In time for World Malaria Day, Elaine Roman blogs on the advantage of integration
By Elaine Roman
This year’s Roll Back Malaria theme for World Malaria Day (April 25, 2012), Sustain Gains, Save Lives: Invest in Malaria, speaks to the importance of maintaining the successes of the last decade while balancing that effort with a continued commitment to move malaria prevention and control to the next level: scaling up country-level programs, controlling the epidemic and eventually eliminating this disease.That’s the call to action, the imperative across the developing world. But on the frontlines, in communities and clinics throughout sub-Saharan Africa, integration of services offers the best chance to ensure that a pregnant woman,a mother of three children,or a child under five receives malaria prevention, treatment and care services whenever she visits a health clinic or accesses services in her community.
That’s smart. That’s strategic. That’s lifesaving.
Malaria is a maternal, newborn and child health issue because of this hard truth: the disease disproportionately affects these groups. In 2011, among the nearly 700,000 deaths due to malaria, approximately 600,000 occurred among children under five and most were in sub-Saharan Africa.Approximately 10,000 maternal deaths each year are attributable to malaria.For pregnant women, malaria has a trickle-down, negative effect in that it causes higher rates of anemia, which contributes to low birth weight and ultimately infant mortality.And a child’s mother and family are her first line of defense and best chance for surviving malaria.
For all of these reasons and complicating factors, integrating malaria prevention and control activities as a core component of both maternal and child health services is a fundamentalstep in helpingcountries further reduce malaria illness and death, as well as in achieving the Millennium Development Goals that seek to keep more women and children alive and healthy.
SMART INTEGRATION
Integration of the health services needed within a population is, in itself, “smart.” Such integration builds on what is already in place and strengthens the health system’s capacityto provide all clients-women, children and their families-quality services.For malaria, a disease that affects the most vulnerable populations,including people co-infected with HIV,strengthening the health system with integrated care requires a coordinated and collaborative approach at all levels within the country-beginning with improved policies, leading to strengthened health services and community level-interventions.The importance of such coordination/collaboration for integration of services is particularly true in countries throughout Africa, where health systems are generally weak.But commitment to a comprehensive, smart integrated approach will lend toimproved health outcomes for women and children-effectively, efficiently and cost-effectively.
Because the majority of pregnant women attend antenatal care (ANC) services at least once and often twice during pregnancy, ANC is an ideal platform for pregnant women toreceive a broad range of services-including malaria prevention and control services.All sub-Saharan African countries where malaria is a year-round threathave adopted the World Health Organization’s three-prong approach:
• Giving pregnant women at least two treatment doses of an antimalarial, currently sulfadoxine-pyrimethamine, following first movement of the fetus andmonthly thereafter;
• Promoting the use of insecticide-treatedbednets; and
• Ensuring that individuals diagnosed with malaria receivethe approvedtreatment promptly.
Health care providers who are trained to prevent malaria as a core component of a woman’s care-integrated with ANC services, throughout her pregnancy-can have a tremendous,positive impact on the health of mothers andbabies who are at risk.
Comprehensive ANC, sometimes referred to as focused ANC or FANC, is the smart way to deliver health promotional and preventive services to pregnant women.The focus of FANCis on the quality of care received at each visit rather than the quantity of visits: health promotion and disease prevention; early detection and treatment of complications and existing diseases; and preparation for birth and complications that may occur.Integrating malaria prevention and control services with the FANC platform is both smart and effective as a strategyfor reaching pregnant women with lifesaving care.
Likewise, integrating malaria prevention and control services with existing child health programs,including vaccination services, can have a direct, positive impact on child health and survival. For parents seeking services for their children, either in their own community or at a health facility,integrated services not only help combat malaria but also address other major contributors to child morbidity and mortality, such as malnutrition, diarrhea and pneumonia.
In Kenya,Jhpiego worked with the Ministry of Health’s Division of Reproductive Health to introduce and scale up FANC services as a platform for delivering prevention and treatment servicesfor malaria in pregnancy. We developed a user-friendly orientation package for frontline health care workers and trained 3,000 providers and 264 trainers-to train even more providers.As newly trained providers returned to their health facilities, they received mentoring and supportive supervision to ensure that their new learning was transferred into practice with actual clients.As a result of this intervention, the number of providers updated on malaria in pregnancy virtually doubled within the intervention area. But more important: uptake ofintermittent preventive treatment in pregnancy (IPTp) increased from 19% to 61% in the intervention areaversus17% to 28% in the control area; the number of women who received the first dose of IPTp increased to 77%; and providers who said they gave the appropriate drug, sulfadoxine-pyrimethamine,increased to 93%.
NO MISSED OPPORTUNITIES
Although many countries have made great strides in addressing and combating malaria, resulting in a drop in malaria cases by 38% in the last decade alone, too few have achieved their goals in reducing malaria illness and deaths.In the last three years, the global community under the Roll Back Malaria Partnership has recognized and promoted the value and necessity ofsmart and effective integration.Within countries, to varying degrees, national malaria control programsare working closely with reproductive health and child health programs, as well as HIV/AIDS programs.
Indeed, these are critical steps in ensuring that malaria prevention and control efforts provide “quick gains” and,ultimately, lasting and sustainable results.
But such results will require ongoing commitment of policymakers and health care providers to work together in achieving smart, strategic and lifesaving integration of services, and “no missed opportunities,” for reducing morbidity and mortality due to malaria illness and other preventable causes.
Elaine Roman is a Senior Technical Advisor – Malaria for Jhpiego, a global health non-profit organization and affiliate of The Johns Hopkins University.
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