Community Case Management of Malaria in Urban Settings: A Feasibility Study in Five African Sites

This 54-page report, published by the Special Programme for Research and Training in Tropical Diseases (TDR) World Health Organisation, describes lessons learned in five African cities using community case management of malaria (CCMm) to provide artemesinin-based combination therapy (ACT) for children less than five years of age. This approach is an established route of distribution of anti-malaria drugs in rural areas, but the feasibility and acceptability of the approach in urban areas has not been explored. The study used community medicine distributors (CMDs) and was conducted in Ghana (two cities), and in Burkina Faso, Ethiopia and Malawi. The investigators found that quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers. Each country provides specific lessons learned in that environment.

Prior to implementation, project working groups consisting of community leaders, health workers, non-governmental organisations, and government officials were formed. According to the report, these groups helped tailor programming to the local context, identify CMD candidates, and, in some cases, contributed to project sustainability. Candidates were then trained over a two-week period which included sessions on malaria symptoms, patient referrals, and drug dispensing procedures. Following training, only candidates that successfully completed written tests were accredited as CMDs and issued with pre-packed, unit-dosed anti-malaria drugs. In Ghana, 28 of 30 training participants successfully completed tests.

To support training, information, education and communication materials were developed. Manuals included information about CMDs' job descriptions, general information about malaria and drugs, as well as how to obtain caregiver consent. Promotional materials were developed for caregivers, including how to identify malaria symptoms, how to administer drugs, and what to do if children needed to be referred to a clinic. Drug distributors also used this information during community gatherings, family meetings, and on community radio programmes.

While CMDs were able to successfully distribute malaria treatment to young children, the report highlights lessons learned and challenges. Researchers found it was important to use local CMDs to increase access to malaria diagnosis and treatment, especially at night. The lack of incentives for CMDs was also a challenge. Cash payments for CMDs were unsustainable when programmes ended. The report suggests that financial incentives could sustainably be tied to periodic trainings versus regular service provision. Difficulties also arose when health education teams tried to schedule home visits. Some mothers and caregivers repeatedly missed these meetings and the report cited a need for better outreach among caregivers to communicate the importance of these visits.