Five steps to wrap technology and optimize impact: community malaria surveillance for elimination in Zambia

Five steps to wrap technology and optimize impact: community malaria surveillance for elimination in Zambia

By Anna Winters on December 5, 2018 in Malaria, News

Image caption: Community health workers (CHWs) provide malaria testing and treatment; line-lists in paper registers and aggregated by “data” CHWs and submitted to the DHIS2. Malaria data are mapped to both CHW posts and health facilities.

Akros supports countries and their partners to design, test, and deploy interventions to scale for impact. Often this involves supporting governments to transition from paper-based to digital data collection and reporting. Below is a case study which outlines our approach of applying simple technology that is wrapped in the necessary processes, protocols, and trainings to deliver quality data and build intervention impact that scales.

Component D was initially implemented in districts of Southern, Central, and Western Province, Zambia. Now multiple partners are supporting the rapid scale up of Component D across Zambia, improving malaria surveillance data, while also expanding access to care across the country. Thanks to PATH-MACEPA for this map.

The Government of Zambia (GRZ) has an ambitious goal of malaria elimination by 2021. One approach to achieve this goal is to improve malaria surveillance at the community level. Akros worked alongside the National Malaria Elimination Program and PATH-MACEPA to develop a community-based malaria surveillance system called “Component D.” The goal of Component D is to build community structures that will increase access to malaria testing and treating, identify and eliminate parasite reservoirs, and understand where (within health facility catchments) malaria transmission is happening. Effectively: to better understand and respond to the “needle in the haystack” which malaria can often be.

To assist the GRZ, Akros applied its five-part approach of “wrapping” technology with the processes, protocols, and training that ensure the technology contributes to impact and is able to scale:

  1. Discover and assess—we explored the systems that were already in place in Zambia, evaluated the data needs, and identified the change agents that needed to understand and action information.
  2. Build a “prototype design”—we leveraged simple technology (java feature phones and open data kit software) and documented and developed the processes, protocols, training materials, and supervision needed to support that technology and make it sustainable. We built feedback loops to assist programs to respond to those data.
  3. Work with country governments and partners to test the design through small-scale implementation—we implemented Component D in Southern, Central, and Lusaka Province, Zambia.
  4. Wrap that implementation with research to understand cost efficiency and disease impact—we learned that Component D was one of the primary drivers expanding access to care and treating reservoirs of parasite infection.
  5. Work with our host governments and partners to iterate and smartly scale—from its initial small-scale implementation, Component D has become country policy. Since then, numerous partners and GRZ have now expanded to 36 districts in Zambia.

Did the country switch over to the new system en masse or was there a pilot area / time period? How was this decided? Discovery and assessment processes began in 2009, leading to implementation throughout several districts in Southern, Central, and Lusaka Province over a period of three years. These districts were determined based upon their malaria burden and their existing leadership being open to leveraging community health worker (CHW) activity to better understand the malaria burden at local levels. Component D has now become the GRZ policy for malaria surveillance in malaria elimination districts. Isdell Flowers, PATH-MACEPA, the Global Fund, USAID PMI, and others are leveraging their resources to assist GRZ to continue to expand and improve Component D.

Was there duplicative reporting on the legacy system during the transition period? Component D brought more rigorous “structure” to existing CHW registers, but still relied on the familiarity of these registers while also introducing simple aggregation processes for digital reporting of data.

What measures did you use (or are you using) to validate that data in the new system is adequately high quality in order to build confidence in the new system’s data and switch off the legacy system? Data validation includes periodic record reviews validating CHW registers with aggregated figures, locations and stock use, and in-built validations within the DHIS2.

What resources (e.g., licensing costs, technical support, new printed training materials) were required in order to make the transition? Resources required to transition toward digital data have been the greatest up front, including technical support to prototype and implement, cascade training costs, and initial “supervision visits” to support system continuity and health. As the system has become embedded in the GRZ, external supervision visits have reduced, while internal GRZ supervision has increased.

What have been some of the impacts of this system?

  • The proportion of children with fever to malaria testing increased from only 9% prior to CHW scale-up to 81% by 2017.
  • Parasite prevalence fell from the normal range of ~30% down to 4% by 2016 and remained stable.
  • Access to care doubled.
  • Community malaria data became available at central and district levels, which was not previously available. These data guide health facility stocking and intervention prioritization and planning.
  • Sub-health facility malaria data now available and mapped within DHIS2.
Component D utilizes a reactive case detection approach to follow-up with malaria cases (index cases) identified at clinics or community health worker posts by testing and treating neighbors of that index case. Figure from: https://www.ncbi.nlm.nih.gov/pubmed/26586264.

 

Links to more information:

https://www.nmec.org.zm/enhanced-surveillance

https://www.ncbi.nlm.nih.gov/pubmed/26586264

https://akros.com/malaria-prevention/community-surveillance/

About Anna Winters, PhD

Anna Winters founded and serves as the CEO of Akros. Winters holds a PhD and MS in epidemiology coupled with extensive field experience leading the development and implementation of community-wide surveillance systems in sub-saharan Africa aimed at targeting health interventions to maximize impact. Through Akros and previously with the Centers for Disease Control and Prevention, Dr. Winters works directly with host country governments to ensure viability and integration of health innovations. Contact her at awinters@akros.com

Prioritizing Interventions – Targeting IRS to Maximize Effectiveness

Prioritizing Interventions – Targeting IRS to Maximize Effectiveness

By Annie Martin on October 30, 2018 in Malaria, News

A team of IRS spray operators prepare for the 2017 spraying season.

Malaria kills a staggering number of people every year — nearly half a million. That number is unacceptable given malaria is both preventable and treatable and somewhat surprising given donors and governments spend hundreds of millions of dollars each year attempting to control malaria.

So why is that number still so high? Well, first of all, malaria is primarily in countries with largely rural and hard to reach populations. Getting to those populations is logistically complicated and costly. Secondly, the mosquitos that transmit malaria quickly adapt to resist insecticides and to evade interventions. Thirdly, the scale of the problem is massive. While there are half a million deaths and over 200 million cases annually, the population at risk is even larger – half of the global population. Half of seven billion people are at risk for malaria.

With this context, hundreds of millions of dollars in control efforts begins to sound like a drop in the bucket. In order to make the most of the resources at hand, we must maximize the impact of each dollar spent. For example, interventions like indoor residual spraying (IRS) – where spray operators move household to household spraying the walls of homes with insecticide in order to kill the malaria transmitting mosquitoes – are very effective at killing mosquitoes and reducing malaria. However, IRS is expensive. We need to ensure we are distributing IRS resources in the most strategic and likely most impactful way.

In 2017, Akros worked with the Zambia National Malaria Elimination Centre (NMEC), the Africa Indoor Residual Spray (AIRS) Project implemented by Abt Associates, and the U.S. President’s Malaria Initiative (PMI) to conduct a comparison control trial of IRS prioritization strategies. The question was simple: If we do not have enough resources to spray every house, where should we spray to see the greatest decreases in malaria incidence? Should we spray one condensed geographic area? Should we spray the areas near the health centers with the highest burden of malaria? Or, should we spray the areas predicted to have the most mosquitoes? Each of these questions defined an arm of the study; one arm targeted IRS by concentrating it in one geographic area, one arm targeted IRS by prioritizing its delivery by health facility-measured malaria burden, and one arm targeted IRS by prioritizing its delivery by predicted mosquito density due to ecological factors. The NMEC implemented each arm in two districts of Eastern Province during the 2017 IRS operations.

Finding a village never before visited by IRS

Finding a village never before visited by IRS

By Ernest Mulenga on March 8, 2018 in Malaria, News

Background

The mSpray tool is more than just a mobile data collection tool that improves data quality and timeliness. The mSpray tool provides spray teams with maps to navigate to areas that might otherwise be difficult to find. These maps are highly accurate and complete, made through our satellite enumeration process. The district mop-up teams are especially reliant on these maps. Mop-up teams, are teams designated by the district with the specific task of revisiting areas that were not sprayed well during an initial visit or areas that were missed completely.

Unsurprisingly, mop-up teams help more areas reach the coverage goal of 90% sprayed and these teams visit some of the most remote villages, some of which have never been visited before. Ernest Mulenga, an Akros Surveillance Officer, documents the Chadiza’s mop-up team visit to a village; because the the team relies heavily on maps to navigate, they adopt vernacular of mapping and navigation, referring to the villages by the codes assigned to the “polygon” shapes appearing on the maps.

The search for polygon 01-455

It was the 9th of November 2017 when the mop-up team left Chadiza IRS base in search of Polygon 01-455 under Mtaya catchment area, which is located to eastern side of Chadiza district about 45 km from the district main post office.

Passing through Ngala area under Miti catchment, the team made a first stop at polygon 01-457 around 11:00 before proceeding to 01-455. The team used the GPS locator on the mSpray application, to navigate to a road that would lead to the village. Discovering the road to be impassable due to flooding from the heavy rain the team was re-directed by locals to a path that went through the mountain, and was said to be passable with a vehicle.

The Mtaya catchment area. The spray team was progressing through this area when they found polygon 01-455, which had never before been visited by a spray team.

The journey through the mountain started off well. After climbing some distance, however, the path became too filled with potholes for the Land Cruiser to continue. The team was left with no choice but to complete the journey on foot. At this point the team felt that they had covered a considerable distance with the Cruiser and that the polygon must not be far off. Thus, the team began to move with the aid of a GPS on the tablet. Once the direction of walking was set, the tablet was switched off for fear of using too much battery power.

USAID Awards Global Contract to PSI and Partners to Advance Malaria Service Delivery in 28 Countries

USAID Awards Global Contract to PSI and Partners to Advance Malaria Service Delivery in 28 Countries

By Akros Media on February 26, 2018 in Malaria, News

We are excited to announce that PSI has been successfully awarded a new contract by USAID to support the President’s Malaria Initiative (PMI) to Advance the Progress of Malaria Service Delivery (APMSD) in 28 malaria-affected countries and selected Akros as an implementing partner. The project, worth over $160 million USD over five years, will be delivered by a consortium of core partners, led by PSI and including JHPIEGO, Medical Care Development International (MCDI) and University of California-San Francisco.

The project will focus on supporting national malaria control programs in USAID-supported Malaria Endemic countries including 25 in Africa and three in Asia. The interventions aim to improve quality of and access to malaria case management and malaria in pregnancy interventions. They will also improve quality of and access to other malaria drug-based approaches and provide support to pilot/scale-up newer malaria drug-based approaches. Global technical leadership, support for operational research, and advances in program learning are priorities as well. In addition to the core team, private sector partner Akros and University of Oslo and Medicines for Malaria Venture will support.

Akros will lean into its experience working with national ministries by leading efforts on strengthening capacity building of Ministries of Health (MoHs) for HMIS and executing a central strategic plan around data use within the MoHs and communities.

Globally, the world has made remarkable progress in controlling malaria; halving the burden of disease between 2000 and 2015, but progress is stalling. The WHO’s most recent World Malaria Report highlights the current state of case management of children under five years and delivery of intermittent presumptive treatment for pregnant women as major concerns.

The President’s Malaria Initiative, led by USAID and implemented with the U.S. Centers for Disease Control and Prevention, is the U.S. Government’s primary vehicle for assisting malaria affected countries to scale up proven malaria control and elimination interventions.

The PMI Strategy for 2015-2020 accounts for much progress over the past decade and offers a strategy for new and emerging challenges. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and protecting communities from infectious diseases. By working with PMI-supported countries and partners, the U.S. Government aims to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.

This new contract comes as PSI launches its new global strategy for consumer-powered healthcare. APMSD will innovate ways to bring healthcare closer to the consumer in developing countries. PSI is proud to be associated with USAID and its partners to achieve this goal.

Akros joins Nonprofit Organizations Knowledge Initiative in webinar for their series on DHIS2 for NGOs

By Akros Media on November 28, 2017 in News, Water and Sanitation Health

If you missed the webinar we did with the Nonprofit Organizations Knowledge Initiative, take a look at the full recording below. Akros team members Dr. Robert Ntalo, Rabson Zimba, and Bethany Joy Larkin share some of the things Akros learned while implementing CLTS across Zambia. The title of the webinar is “Data Empowers Decisions – How Traditional Zambian Leaders are Making Decisions using DHIS2 Mobile Platforms.”

Akros GHC crew hosts webinar on what it’s like to be a GHC fellow at Akros

Akros GHC crew hosts webinar on what it’s like to be a GHC fellow at Akros

By Akros Media on November 21, 2017 in Capacity Building, News

On November 16, current and former Akros GHC fellows shared their experiences and fielded questions from hopeful GHC candidates. Each year, GHC a diverse group of young leaders with a vested interest in health equity joins GHC to complete a 13-month fellowship with partner organizations in five countries: Malawi, Rwanda, Uganda, Zambia, and the U.S.

Below is a full recording of the webinar in case you missed it!

“The Professor” Charles Mwiinga on life as a teacher, farmer, and Community Champion

“The Professor” Charles Mwiinga on life as a teacher, farmer, and Community Champion

By Andy Prinsen on November 19, 2017 in News, Water and Sanitation Health

I’ve realized that, in Zambia, almost everything is done in groups. I’ve arrived at a village called Ngandu Jakalasi expecting a short sit-down interview with a certain Mr. Mwiinga, but am instead greeted by every adult in the village, beginning to spread out on blankets and on logs. “Yes, everything in groups,” laughs my companion, Akros Surveillance Officer Anne Mutunda. “It’s the way we do transparency!” she muses, though I think she’s actually quite serious.

When my subject arrives I am at first a bit confused because my preparation notes say the man is 70. Instead the man I meet is spry-looking, wearing a trim gray goatee, a mischievous grin and a red bucket hat. After we exchange greetings and have a seat on opposing logs, ingeniously supported about a foot and a half above the ground by separate, y-shaped logs, I ask him about this apparent age discrepancy. “I am 70!” he tells me, “though I feel younger than that. Look, I can even run!” he says as he springs back up from his log and gives a demonstrative lap around the collected audience who clap and laugh in approval.

Elijah Charles Mwiinga, 70, sits with his neighbors to discuss bringing the message of CLTS to his community.

He attributes much of this energy to his having been a teacher for 20 years, first in Zambia’s Western Province and then in its Southern Province. When Mr. Mwiinga was a boy, his uncle was a teacher, and he envied the man, who he saw as getting to spend enjoyable days with the children of his class, having fun while passing down knowledge. So go into teaching he did, and successfully, rising through the ranks of teacher and head teacher and, eventually, school principal. He says his job was difficult at first – the schools at times had no materials. As the years went on, the job got easier as he knew more of what to expect.

In 1990 he retired from teaching and decided to return home. He had grown up in the village and he wanted to return. “I was brought up as the son of a farmer so I decided to come back and farm,” he said. “We depend on the farms. We grow what we eat.” He now grows cabbage, tomatoes, onions, rape, and sometimes carrots. Though he had begun his new “retired” life as a farmer, Charles was still a connector of people – he maintained his teacher’s proclivity for explaining things in ways people could understand. (He has been given the nickname “The Professor” in his community as a result.) It was likely for this reason that the Environmental Health Technician (EHT) for his community chose him to attend a workshop in Mazabuka when the first training for Community Champions began. “I didn’t know exactly what it was but I went,” he said.

Akros featured in recent reports

Akros featured in recent reports

By Akros Media on August 28, 2017 in Capacity Building, Health Data Systems, Malaria, News, Uncategorized, Water and Sanitation Health

We strive to be consistently on the cutting edge of the development and technology sector. And the cutting edge does not form without a stalwart commitment to research and a collecting of best practices. We are excited to have been mentioned in several recent pieces of independent research as having implemented technologies and systems that are furthering development work around the world.


Mobile Solutions for Malaria Elimination Surveillance Systems: A Roadmap

The first is in a report titled “Mobile Solutions for Malaria Elimination Surveillance Systems: A Roadmap” funded by the Gates Foundation and carried out by Vital Wave. The study was done to “develop key recommendations regarding appropriate, scalable strategies to promote further innovation and coordination among technology partners” and to “Develop specific recommendations for a coherent and effective Foundation strategy for strengthening data collection systems and associated platforms.” Our mSpray system was featured as a highlight of the geolocation category for the way it increases the efficiency and effectiveness of indoor residual spraying (IRS) campaigns (page 48 of the report).

In its conclusions and recommendations, the report points out that “many of the key elements needed to improve the development and implementation of robust mobile tools for malaria surveillance already exist.” It also says that coordination among malaria program implementers will be key to success and will help keep current the list of necessary features within these digital tools.