both in-service and pre-service education materials with MIP. This positions each country to focus training on evidence-based updates and maintenance of critical MIP competencies.
5. Quality Improvement- In each of the 3 countries routine supervision and performance standards are in place. However, due to lack of funding and competing responsibilities among Ministry of Health staff who are tasked with conducting supervision and assessment, comprehensive QA systems are not currently functioning in any of the 3 countries.
6. Community Engagement- All 3 countries are actively supporting community involvement to enhance and engender community education and mobilization. Examples include promoting ANC attendance, IPTp uptake and ITN use. However, this support is not consistent and more strategies are required to adequately not only involve communities but also foster the link between communities and facilities.
7. Monitoring and Evaluation- While some level of MIP program data is recorded at the health facility, the data is not always integrated as part of the national health information system.
8. Finance- While MIP does receive some level of government funding in all 3 countries- there is still heavy reliance on donors- especially PMI and the Global Fund.
The case studies highlighted key cross-cutting recommendations including:
- Promote integration and coordination of reproductive health, HIV and malaria control programs through MIP working groups;
- Advocate through MIP working groups and other fora to ensure consistent stocks of SP and ITNs at ANC clinics;
- Increase support for community initiatives to overcome barriers to care-seeking;
- Dedicate increased resources to strengthening existing M&E systems and integrate data management and data use for decision-making into pre-service education and in-service training programs;
- Promote capacity-building strategies, including strengthened pre-service education, on-the-job-training, mentorship and supervision, in addition to group-based in-service training; and
- Strengthen quality assurance systems.
Moving forward, MIP implementation will require strong and consistent leadership from ministries of health in order to coordinate donors and implementing partners and target resources towards key interventions. For other malaria-endemic countries, many of the key findings likely apply and can inform programming. Although many obstacles still remain in eradicating malaria and malaria in pregnancy, lessons learned from both our successes and our challenges thus far demonstrate that they are not insurmountable and that the PMI and RBM goals for MIP are still within reach.