Probably, one of the most important building blocks is human resource capacity building. Planning all the issues of keeping records all the issues of delivering services will not be achieved if we don't have trained health workers to carry out those functions, to implement those building blocks. So, we want to make sure that when we train health workers, we're building their knowledge and skills based on evidence-based policies. So, as you can see, the different building blocks tie together. So, once we have evidence-based policies and guidelines, we have a foundation for developing a curriculum to train health workers. Whether these are village health workers in the community, whether these are nurses, midwives, a pharmacists: whoever happens to be working for the delivery of malaria services in our case. There are different ways of providing training, providing education, providing knowledge and skills to health workers. First, we need to start with pre-service (or basic) education. Where you start off in a school of nursing, in a medical school and a health technology training institution. Assuming these people have graduated and they started working, it's recognized that new ideas come along, new policies are developed, innovations in malaria control happen. And so, these people need continuing education, continuing professional development, in-service training. It goes by a number of names, but the idea is that we want to ensure that health workers do not stop learning once they have graduated with their basic diploma, but they keep up to date. It's important to recognize too, that we're not just focusing on workshops. We're concerned about on-site activities, where supervisors can do mentoring, where they can encourage health workers who have access to things like the Internet to do guided self-learning. Whatever it is, we want to make sure that one, the basic skills that they gain in school, are evidence based and form a foundation from which they can continue to update themselves as they continue to work. So, we want competency based learning, where health workers are actually performing what they've learned. That they develop those skills necessary based on evidence-based policies, so that we know that the performance the activities that the health workers are doing actually make a difference. That the services they are providing actually make a difference. That the way they provide the services make a difference. One of the concerns that we have is that they should start off with a solid technical foundation, that they can use immediately upon graduation and then keep them up to date. It was interesting when we first started working in one of the West African countries in Chicago. And one of the assignments that was given in the project, was that we were expected to train almost 2000 newly graduated health workers on malaria case management. And the question that came to mind, is why would a newly graduated health worker not be able to manage a patient with malaria? So, we went immediately to the School of Health Technology where they were training the various cater of people, the nurses, the midwives, and asked them, "Okay, well what are people being taught about malaria?" And unfortunately, there really wasn't a good curriculum guide to show this. There were a few things where listing things like malaria is caused by Anopheles mosquitoes. There were maybe lists of the medicines that were used, although it was not up to date. But there really wasn't a specific curriculum component for malaria, which was one of the most common diseases in the country. So, what we had to do was to say okay we will train these newly graduated people, so they can start saving lives by treating malaria. But in the meantime, we formed a committee with the National Health Training institutions to help develop the pre-service training based on WHO evidence and their own National Malaria Control policies. So, it's very important that we start off with a good foundation and then we use continuing education to improve and update the health workers as time goes on. There are a number of terms, and they change quite often. It used to be in-service training. It was recognized that people don't just learn through formal training activities. And so, the concept was broadened to continuing professional development. Different ways to enhance the knowledge skills and experiences of people after they have finished their pre-service education. And it recognizes that such learning for the professionals, is lifelong, systematic but it needs to also be a planned process to ensure it happens. The issue is not just improving the performance of individual health workers, but also involving the profession in improving the quality of people that are affiliated with them. So, the National Association of Nurses and Midwives, has an important stake in the quality of the people who call themselves nurses and call themselves midwives who are registered that way. But you want to be sure, that if somebody is a registered nurse, that they have certain competencies. That they're capable of doing things. That they're up-to-date. And here again is where continuing professional development helps. One of the things we recognize is that it doesn't have to happen in a workshop, that it is important that they receive mentoring, both from for example, if they're in a health facility from the district health team, but also from the more senior staff in their health center. Another thing that we'll talk about a bit under quality, is this issue of performance standards. That there are specific expectations of how a health worker will, for example, handle patients with suspected malaria. What are the steps? What are they expected to do according to national guidelines? And these standards not only help ensure quality, but they are a guide for the individual health worker, on areas where she or he needs to improve knowledge and skills and problem solving ability. So, the overall overarching goal of continuing professional development, is to ensure continued high quality of services. One of the important things Jopago does, is work with organizations as we said, trying to develop basic curriculum, as well as continuing education curriculum that are in line with national guidelines, and to make sure that the curriculum is flexible and fluid because things change. Over the years, we have changed the kind of malaria preventive activities that are provided for pregnant women. It used to be that they would get a monthly dose of chloroquine. This was called a prophylaxis. It was a sub-treatment dose and it helped for a while until the parasites developed resistance to chloroquine. Then, they shifted to another drug, sulfadoxine/pyrimethamine. And that drug was given approximately once a month. The minimum in those days of two times during pregnancy, a full treatment dose to clear any parasites from the pregnant woman. Then it was discovered of course that two times was not enough because of developing resistance by the parasites. And so, now it's recommended that this intermittent preventive treatment, with sulfadoxine/pyrimethamine is delivered in the first week of the second trimester, on a monthly basis up until delivery. So, these things keep changing and because of the evolution of resistance of the parasite to many drugs, research is going to turn up new drugs. And there will need to be changes in policy based on those new drugs. So, things are constantly changing. So, if policies are changing based on evidence, then curricula should be changing. This is the key message here for keeping health workers up-to-date. That when they graduate, they know the latest according to National Malaria Guidelines or other health programs their guidelines, and that they be kept up to date. Related to the issue of the health workforce, of course is quality. We're concerned about the performance of the health workers. Are they doing what they were trained to do? Are they following national guidelines? And in the process of ensuring quality, we're very concerned about providing supportive supervision. Supervision that just doesn't check whether somebody is doing the correct thing and scold them if they're not, but supervision that works with the health workers to understand the challenges they have in implementing programs and encouraging them to think about how to solve those problems. So, basically, the quality assurance mechanism, there are various tools that take then operationalize the guidelines into criteria or steps that one would observe a health worker performing, and these performance assessments are done. They can be done in two ways. You can have the district health team come to a health center and observe health workers, or you can provide the guidelines to the health workers themselves and they observe each other in the clinic. In either case, it's important not only to observe, but to ensure that all parties, whether they are supervisors or whether they are health workers directly, are familiar with these performance standards that after an assessment is done, there's immediate feedback to the areas where the health worker perform well and where there were gaps in performance. Jhpiego has used this type of quality assurance process for many years. Usually, there is a baseline observation assessment whether it's in a specific program area like antenatal or prenatal care, emergency obstetrics, ACE Management, and then subsequently about once a quarter follow up assessments are done and after each assessment there's feedback. The people in the health center get together and develop an action plan about how to improve performance. Inevitably, each quarter, the performance improves. And this needs to be an ongoing process where the health workers themselves don't have to rely on someone coming from the district or the state level, but they can use the instrument to observe each other and internally plan on how to upgrade the quality of services in their clinics. People do ask questions about supervision versus quality assurance versus monitoring. Is there a difference? Quality assurance often is linked with specific instruments. Supervision is a process that not only observes health workers but encourages them to learn and improve their performance. As we said before, the supportive supervision encourages them recognizing that they do have challenges in implementing what they've learned and that together the supervisor and the health worker can work toward finding solutions to the problems of delivering services in their particular health facility. Supervision starts at the national level. National staff are concerned how the regional offices are performing. The regional offices help supervise the district health teams. The district health teams look at the performance of health facilities staff, and it's very important to recognize that the health facility staff provide supervision to the communities in general. Because, again, we have communities involved in doing things like mobilization for nets or immunization but also to provide technical supervision for the community volunteer health workers that they are delivering essential services right there in the community. So, we want to make sure that this supervision works at all levels. Recognizing that there are different challenges at each level, the challenges that the district may have in terms of its mobility to reach out to the clinics, the challenges of the clinics in terms of working with communities and gaining their trust. So, we have to recognize that the health workers need to be prepared at each level on how to supervise. So, we do have supervisory training for the regional staff, how to work with districts, so then pass that on to the district level staff can do their supervisory duties at the health center and the health center staff learn how that they can be supportive and supervise and improve the quality of community health workers. Ultimately, they want to be enablers of good performance and not being punishers of bad performance. One of the other challenges that we obviously have seen in the malaria program is that you cannot necessarily have a dedicated malaria person at the district level and at the health center you certainly have many health issues, disease control problems in the district, you have shortages of staff. So one person may be responsible for disease control generally including malaria. So you can't expect that one person to go out and always supervise every single health facility. There may be 10 or 15 or more health facilities in the district. So what happens is we have integrated supervision where a team of health workers go on a rotational basis to different health centers. It may not be the same team members. So what we need to be sure of is that we have a good tool that includes the essential elements of performance for each of the program areas, whether it's looking at supervising antenatal care, supervising pharmacy performance, supervising treatment of common diseases. So the integrated case management for childhood illnesses, so that whoever goes out is familiar with this instrument and can help supervise for malaria even if they are not the designated malaria officer. This is always a challenge because when you combine things like this to ensure that every health center gets covered, you may not have the depth of supervision on any one particular area. And so, you still may need to have ways of bringing people together to look at how malaria services are being delivered. One way to help with that is to look at the records that are submitted each month by the clinics and seeing if they are, in fact, performing the diagnostic tests if they are, in fact, giving the correct malaria drugs. So these are some of the things that may prompt a subsequent or special visit to a clinic to check on malaria services. And this principle would hold for whatever kind of service you're dealing with. Performance standards again, the idea of integrating malaria into broader performance standards. For example, when Jhpiego is looking at performance standards for prenatal or antenatal care. They include all the activities whether it's tetanus toxoid immunization, whether it's measuring fundal height, whether it is ensuring that pregnant women are tested for anaemia. There's also the components of what the midwife or a nurse should be doing to test for, prevent and treat malaria in pregnant women. So again, the performance standards are usually integrated for a comprehensive service such as antenatal care or child health care. It's often said that if we do not document the services delivered maybe they never happen. And this is why is very important as a component of malaria service building blocks to stress monitoring evaluation and research. This cuts across all other components because not only do we document the services delivered, we document the number of people who have been trained, we document the supplies coming and going of malaria drugs and test kits. We document quite a number of elements of the supervisory visits, quite a number of the elements of program activities. So, it's important to do this documentation so that we know. One, we can identify gaps and we can identify reasons for those gaps. This provides data that can help us make informed decisions about improving services. And also in reality, donors expect that if they're giving money to improve malaria case evidence that there is evidence that these case management activities are being provided that people are being tested. How many people reported with fever? How many of those were tested as suspected malaria cases? How many of those were positive? Out of those positive, how many got the correct medication? So this is the type of thing we want to document to prove that the program is actually being delivered as intended. We can also conduct operational research to find out what are better ways of collecting data. We can do operational research to test different ways of counseling to ensure adherence to malaria medicines. So we should also recognize that we can collect information again in a research capacity, to improve the quality of services. You can see in our simple drawing that we have in our Jhpiego manual. But first, you must develop standard instruments that can collect the information you need, whether this is a checklist for a semi literate village health worker where the number of people seen and possible age groups mere can be marked off that this information then can be forwarded up to the clinic level from there correlated and sent forward to the district level. We want to ensure that the data is of high quality. Quality includes completeness in filling out information, accuracy in filling out information about the different programs and timeliness of submitting the information. Without prompt reporting, we may miss certain trends. We may miss an upsurge in detected malaria cases or the opposite. We may miss that there are shortages of drugs or stock outs as they say, in a particular clinic or area. And when we have prompt and accurate information, we can then do decision making and planning to address any gaps and services. We also want to have data feedback. It's not enough for the health center to summarize what they've accomplished the past month and send it forward to the district. But the district when supervisory visits occur, needs to give feedback to the clinic about where things are performing well, where there are gaps and also the health system, the health center, it would be nice if they also gave feedback to the communities about how well things are going. If we find that there's a drop off in people reporting to the health center for certain problems, we can discuss with the community why. So, this information forward and backward up and down the system with feedback is an extremely important process. Monitoring and evaluation of malaria programs is extremely important no matter what stage the program is in. Whether there is a high level of transmission and we're trying to document. Whether we've provided insecticide treated bed nets for all households in the community, a minimum of one net per every two people in the household. Whether we are documenting, whether guidelines are being followed in terms of testing and treating. But as we get closer to eliminating the disease in an area and transmission drops, we have an even more important role for keeping track. What happens is that as malaria cases drop, we will not necessarily see a drop in number of people having fever, febrile illness because there are many other parasitic, bacterial, and viral diseases that come with fever. So, the importance of data on testing and the test results are extremely important. This is important to give feedback to health workers because they may be tempted to go against guidelines and say, "Well, this looks like malaria. I'm going to treat it for malaria and use drugs indiscriminately for other diseases." Obviously, if a child is febrile because she has pneumonia, giving her malaria drugs is not going to solve the problem and the child may die. So, we really really want to educate the health workers through the data that, it's important to see changes. There may be seasonal changes too. I recall in one country where we were doing an assessment of the use of the rapid diagnostic tests for malaria and health workers were saying often when we interviewed them, "Well, we don't understand why the tests are more negative in December and January and February even though there are all these children who are coming with fever." And of course, the reason in those months was that it was the dry season, there were fewer mosquitoes, there was less malaria. But there were other viral illnesses and respiratory illnesses during that period that did have fever. So, using the data to give feedback and training health workers is very important. And again, the importance of finding out what's going on because if they don't test, if they don't record the testing, if they don't record that they followed the testing results, what may be happening is that they would be using the wrong drugs to treat the illnesses that are brought to the health center. So, giving feedback with the data that they collect is extremely important for encouraging compliance with national guidelines encouraging correct treatment. We see here a map of Kenya, malaria epidemiological map. We realized that in some countries when they adopt a national strategy, let's say, the intermittent preventive treatment for pregnant women. They often say that all women should receive this intermittent preventive treatment during antenatal care. One thing that has been learned over the years is that, this intermittent preventive treatment is only appropriate if there is a stable and relatively high level of transmission. If it's low transmission, there are fewer cases of malaria, there are more severe and you need to concentrate on case management, quick identification and case management of pregnant women, who might actually have malaria. So, Kenya refined it's malaria map and found that there were certain areas of the country that had much higher transmission of the disease. The area and the darkest color is near Lake Victoria, you know there are a lot of still waters and ponds near the lake that can be great for mosquito breeding. Some of the coastal area for similar reasons. And so they recognize that they needed to adapt their national strategy to reflect these geographical and epidemiological differences. Again, collecting data, collecting our regular routine data that show malaria test results. And then, using that to inform and the need for more thorough epidemiological surveys help Kenya be able to say that, "Okay, it's only in certain regions where we will now give this intermittent preventive treatment and we'll focus on prompt case management to prevent severe malaria in the areas that are of very low transmission." So without attention to the monitoring and evaluation data, Kenya could be wasting a lot of resources. And it also might be missing out on areas that would be close to elimination that would require a different strategy. So again, our data is very important for future planning.
