Assessment of Malawi's success in child mortality reduction through the lens of the Catalytic Initiative Integrated Health Systems Strengthening programme: Retrospective evaluation

A qualitative study exploring hand hygiene practices in a neonatal unit in Blantyre, Malawi: implications for controlling healthcare-associated infections

Background: Neonatal sepsis causes morbidity and mortality in sub-Saharan Africa. Antimicrobial resistance exacerbates outcomes. Poor Infection Prevention and Control practices (IPC) by healthcare workers and caregivers drive infection transmission. The Chatinkha Neonatal Unit in Malawi has experienced Klebsiella pneumoniae outbreaks of neonatal sepsis. We aimed to identify barriers to optimal IPC, focusing on hand hygiene. Methods: We used a focused ethnography to meet the study aim. Combining participant observation over a seven-month period with semi structured interviews with health care workers and patient carers (23) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. To analyse the data, we drew on the framework approach. Results: We found that staff and caregivers had a good understanding and recognition of the importance of ideal IPC, but faced substantial structural limitations and scarce resources, which hindered the implementation of best practices. We present two key themes: (1) structural and health systems barriers that shaped IPC. These included scarce material resources and overwhelming numbers of patients meant the workload was often unmanageable. (2) individual barriers related to the knowledge of frontline workers and caregivers, which were shaped by training and communication practices on the ward. We highlight the importance of addressing both structural and individual barriers to improve IPC practices and reduce the burden of neonatal sepsis in resource-limited settings. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

A qualitative study exploring hand hygiene practices in a neonatal unit in Blantyre, Malawi: implications for controlling healthcare-associated infections

Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging.  For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging.  Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

A qualitative study exploring health workers and patient caregivers’ hand hygiene practices in a neonatal unit in Blantyre, Malawi, implications for controlling outbreaks of drug resistant infections

Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging.  For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging.  Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique

Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.

End-user perspectives of two mHealth decision support tools: Electronic Community Case Management in Northern Malawi

BACKGROUND

The introduction of a paper-based Community Case Management (CCM) in Malawi has contributed to a reduction of child morbidity and mortality rates. In addition, the introduction of electronic Community Case Management (eCCM) (smartphones with built in CCM apps) may help to reduce the under-five mortality rates even further.

PURPOSE

It is not uncommon for Apps with a similar area of interest to develop different features to assist the end users. Such differences between Apps may have a significant role to play in its overall adoption and integration. The purpose of this research was to explore end users perspectives of two eCCM decision support tools developed and implemented by the Supporting LIFE project (SL eCCM App) and D-Tree International's (Mangologic eCCM App)in Northern Malawi.

METHODS

A mixed methods approach was applied, involving a survey of 109 users (106 Health Surveillance Assistants (HSAs), and 3 Integrated Management of Childhood Il6lnesses (IMCI) coordinators). This was followed up with semi-structured interviews with 34 respondents (31 HSAs, and 3 IMCI coordinators). Quantitative data was analyzed using SPSS version 20 where descriptive statistics and Chi-Squared tests were generated. Qualitative data were analyzed based on thematic analysis.

RESULTS

Participants reported that both Apps could assist the HSAs in the management of childhood illnesses. However, usability differed between the two apps where the Supporting LIFE eCCM App was found to be easier to use (61%) compared to the Mangologic eCCM App (4%). Both Apps were perceived to provide credible and accurate information.

CONCLUSION

It is essential that the quality of the data within Mobile Health (mHealth) Apps is high, however even Apps with excellent levels of data quality may not succeed if the overall usability of the App is low. Therefore it is essential that the Apps has high levels of data quality, usability and credibility. The results of this study will help inform mobile Health (mHealth) App designers in developing future eCCM Apps as well as researchers and policy makers when considering the adoption of mHealth solutions in the future in Malawi and other LMICs.

The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980-1998

Background

Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates.

Methods

We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach.

Findings

We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI − 1.4 to − 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI − 1.6 to − 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044]).

Conclusion

Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors.

Examining coverage, content, and impact of maternal nutrition interventions: the case for quality-adjusted coverage measurement

Background

Reductions in neonatal mortality remain stagnant, despite gains in health care access and utilization. Nutrition interventions during antenatal care (ANC) and in the immediate postpartum period are associated with improved neonatal outcomes. Adjusting coverage estimates for the quality of care provided yields greater insight into health system performance and potential population health benefits of accessing care. In this cross-sectional study, we adjust maternity care coverage measures for quality of nutrition interventions to determine the impact on infant birth weight and breastfeeding.

Methods

We used household data from the Malawi 2013-2014 Multiple Indicator Cluster Survey to assess use of maternal health services and direct observations of ANC and delivery from the 2013 Service Provision Assessment to measure nutrition interventions provided. We adjusted coverage measures combining self-reported utilization of care with the likelihood of receipt of nutrition interventions. Using adjusted log-linear regression, we estimated the associations of these nutrition quality-adjusted metrics with infant birthweight and immediate breastfeeding.

Results

Health facility data provided over 2500 directly observed clinical encounters and household data provided 7385 individual reports of health care utilization and outcomes. Utilization of ANC and facility-delivery was high. Women received nutrition-related interventions considerably less often than they sought care: over the course of ANC women received a median of 1.6 interventions on iron, 1 instance of nutrition counseling, and 0.06 instances of breastfeeding counseling. Nutrition quality-adjusted ANC coverage was associated with a reduced risk of low birthweight (adjusted relative risk [ARR] 0.87, 95% confidence interval (CI) = 0.79, 0.96) and increased likelihood of immediate breastfeeding (ARR = 1.04, 95% CI = 1.02, 1.07); nutrition quality-adjusted post-delivery care was also associated with greater uptake of immediate breastfeeding (ARR = 1.08, 95% CI = 1.02, 1.14). Based on these models, delivering nutrition interventions consistently within the existing level of coverage would decrease population prevalence of low birthweight from 13.7% to 10.8% and increase population prevalence of immediate breastfeeding from 75.9% to 86.0%.

Conclusions

Linking household survey data to health service provision assessments demonstrates that despite high utilization of maternal health services in Malawi, low provision of nutrition interventions is undermining infant health. Substantial gains in newborn health are possible in Malawi if quality of existing services is strengthened.

Closing the inequality gaps in reproductive, maternal, newborn and child health coverage: slow and fast progressors

Introduction

Universal Health Coverage (UHC) is a critical goal under the Sustainable Development Goals (SDGs) for health. Achieving this goal for reproductive, maternal, newborn and child health (RMNCH) service coverage will require an understanding of national progress and how socioeconomic and demographic subgroups of women and children are being reached by health interventions.

Methods

We accessed coverage databases produced by the International Centre for Equity in Health, which were based on reanalysis of Demographic and Health Surveys, Multiple Indicator Cluster Surveys and Reproductive and Health Surveys. We limited the data to 58 countries with at least two surveys since 2008. We fitted multilevel linear regressions of coverage of RMNCH, divided into four main components-reproductive health, maternal health, child immunisation and child illness treatment-to estimate the average annual percentage point change (AAPPC) in coverage for the period 2008-2017 across these countries and for subgroups defined by maternal age, education, place of residence and wealth quintiles. We also assessed change in the pace of coverage progress between the periods 2000-2008 and 2008-2017.

Results

Progress in RMNCH coverage has been modest over the past decade, with statistically significant AAPPC observed only for maternal health (1.25, 95% CI 0.90 to 1.61) and reproductive health (0.83, 95% CI 0.47 to 1.19). AAPPC was not statistically significant for child immunisation and illness treatment. Progress, however, varied largely across countries, with fast or slow progressors spread throughout the low-income and middle-income groups. For reproductive and maternal health, low-income and lower middle-income countries appear to have progressed faster than upper middle-income countries. For these two components, faster progress was also observed in older women and in traditionally less well-off groups such as non-educated women, those living in rural areas or belonging to the poorest or middle wealth quintiles than among groups that are well off. The latter groups however continue to maintain substantially higher coverage levels over the former. No acceleration in RMNCH coverage was observed when the periods 2000-2008 and 2008-2017 were compared.

Conclusion

At the dawn of the SDGs, progress in coverage in RMNCH remains insufficient at the national level and across equity dimensions to accelerate towards UHC by 2030. Greater attention must be paid to child immunisation to sustain the past gains and to child illness treatment to substantially raise its coverage across all groups.

Evidence of Impact: iCCM as a strategy to save lives of children under five

Background

In 2013, the World Health Organization (WHO) launched the Rapid Access Expansion (RAcE) programme in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria to increase coverage of diagnostic, treatment, and referral services for malaria, pneumonia, and diarrhea among children ages 2-59 months. In 2017, a final evaluation of the six RAcE sites was conducted to determine whether the programme goal was reached. A key evaluation objective was to estimate the reduction in childhood mortality and the number of under-five lives saved over the project period in the RAcE project areas.

Methods

The Lives Saved Tool (LiST) was used to estimate reductions in all-cause child mortality due to changes in coverage of treatment for the integrated community case management (iCCM) illnesses – malaria, pneumonia, and diarrhea – while accounting for other changes in maternal and child health interventions in each RAcE project area. Data from RAcE baseline and endline household surveys, Demographic and Health Surveys, and routine health service data were used in each LiST model. The models yielded estimated change in under-five mortality rates, and estimated number of lives saved per year by malaria, pneumonia and diarrhea treatment. We adjusted the results to estimate the number of lives saved by community health worker (CHW)-provided treatment.

Results

The LiST model accounts for coverage changes in iCCM intervention coverage and other health trends in each project area to estimate mortality reduction and child lives saved. Under five mortality declined in all six RAcE sites, with an average decline of 10 percent. An estimated 6200 under-five lives were saved by malaria, pneumonia, and diarrhea treatment in the DRC, Malawi, Niger, and Nigeria, of which approximately 4940 (75 percent) were saved by treatment provided by CHWs. This total excludes Mozambique, where there were no estimated under-five lives saved likely due to widespread stockouts of key medications. In all other project areas, lives saved by CHW-provided treatment contributed substantially to the estimated decline in under-five mortality.

Conclusions

Our results suggest that iCCM is a strategy that can save lives and measurably decrease child mortality in settings where access to health facility services is low and adequate resources for iCCM implementation are provided for CHW services.

Efforts to alter the trajectory of neonatal mortality in Malawi: evaluating relative effects of access to maternal care services and birth history risk factors

BACKGROUND

The neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality.

METHODS

A causal inference approach was used to estimate a population attributable risk parameter for each exposure, adjusting for co-exposures and household, maternal and child-specific covariates. The maternal exposures evaluated were unmet family planning needs, less than 4+ antenatal care visits, lack of institutional delivery or skilled birth attendance, having prior neonatal mortality, short (8-24 months) birth interval preceding the index birth, first pregnancy, and two or more pregnancy outcomes within the preceding five years of the survey interview.

RESULTS

We included 9553 women and their most recent live birth within 3 years of the survey. The sample's overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05.

CONCLUSIONS

Our analysis addresses the gap in the literature on evaluating the effect of these exposures on neonatal mortality in Malawi. It also helps inform programs and current efforts such as the Every Newborn Action 2020 Plan. Increasing access to maternal care interventions has an important role to play in changing the trajectory of neonatal mortality, and women who are at an increased risk may not be receiving adequate care. Recent studies indicate an urgent need to assess gaps in service readiness and quality of care at the antenatal and obstetric care facilities.

Factors associated with malnutrition among children <5 years old in Burkina Faso: evidence from the Demographic and Health Surveys IV 2010

Objective

To assess the factors associated with malnutrition among children <5 years in Burkina Faso.

Design

This study was based on secondary analysis of cross-sectional population-based data from Burkina-Faso Demographic Health Surveys 2010.

Setting

This study was carried out in Burkina Faso, West Africa.

Participants

The participants were 6337 children <5 years and their mothers.

Main outcome measures

Demographic characteristics, child nutrition and health status, and maternal and household information were collected. Survey-specific SAS procedures for weighting, clustering and stratification in the survey design were used. The distribution of different nutritional status, such as underweight, stunting and wasting and the effects of risk factors on malnutrition was analyzed.

Results

Out of 6337 children <5 years, 51.0% of children were male and 57.8% of children had an average size at birth. There were 15.6, 21.5 and 10.6% of children who recently suffered from diarrhea, fever and acute respiratory infection, respectively. Child sex, age, size at birth, child morbidity, mother's education and body mass index and household wealth index were significantly associated with undernutrition among children <5 years in Burkina Faso.

Conclusions

In addition to the improvement of household wealth index, more health and nutritional education for mothers should be implemented by the government to improve health and nutritional status of children <5 years in Burkina Faso.

The 'community' in community case management of childhood illnesses in Malawi

BACKGROUND

Malawi has achieved a remarkable feat in reducing its under-5 mortality in time to meet its MDG 4 target despite high levels of poverty, low female literacy rates, recurrent economic crises, a severe shortage of human resources for health, and poor health infrastructure. The country's community-based delivery platform (largely headed by Health Surveillance Assistants, or HSAs) has been well established since the 1960s, although their tasks and responsibilities have evolved from surveillance to health promotion and prevention, and more recently to include curative services. However, the role of and the form that community involvement takes in community-based service delivery in Malawi is unclear.

DESIGN

A qualitative rapid appraisal approach was utilised to explore the role of community involvement in the HSA programme in Malawi to better understand how the various community providers intersect to support the delivery of integrated community case management by HSAs. Twelve focus group discussions and 10 individual interviews were conducted with HSAs, HSA supervisors, mothers, members of village health committees (VHCs), senior Ministry of Health officials, district health teams, and implementing partners.

RESULTS

Our findings reveal that HSAs are often deployed to areas outside of their village of residence as communities are not involved in selecting their own HSAs in Malawi. Despite this lack of involvement in selection, the high acceptance of the HSAs by community members and community accountability structures such as VHCs provide the programme with legitimacy and credibility.

CONCLUSIONS

This study provides insight into how community involvement plays out in the context of a government-managed professionalised community service delivery platform. It points to the need for further research to look at the impact of removing the role of HSA selection and deployment from the community and placing it at the central level.