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Sustainability of Intervention for Home Management of Malaria: The Nigerian Experience | OMICS International
ISSN: 2161-0711
Journal of Community Medicine & Health Education

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Sustainability of Intervention for Home Management of Malaria: The Nigerian Experience

Ikeoluwapo O. Ajayi1,2*, Ayodele Samuel Jegede1,3 and Catherine O. Falade1,4

1Epidemiology and Biostatistics Research, Institute of Medical Research and Training, College of Medicine, University of Ibadan, Nigeria

2Epidemiology and Medical Statistics Department, College of Medicine, University of Ibadan, Nigeria

3Department of Sociology, The Faculty of Social Sciences, University of Ibadan, Nigeria

4Department of Pharmacology & Therapeutics, College of Medicine, University of Medicine, University of Ibadan, Ibadan, Nigeria

*Corresponding Author:
Ikeoluwapo O Ajayi
Epidemiology and Biostatistics Research
Institute of Medical Research and Training
College of Medicine
University of Ibadan, Nigeria
E-mail: [email protected]

Received date: September 02, 2012; Accepted date: September 24, 2012; Published date: September 26, 2012

Citation: Ajayi IO, Jegede AS, Falade CO (2012) Sustainability of Intervention for Home Management of Malaria: The Nigerian Experience. J Community Med Health Educ 2:175. doi: 10.4172/2161-0711.1000175

Copyright: © 2012 Ajayi IO, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: An important challenge to community-based intervention is sustainability. This study evaluated sustainability of an intervention to improve Home Management of Malaria (HMM) in Ona-Ara Local Government Area of Oyo State, Nigeria two years after end of intervention.
Methods: A total of 13 FGDs was conducted among trained Community Medicine Distributors (CMDs), mothers of children aged 0-5 years and community members; 14 Key Informant Interviews were held with community leaders, Primary Health Care (PHC) Coordinator and Rollback Malaria Manager.Observation was carried out on 13 CMDs to check AL stock and registers. Thematic approach was used to analysed the data.
Results: Utilization of CMDs was said to be high when the project started but dwindled after the researchers left the community. Some of the CMDs have not had drug to distribute in the two years preceding this study. Thus, majority of the caregivers sought care at other alternative care providers or used herbs. While some CMDs have abandoned the assignment, a few continued to provide care to febrile children as their own contribution to the good of the community. The functioning CMDs prescribed paracetamol, sulfadoxine-pyrimethamine, amoxycillin and chloroquine when out of AL stock or referto PHC center. Source of AL was still the nearest government health facilitiesbut supply was irregular and hindered by incessant transfer of trained health workers. All the CMDs mentioned they did not receive any support from the community as promised and this wascorroborated by community members/leaders and health facility workers. None of the CMDs observed had AL in stock orrecord of patronage in the last one year. They mentioned that health centres have not had AL stockedin recent times.
Conclusion: Mechanisms to draw unflinching commitments from the government and community to sustain community-based intervention, the major sustainability challenge identified in this study, should be explored.

Keywords

Home management of malaria; Intervention sustainability; Rural under-five caregivers; Community medicine distributors

Introduction

The incidence and mortality due to malaria still remains unacceptably high especially in sub-Saharan Africa [1]. Persistence of the scourge in sub-Saharan Africa has been attributed to poor access to prompt and effective treatment as well as inaccurate diagnosis. In the bid to improve access to prompt and effective treatment, a variety of strategies have been used and notably is the Home-based Management of Malaria (HMM) which has been shown to be an effective strategy in Africa [2-6]. The strategy involves treating febrile children with pre-packaged antimalarial drugs distributed by trained members of the community [7]. In countries where HMM has been adopted, lay people in the community, Community Oriented Resource Persons (CORPS) and drug sellers have been trained to be role model mothers/mother trainers/role model caregivers also referred to as Community Medicine Distributors (CMDs) [3-6,8]. They provide health education on malaria and its treatment to their communities and distribute antimalarial drugs to febrile children presumptively diagnosed to be malaria. Where adequately practised, HMM has been effective in reducing malaria morbidity and mortality in children less than five years. In Ethiopia, a programme to provide home treatment for malaria reduced all-cause mortality by 40% and malaria-specific mortality by 3 times [6]; in Burkina Faso, prompt treatment of children with uncomplicated malaria with pre-packaged antimalarial drugs reduced progression to severe malaria by 50% [3]. In Nigeria, HMM was acceptable to communities and increased the correctness of use and coverage of effective antimalarial drugs [4,9,10].

Most of HMM interventions were externally driven and a major concern is that many community-based health programs implemented in developing countries are discontinued soon after initial funding ends [11]. In most HMM programmes CMDs are volunteers, who provide care to the members of the community in exchange for small nonmonetary incentives, sometimes complemented by a small monetary remuneration - in the order of 2 to 5 US$/month from top up on price of drug or provided by funding agency [2,5,7,12]. This approach has often resulted in a high attrition rate of CMDs, with many CMDs abandoning the job after a period of time more so after withdrawal of the funding agency from the community at expiration of the project. In Nigeria attrition rate ranging from 10.0% to 49% [13-15] were observed over a period of 12 months. Similarly in Uganda, a dropout rate of up to 16% was observed after 18 months of service [16]. A major challenge to stem attrition of CMDs is how to maintain motivation. Attention to the sustainability of health intervention programs has increased in recent years as policymakers and funders become ever more concerned with allocating scarce resources effectively and efficiently [11]. However, this still remains a challenge in implementation of intervention programmes in the community.

In Ona-Ara Local Government Area, Nigeria an intervention to improve HMM using Artemether Lumefantrine supported by the World Health Organisation was carried out between 2005 and 2007 [15]. At the end of the intervention the communities were informed of the project withdrawal and their role in the sustainability of the project were re-emphasised having mentioned this to them at the outset of the intervention. To support the communities, the CMDs were linked to primary health care facilities in their domain and the National Malaria Control Programme was requested to ensure availability of AL to the CMDs by regular and adequate stocking of the PHC where the CMDs replenish their stock. The community promised to support the CMDs by providing transport or money in lieu to CMDs to collect drugs from PHC and the CMDs accepted to continue the assignment and carry out community mobilisation periodically. However, observation of the activities by the CMDs in subsequent years during visits showed that the intervention was not being carried out effectively. To assess sustainability of the intervention, this study was carried out two years post intervention to determine the extent to which the programme continued, the prospects and challenges encountered and the way forward.

Methods

Study site

This study was conducted in two rural health districts selected by random sampling from the eight health districts that make up Ona-Ara Local Government area (LGA), in south western Nigeria in 2010. The study site has been described in detail by Ajayi et al. [9].

Study design

Focus Group Discussion (FGD) and Key Informant Interview (KII) were conducted in communities in two selected rural wards where prior intervention was carried out. The participants for the FGD which comprised trained CMDs, caregivers of under-five children were selected purposively based on their role in the intervention, experiences visiting CMDs for treatment of febrile illness and ability to discuss freely as well as residing in the community when the intervention was carried out. Focus group discussions (FGDs) were held in groups of six to nine women or men. The key informants were purposively selected based on their position/status in the community and health system, their role in implementation of the intervention, or because of the special information they possessed based on their involvement in the management of childhood fevers. A total of 13 FGDs was conducted among CMDs [2], mothers of children aged 0-5 years [6] and fathers [5]. Fourteen KII were conducted with community leaders [7], Primary Health Care Coordinator [1], Head of PHC facilities [4] Rollback Malaria Manager [1], and malaria control programme officer at the Local Government PHC unit [1]. The CMDs in this study comprised PMS and mothers selected by the communities to be trained as “mother trainers” now referred to as “role model caregivers”.Two teams of three trained assistants (moderator, note keeper and recorder) conducted the sessions with the aid of FGD and KII guides. The guides consisted open ended questions to explore caregivers’ and community members’ opinions on the activities and functioning of the CMDs, the CMDs perception of the support they got from the community and health care facilities in discharging their duties after the researchers withdrew from the communities, and the challenges and strengths to the functioning of CMDs. The sessions and interviews were recorded in audio-cassettes. The teams were supervised by the social scientist (SAJ) on the research team. Observation was carried out on 13 CMDs selected randomly from the list of trained CMDs [5PMS and 8 mother trainers] to check their stock of AL andclient register. Verbal informed consent to carry out the exercise and to audio- record the sessions and interviews was obtained from each participant. Ethical approval to carry out the study was obtained from the Oyo State Ethical Review Board.

Thematic approach was used for data analysis. All data were transcribed and translated into English. The transcriptions were done daily. From the transcripts and field notes, the responses from different informants or groups (FGD) were grouped together, coded and analysed according to themes. Content analysis was performed independently by two of the authors SAJ and IOA as well as two of the research assistants who participated in data collection. They compared notes for congruency and where there was incongruence they re-read the transcript and made necessary corrections. The findings were described, interpreted and reported in form of narratives.

Results

Awareness on community medicine distributors activities

Majority of the participants in FGDs and KIIs mentioned they were aware of the HMM project in the area and activities of the CMDs. They were aware of the training held for the CMDs in the communities at the commencement of the project. The following are quotes of their responses:

“... I know of people trained”. KII, community leader Badeku.

“The programme went fine and we saw the result...” FGD woman, Ajia

“…We have heard about the programme. Those that were selected and trained here tried their best and they have been very passionate about the exercise.” KII woman, Jago.

“…It was very effective. We selected some people for them to train and the programme was a success…” KII community leader, Ojoku.

In addition, the participants commented on their perception of the CMDs and the drugs provided to them. They mentioned that the use of trained CMDs in the community was acceptable and the treatment guideline given to households was of good assistance for treating children with malaria. Some participants could still recapitulate the correct dosages of AL for treating malaria among children of different age groups. The participants were of the opinion that AL is effective and that the use has led to reduction of occurrence and severity of malaria in the area. The following are representations of their responses:

“The programme is going very well in this community and the medicine (AL) is really working”. KII, Ojoku.

However, many of the respondents noted that the activities of the CMDs are not as vibrant as when the programme was newly implemented. A respondent had this to say:

“….It is still going on well but it’s not as vibrant as when it started about 2-3 years ago….” FGD woman, Badeku.

Utilization of CMDs

Utilization of CMDs was said to be high when the project started. However, this dwindled after the researchers left the community. While some CMDs have abandoned the assignment, few continued to provide care to febrile children and distribute AL when available as their own contribution to the good of the community. Few of the functioning CMDs prescribed paracetamol, sulfadoxinepyrimethamine, amoxycillin and chloroquine when out of stock of AL; they also refer febrile children to the PHC center. Some of the CMDs have not had AL to distribute in the last two years preceding this study. This led majority of the caregiverstosought care for their sick under-fives at other alternative care providers such as PMS, public health facilities and traditional healers. There was a general consensus that under-five children were taken to health facilities including PHC centres and/or Private clinics in their various communities. However, some community members patronized the outreach clinic established by University College Hospital, Ibadan in Jago community which is run one-day weekly by nurses from the hospital. Statements below are representations of their responses:

“They are taken to hospital and they respond to treatment”. FGD father, Badeku.

“…According to my knowledge, they take them to Primary Health Centre and where AL is available, it’s prescribed to them....” KII PHC coordinator, Ona-Ara.

“They bring them to centres and there are some volunteer health workers that help to bring them down to this centre”. KII, Head of PHC, Ojoku.

“We go to UCH people that comes to Jago...when they don’t come, we go to the newly established state health center at Butubutu..”FGD, Kupalo.

Performance of CMDs

The study assessed the opinions of the respondents on the performance of the CMDs. The opinions were diverse. While some assessed the performances of the CMDs as satisfactory, others felt some of them were no longer effective. Quotations of their responses are highlighted below:

“Their performance has been satisfactory”. KII, Opinion Leader, Jago.

“Going by the report before me, they are really doing well”. KII, PHC Coordinator, OnaAra.

The quotations below are representation of the reasons given for the good performances of CMDs:

“They (CMDs) didn’t want children to die”. FGD, Community Members, Badeku.

“It is the love we have for the community and our interest in reducing the infant mortality rate that has kept us going”. FGD, CMD, Badeku.

“I think they performed well because they were trained and they deserved to be praised”. KII, Opinion Leader, Ojoku.

For those CMDs that performed poorly, family responsibilities, challenges, unavailability of drugs, lack of remuneration for their services, discouragement and residence outside the community were cited as possible reasons.The quotations below summarises the reasons given for the bad performances of CMDs:

“….There cannot be but few people who will not perform to expectation; most times, it happens as a result of challenges in their homes…” KII, PHC Coordinator, Ona-Ara.

“….Some people may not wholeheartedly do the job because they may say how much will I be given for this...” KII, Head of PHC, Ajia.

“...We have married women who have children amidst them; such may not be readily available...”KII, Opinion Leader, Ojoku.

“When they have no AL to distribute, definitely, it will affect their performance”. KII, Head of Primary Health Centre, Ojoku.

The community/opinion leaders and CMDs were asked the number of CMDs in their community. There was no consensus in the numbers of CMDs mentioned especially in Badeku. Some said 3, some 6. However, the FGD held among CMDs in Badeku revealed that they were 9 but many were no longer functioning and some have left the community to other places for various reasons including further studies, transfer of husband at place of work and relocation by family (Table 1).

Community No of CMDs trained No of CMDs Still Active
Ajia 5 0
Ojoku 4 1
Badeku 9 2
Kupalo 2 2
Jago 3 1
Total 23 6

Table 1: The distribution of trained CMDs by community and those still active.

Also the performance of the CMDs was assessed based on the practices of the caregivers/ community they were expected to train and distribute guideline and drug to. In the KIIs and FGDs conducted, the knowledge of the participants on correct use of ALfor children of ages two to three years was explored.Various dosages were stated with some correct and a few incorrect. Below are citations of their responses:

“It is already shown on drug sachet that AL should be taken in the morning and at night for three days...for children between one and three years old, one in the morning, one at night for three days. Those three years old to five will use two in the morning, two at night...” KII PHC Coordinator, Ona-Ara.

“Six months to one year, half tablets to be given three times a day... one to three years, one tablet to be given a day...three years to five years, two tablets to be given three times a day”. KII Woman Opinion leader, Jago.

“….We give some children 2 tablets and some one. I don’t know the dose off hand except I see the guideline….” KII caregiver, Badeku.

“There is AL package of two tablets. One should be taken in the morning and another in the evening for children six months to one year...for children one to three years, two tablets are to be taken in the morning and another two in the evening for three days; but in my own view, I thought it will be too much hence for three to five years old...to me I give them one tablet in the morning and one in the night because some children that are five years old may be of the stature of three to four years old...” Health Worker, Ajia.

Few of the respondents could not mention any dosage for the administration of AL for children. Below is an excerpt of a response supporting this:

“…I don’t have any idea. Only those that were distributing it and those that use it for the children will know...” KII, Community Leader Ajia.

Effect of the programme on the treatment of malaria

There was a consensus on the usefulness of the treatment guidelines provided for households by the community members. However, few of the respondents made it known that they have misplaced their copies. Below are excerpts of their responses:

“The CMDs really know the import of the guideline...it is like a tool...it enables them do their work correctly”. KII, PHC Coordinator, OnaAra.

“It is useful. These pictures do teach us how to administer the medication. Even if you cannot read, you can follow the pictures as a guide.” KII, Community leader/ Opinion leader, Jago.

“The moment the pamphlet (guideline) was given, it serves as a guide. There was no need to memorise how to use the drug... “KII, Opinion Leader, Ojoku.

Enquiry on the effect of AL distribution to caregivers in the locality revealed that communities felt the impact. The PHC Coordinator in Ona-Ara community responded that the impact of the distribution is being felt. The quotation below captures the response:

“...before, if we give them drugs like chloroquine, they will still come complaining of the persistence of the disease or the side effects such as itching in their children; but with the AL, anytime they come for review, there was always good report about it and even sometimes, when sample opinion of some mother they report that the drug is good” KII, PHC Coordinator Ona-Ara.

Similarly it was perceived that the use of AL has been effective and this encouraged its use and utilisation of CMDs. Below is an excerpt from KII representing the opinion of the community on factors influencing the use of AL:

“...People have used different types of malaria drugs and yet kept complaining but when AL was brought and was used and discovered to be “active” against malaria that was when we had positive attitude towards it...” KII, Head of PHC Ona-Ara.

The general consensus among the study population is that the drug is very effective and well sought after.

Hindrances to performance

The major hindrances to the performance of the CMDs were the far distance of health facilities where AL are collected to the CMDs’ communities and poor transportation facilities. It was indicated by the respondents that distribution of AL in the community was affected by logistics. Excerpts from the transcripts to support this are thus:

“If logistics is okay, it will not be difficult to reach the rural areas” said one of the community leaders.

“...It not easy to go to our local government health quarters since it is a bit far and we are going to give the drug out free…” FGD, CMD, Butu-Butu.

“One of the challenges is distance. The distance from here to where we get the drug is far. Also, there are times when one will not be financially buoyant to get transport fare or bike fare... but if they can bring the drug here for us, bike owners within the community will help in distributing it from one village to the other.”KII Head of PHC, Ajia.

Another important hindrance is the irregular supply of AL. When participants were asked about how they usually get their supply of AL, they mentioned the source of AL was still the nearest government health facilities but supply was irregular and hindered by incessant transfer of health workers who were familiar with the project. A respondent (FGD, Community Members, Badeku) indicated that the person in charge of the programme usually informs them of the availability of the drug.

Generally, apart from their individual communities, the CMDs get their AL supply from research team or the state government through the LGA PHC unit and PHC centres. The statements below capture some of their responses:

“...Drug stock out is a major problem. There may not be drugs at times. They (health workers) will never tell us the reason for this shortage”. FGD CMD, Badeku.

“…They do bring a bit from UCH (research team) but when they stopped bringing it from UCH, we started collecting from Badeku PHC but when the center is out of stock, there was nothing to receive or distribute..”. KII, Head of PHC, Ojoku.

“…We get it from the State Government.When it arrives from the Federal Government... “KII, PHC Coordinator, Ona-Ara.

On the factors affecting the supply of the drugs, respondents had this to say:

“…It is only those that have been trained that can go for the supply…” FGD, Community Members, Badeku.

In addition it was stated that in recent times there had not been stock of AL in the health centres and when available, little quantity was given that they do not have to give the CMDs.

To ascertain the stock of AL, the record of CMDs and their drug box were inspected. None of the shops inspected had AL in stock, neither was there a record of patronage in the last one year – Observation by research assistants.

Community support to community medicine distributors

Inquiries were made during the FGDs and KIIs from the respondents about the attitudes of PHC centers and the entire community to the CMDs and the type of support given to them. It was revealed that the general community do not render any form of financial support to these CMDs as pledged 2 to 3 years earlier during project result dissemination meetings. Although the community members commended the work of the CMDs and their contribution towards child care, they were unwilling to express their appreciation in tangible ways. The following captures their responses:

“….None of the CMDs was given any financial support by the community...” KII Opinion leaders, Badeku and Ajia.

“…..We only thanked them. No financial or monetary appreciation. It’s only verbal….” KII for Community Leaders/ Opinion Leaders, Jago.

“…There has been no support from any quarters. The community is not giving the CMDs any money or anything to support them....” KII Head of PHC Ojoku.

“….we did nothing, although I gave N30 (25 cents) on two occasions. I wouldn’t know if others gave them money and I don’t think so…..” KII, A male opinion leader in Ajia.

Findings from the FGDs conducted among the CMDs corroborated these findings. All the CMDs mentioned they did not receive any support from the community. Most of the participants wanted the project to continue to support treatment of malaria in the community. This is illustrated by the quotes below:

“….There is nothing given to us. They believe we are doing our duties…” FGD CMDs Badeku.

“…We have never been given any financial assistance...Even when we board the same cabs/taxi with community members they even expect us to pay their fares...” FGD, CMDs Badeku.

Members of the community and health facility workers corroborated the fact that CMDs were not being supported. The community members had a wrong notion that the CMDs were been paid salary by the government and this was said to have contributed to the lack of support from the community members. Below are representations of their responses:

“….People did not support these CMDs in any way because they believe it is their right to be given drugs free of charge especially under this democratic government. They also believed that these CMDs are being paid…”KII, PHC coordinator, Ona-Ara.

“…..Some even though it is government work and there shouldn’t be any thank you to us….” FGD CMDs, Badeku.

“…A woman in the community even fought with me that we are collecting salary for the assignment and I didn’t inform her to be part of it...” FGD CMD, Ojoku.

Another reason given for not supporting the CMDs is that the people believe the CMDs are doing it for the good of the community.

“….No payment was given. We believe she is part of the community and doing that to serve her locality...” FGD women, Ojoku.

Community members felt that the prayers they render to God for them regularly will impact positively on the lives of the CMDs as they carry out their duties. The following responses corroborated this finding:

“…It’s only prayers we offer them and we can see it’s working for them. Nobody is giving them anything. FGD Community Members, Badeku.

“….We don’t actually do anything for them, we are only praying to God to bless them in return…” FGD men, Ajia

Findings show that the relationship between the CMDs and community members as well as health facilities is cordial.

“…..The relationship is cordial because this is where instructions emanate to all the CMDs and health facilities under us…” KII PHC co-ordinator, Ona-Ara.

“…..We do greet them well ... We don’t use to overlook them…” FGD Community members, Ajia.

The CMDs also commented on the relationship thus:

“…They (health workers) do not get annoyed with us at all. They are very happy and they attend to us very well and ask if we still have the drugs with us…” FGD CMDs, Ajia.

“…The CMDs come here and we give them AL. Also they assist to attend to sick children in the community faster due to their closeness to the people…” KII Head, PHC Badeku.

Primary Health Care Support to sustainability of the programme

The contribution of PHC unit to the continuation of the programme with regard to supply of AL was sought. The PHC Coordinator commented thus:

“The PHC has some centres to which are supplied AL. The centres also distribute these drugs to all the health facilities in the local government. They ensure that every facility that is given drug is registered and the number of drugs is also recorded. This gives us the assurance that the drug get to its final destination”. KII PHC Coordinator, Ona-Ara.

Furthermore, the performance of health centres in distributing AL was explored. The following are representation of the responses:

“...when you put the drug in PHC centers...awareness would be created among the people in the community…” KII Head of PHC, Ajia.

Supervision of CMDS: Health care workers did not render any form of supervision to the CMDs neither did the CMDs saw any justification for supervision by the health workers:

“….When we were trained, we were not instructed to supervise. They only inform us to distribute AL to CMDs….” KII Health worker, Badeku

Also the CMDs did not seek assistance from health workers in respect to discharging their duty – distributing AL.

”…None of the CMDs reported to us that they had difficulty because they were all there at the training and they are also literate…” KII, PHC Head, Ojoku.

Suggestions on how to improve the activities of the CMDs and sustainability of the programme

Majority of the respondents suggested that the CMDs should be given a token in order to encourage them to continuing the selfless work they are doing. This is support by these quotes.

“…We should be made to pay a token so as to enable the CMDs have some earnings from it…” KII Opinion Leader, Badeku.

“…The CMDs should be supported financially, even, if it is with a little stipend. The woman that came here this morning came all the way from Odeyale which is quite a distance from here. Is she expected to be trekking about distributing the AL?” KII Head of PHC, Ajia.

Some respondents suggested that AL for adults should be included in the supply. Their opinion is that if the adults who are also caregivers are not in good health, they will find it difficult to take care of the children. The following is a representation of their view:

“…The government should also bring drugs for adults so that parents would be available to take care of the children effectively... If parents are not taken care of, caring for the children would be somehow difficult...they should make AL available for both parents and children….” FGD men, Kupalo.

Suggestions were made for the training of more CMDs to build capacity in the community more so with exit of some trained CMDs. It was also suggested that the programme should be extended to other communities so that these other communities can benefit from the programme. Below are excerpts from the respondents on this:

“…I think there’s need to train new CMDs in this community. The two trained ones do not reside in the community anymore….” KII Opinion leader, Ojoku.

“….We will need additional CMDs to assist in the distribution of AL... You should help get more people to distribute this medicine...” FGD a community Members, Badeku (the largest community in the LGA).

“We have 17 health centres in Ona-Ara, if it could cover the whole 17, it would be better. Some mothers have been trained in other communities by the state government recently under the National HMM scaling up programme and called “role model mothers”; they too should be given drugs to distribute…” PHC, Co-ordinator, Ona- Ara.

Some respondents were willing to pay for AL in order to sustain the CMDs activities. They suggested some ways the government can contribute to sustainability. The citations below highlight their opinions:

“ ITNs can be given to the health facilities to distribute along with AL to CMDs who will in turn distribute at the community. This may encourage patronage of the CMDs by the community members. The primary health care workers should also be given a means of transportation like motorbike to ease the stress of moving around to check the activities of the CMDs and also their patients to ensure AL is dispensed correctly by the CMDs and the patients used their drug correctly too….” KII PHC co-ordinator, Ona-Ara.

“…The encouragement should be from the government. They should make drug to be readily available...” FGD Women, Jago.

“…The supply of drug should be more than it used to be...” FGD Women, Jago.

“…We will need to plead with you people (research team) to please bring AL to us. It is very useful and effective ...AL should be made available in our health centre for us even if it is for sale, we will all know and prepare for the purchase…”FGD Community Members, Badeku.

“…The facilitators (research team) should not leave the monitoring and supervision of the CMDs to us (health workers) alone…” KII Head of PHC, Ajia.

An opinion leader from Jago community was of the view that the community has no plan for the CMDs and only the implementers of the programme can help them. He stated thus:

“There’s nothing we can do from here.The community has no plan to do anything for these CMDs. It is only you people that can help them”. KII Opinion Leader, Jago.

Discussion

The findings of the intervention [9] which this study assessed the sustainability, was one of the studies that provided evidence for scale up of HMM strategy in Nigeria. However, sustainability of the programme in the community had always been a concern and this was corroborated in this study. While communities could be receptive to interventions perceived to be beneficial it was evident from this study that willingness to sustain such intervention even if laudable is questionable. The nonadherence to the pledge made by the community and PHC unit of the LGA to provide continuing support to the CMDs at the expiration of the project led to non-sustainabilityof AL distribution in this study area. The attrition rate was very high and CMDs who were still willing were left incapacitated and disenfranchised.

Potential influences on sustainability may derive from three major groups of factors: (1) project design and implementation factors, (2) factors within the organizational setting, and (3) factors in the broader community environment [11]. These were addressed in the implementation of the main intervention study. Community participation from outset which included determining an affordable price for AL, distribution point and selection of volunteers was ensured as part of effort to sustain the programme [10]. However, this fluttered. One lesson learned is that the choice of who to serve as CMD could contribute to duration of volunteerism. For those CMDs that performed poorly in this study, family responsibilities and challenges, unavailability of drugs, lack of remuneration for their services, discouragement and residence outside the community were cited as possible reasons. The family responsibilities of a would-be volunteer should be well scrutinized before recruitment. However, in communities where there are not many eligible community members ready to volunteer, such factors would have to be addressed and the CMDs may need to be empowered appropriately.

One other area identified as important for sustainability is the supervisory role of health workers and PHC unit. The health workers in this study area could not discharge their supervisory role which stands to encourage as well as motivate the CMDs and ensure that quality service is provided by the CMDs. The health workers did not perceive their role as supervisors to the CMDs and it appears that the research team did not emphasise the role during the study implementation. Some health workers mentioned that non-provision of transport was a hindrance to providing this service. The health facilities were also incapacitated by non-supply or irregular supply of AL by the state government. One other limitation of the health facilities was the incessant transfer of the health workers at the Local Government level. Many of the trained health workers in the study areas were transferred before the project was over and those trained thereafter had also been transferred before this evaluation study. This high staff turn- over rate hindered continuity and thus affected sustainability.

Suggested indicators for monitoring sustainability include maintenance of health benefits achieved through initial program, level of institutionalization of a program within an organisation and measures of capacity building in the recipient community [11]. In this study, the health benefits achieved during intervention could not be sustained even though the beneficiaries attested to the effectiveness of AL and benefit to the community. Non-availability of AL was a major challenge in sustaining the HMM programme in this study site and this is similar to report in some other countries that have adopted Artemisinin-based Combination Therapy (ACT) for home management of malaria. [17,18]. Meanwhile in countries that have maintained regular supply and sustained community use of the drug in correct dose have reported marked reduction in occurrence of malaria in children and transmission in the community. The revert to use of monotherapy for treatment of malaria during stock-out of AL is a major drawback to malaria control in the study environment and stands to encourage development of drug resistance by malaria parasite. Referral to other health facilities or care provider constitutes additional out-of-pocket cost for treatment of malaria and increase in household expenditure with resultant effect on other priority needs of the home.

The inability of the government to sustain drug supply in the programme raises a need to re-visit the long standing controversy on whether to provide antimalarial drugs free, or to subsidize the price or to provide at a fee for profit. The submission by some of the participants in this study that they are willing to pay for the drug if only it is made available regularly suggests that providing antimalarial drugs at an affordable price to the community is acceptable and stands to ensure regular supply as the government would have money for continuing purchase and supply. In addition, policy change to charge a fee for drug and to engaged the private sector more in antimalarial drug purchase and distribution is needed.

One major issue that came out from this study is the need to provide incentives to CMDs. Many studies have suggested that mechanism of providing incentives to CMDs need to be developed to retain CMDs and allow them to deliver the service over time [references]. In support of the importance of incentives in retaining CMDs is the fact that during the main intervention in this study CMDs were given token amount as incentives either as fee charged for drugs or money given by the project as commission on sale of drug, there was little or no attrition. However, soon after the withdrawal of project team and introduction of the policy that AL supplied by government should be provided to children free attrition became pronounced. In most HMM programmes CMDs are volunteers, who provide care to the members of the community free of charge and who also have primary assignment as bread winner or co-bread winner in the home. This makes it imperative that their service is supported by enabling environment such as regular supply of drugs, provision of transportation or other mechanism to ensure access to the drugs and other materials so that they do not waste much time on logistics for getting drugs and other materials.

Incentive mechanisms suggested in this study include given permission for CMDs to charge a token on the drugs, charging a token fee for consultation and community providing transport fare or vehicles to CMDs to collect drugs from the health facilities. However, provision of transport fare was what the CMDs mentioned will be needed to enable them continue their assignment and this was the main arrangement concluded with the community prior to disengagement of the research team from the community. Relent of the community on this pledge calls for concern and corroborates report in the literature that community financing of CMDs has been largely advocated, but almost no examples of a sustained form of this exist [7]. However, in this study the belief that CMDs were being paid to the extent that one of them was accused of hiding the information could have been responsible for the poor cooperation of the community. The irregular and non-availability of drugs which resulted in incessant stock-out of drug must have compounded the communities dis-interest in sponsoring their CMDs; as the money provided stands to be a waste from futile travels to the health facilities. In addition to monetary incentives other incentives suggested in this study include continuing training and formative supervision which should be provided to encourage the CMDs to provide quality service to the community [19].

The clamour for inclusion of adults in the HMM programme needs attention. It stands to reason that treating just one group of people in the community may not be adequate and encouraging to the community. Adult members of the community may better appreciate the role of the CMDs if they are also clients. This could translate into a form of incentive for the community as the adults are the ones to provide the funds to support the CMDs. Furthermore the provision of prompt and effective treatment to adults with clinically diagnosed malaria may also help with break in transmission of malaria as they often have asymptomatic parasitaemia which fosters transmission of the disease.

Institutionalisation of the programme is another indicator of sustainability that could be addressed in the case of scaling up HMM in Nigeria. The belief that CMDs are being paid could be a reflection of the understanding of the community that government is meant to be responsible for provision of enablement for community volunteers. There has been debate on whether welfare of volunteers can be provided for in the budget of the local government and whether volunteerism should be institutionalised for sustainability. In this study the CMDs were not given due recognition and the link to health care system could not be established. This corroborates the submission that in many community-based programmes local implementing agencies, including community organisations, often lack technical links with central government or other agencies capable of providing appropriate support. Without these links, strategies are often hampered, or fail, for lack of institutional support and expertise. The National Malaria Control Programme (NMCP) in Nigeria should start thinking along this line and develop a mechanism for the inclusion of incentives to community based health care providers in the policy and subsequently consider them as part of the health care system.

Conclusion

Community Medicine Distributors play a key role in communitybased initiative for malaria control. They complement the effort of Primary Health Care services to deliver prompt and effective treatment for uncomplicated malaria and prompt referral of severe cases in the community. However, high attrition rate of CMDs – often resulting from lack of motivation and incentives – can be a major obstacle to the sustainability and effectiveness in any intervention. While the HMM intervention project has proved to be life transforming in this study area, community support for CMDs was a serious challenge to sustainability of the programme. Providing CMDs with incentives to motivate them to continue their volunteering work over a prolonged period of time and regular supply of AL in the health care facilities are paramount to sustainability. Mechanisms of providing incentives to CMDs need to be developed. Operational research to determine the reasons for community non-committal and comparison of effectiveness of various incentives mechanism suggested in this study and other related past studies is recommended.

Acknowledgement

We acknowledge the role of the community members, opinion leaders, CMDs, the health workers, research assistants and field supervisors. This study received financial support from the Epidemiology and Biostatistics Research Unit of Institute for Medical Research and Training, College of Medicine, University of Ibadan.

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