A Malaria in Pregnancy Country Case Study: Malawi

This 49-page case study shares findings and lessons learned from malaria in pregnancy programming (MIP) in Malawi. Although multiple challenges remain, Malawi is one of the few countries in sub-Saharan Africa that have shown improved malaria outcomes and so it is considered to likely have applied successful strategies or best practices that could potentially be adapted and replicated in other malaria-endemic countries. Conducted by the United States Agency for International Development (USAID) Maternal and Child Health Integrated Program (MCHIP) with support from the President's Malaria Initiative, the case study identified strengths in MIP programme implementation in the areas of policy, community awareness and involvement, and financing.

According to the report, Malawi was selected for the case study based on its progress on two MIP-related indicators: Intermittent Preventive Treatment in Pregnancy (IPTp) uptake and insecticide treated net (ITN) use, as well as its widespread malaria endemicity. The report states that several of Malawi's practices in programming can serve as models for and be adapted to other country situations. These are:

• Integration of MIP interventions with Focused Antenatal Care (FANC) at the facility level - At the central level, there is weak integration of MIP with reproductive health, but at the health facility level, MIP interventions are fully integrated with FANC service delivery. Distributing free ITNs and administering IPTp during routine FANC visits have helped improve coverage of these interventions. Although several challenges remain to attain complete coverage, including ensuring adequate commodity stocks and human resources, integration of MIP and FANC is routine.
• Leadership in the investigation and rollout of drug regimens for IPTp and MIP case management - With support from donors and implementing partners, Malawi has and continues to play a leadership role in investigating treatment failures with current drug regimens for MIP.
• Well-developed information, education and communcication (IEC) strategy with creative platforms for effective communication of malaria messages - Through successful use of print and mass media campaigns, malaria messages have reached more than three-quarters of the intended population. Radio spots, posters, music videos, and public service announcements encouraging use of ITNs and IPTp by pregnant women have been disseminated nationally. Publicity surrounding high-profile events, such as the 2010 Football World Cup, have been effectively utilised to promote use of malaria interventions. Reproductive Health and malaria stakeholders credit such programmes with the significant increase in ITN usage among pregnant women between 2006 and 2010.
• Involvement of CBOs and CHWs to increase access to MIP services - The National Malaria Control Program works through community-based organisations (CBOs) and community health workers (CHWs) to reach pregnant women in the most remote areas with messages about the importance of attending ante-natal care (ANC), taking Sulfadoxine-Pyrimethamine (SP), and using ITNs. CHWs are an important link between pregnant women and facilities, ensuring that women understand and access MIP interventions available to them through ANC.
• Delivery of maternal health services, including MIP education and referral, closer to the household level - The pilot launch of the Community Maternal and Newborn Care Package is a significant step toward bringing health services closer to the family and strengthening referral systems for facility-based care, such as FANC. According to preliminary anecdotal reports, this intervention is increasing women's willingness and ability to access maternal health services, thereby reducing morbidity and mortality.

The case study has also identified several specific gaps in programme implementation and scale-up. Based upon the findings, the following communication related actions are recommended:

• Re-establish MIP Working Group - Routine, quarterly meetings could serve as an opportunity to jointly plan MIP activities, leverage funding, and share expertise. Regular, constructive communication could further prevent inconsistencies in policy and programmatic strategies and prevent future disputes, such as that over community IPTp.
• Harmonise Reproductive Health Unit (RHU), NMCP, and HIV policies and messaging and dedicate increased resources to guideline dissemination - Inconsistencies in FANC and MIP policies, guidelines, and performance standards, specifically the timing and number of doses of IPTp and regimens for HIV-positive pregnant women, should be jointly reviewed and harmonised so that the Ministry of Health (MOH) has one clear FANC and MIP policy that all health programmes and service providers can follow. These guidelines should be consistent in language and should be reflected in pre- and in-service curricula, as well as facility- and community-level IEC.
• Advocate through the MIP Working Group and other fora to ensure consistent
  stocks of SP and ITNs at ANC clinics - Many countries across the Africa region are experiencing widespread and frequent stockouts of SP. Pending reform, donors and implementing partners must continue to exert pressure on the Government of Malawi to ensure consistent stocks of SP at the central and facility level.
• Promote capacity-building strategies, including strengthened pre-service education, on-the-job training, mentorship, and supervision, in addition to group-based,
  in-service training - MIP is already included in pre-service training, but Malawi may need to examine the quality of pre-service training and whether additional training is the answer, considering that issues, such as limited numbers of skilled providers and weak supervision, have been identified as primary challenges. Because off-site training is expensive and has reinforced a culture of per diems, a more cost-effective approach may be to direct funds toward preservice institutions for training and strengthening infrastructure and, at the district and facility levels, toward on-the-job training, mentorship, and supervision.
• Support community-directed initiatives to overcome barriers to care-seeking - Many of the barriers that inhibit access to FANC and MIP interventions - including
  household power dynamics, lack of transport, and lost income - can be addressed by
  community-directed interventions that raise awareness about the importance of FANC and MIP services and malaria prevention. They also bring services closer to the community. Other interventions, such as community-based agents demonstrating and assisting in proper hanging of LLINs in households, can also eliminate simple but significant barriers to implementation of malaria prevention strategies.
• Develop more nuanced IEC regarding potential causes of fever and appropriate
  use of SP - The public health community in Malawi has effectively raised awareness of the causes, signs, and symptoms of malaria. The unintended consequence of this awareness, however, is the widespread association of all fevers with malaria. In light of the development of resistance to chloroquine and SP for case management, it is crucial that communities and service providers alike understand that although fever is a symptom of malaria, not all fevers are malaria.