Malaria in Pregnancy Case Study: Zambia’s Successes and Remaining Challenges for Malaria in Pregnancy Programming

According to this 56-page case study, among malaria-endemic countries in Africa, Zambia stands out as a leader in the successful implementation of interventions to prevent and control malaria in pregnancy (MIP). With support from the President's Malaria Initiative (PMI), the Maternal and Child Health Integrated Program (MCHIP) conducted a case study from August through November 2009 to examine MIP implementation in Zambia. The case study shares experiences and lessons learned from Zambia. Major strengths noted are: integration, policy, training, and community-based programming. Areas that require further, significant strengthening include: commodities, quality assurance, monitoring and evaluation, and financing.

The Zambia programme includes a wide range of strategies to improve uptake of intermittent preventive treatment in pregnancy (IPTp), and use of insecticide-treated bed net (ITN) coverage among pregnant women. In terms of communication and awareness, in health facilities countrywide a variety of cadres of community volunteers have become increasingly involved in community sensitisation in MIP and service delivery assistance at health centers and in the community. There has also been community awareness raising through the production of information, education, and communication (IEC) materials.

According to the case study, Zambia's Community Awareness and Involvement intervention is one of the most recently developed and promising in Zambia. The Ministry of Health and partners are working with various community groups, such as Community Health Workers (CHWs), Health Workers (HWs), Neighborhood Health Committees (NHCs), and Safe Motherhood Action Group (SMAGs), to raise community awareness about MIP and empower people to take more active roles in their own health. This also has the benefit of alleviating some of the burden on health care providers in settings of severe human resources shortages. Preliminary reports of such programmes show promising gains in community acceptance of MIP interventions, though resources are necessary to sustain these activities.

According to the document, IEC campaigns in Zambia on malaria and MIP have seen success in increasing people's awareness of the causes and symptoms of malaria. The unintended consequence, however, has been the common association of any fever with malaria, which puts pressure on health care providers to treat fevers with anti-malarials in the absence of RDTs or in spite of negative results. Malaria campaigns should thus craft messages more carefully to avoid frequent misuse of treatment, increased drug resistance, and negative health outcomes (in the event that other causes of fever are overlooked).

Key best practices identified in Zambia include:

• Integrating the MIP programme into the Ministry of Health (MOH) Reproductive Health Unit;
• Rolling out MIP through a focused antenatal care (ANC) package;
• Distributing insecticide treated nets (ITNs) through ANC;
• Integrating focused ANC/intermittent preventive treatment for pregnant women into the prevention of mother-to-child transmission of HIV in-service curriculum;
• Using provincial focused ANC mentorship teams that provide support to facilities through supervision; and
• Involving communities through Neighborhood Health Committees and Safe Motherhood Action Groups.

For the Zambia programme to meet its target of having these MIP interventions accessible to 80% of pregnant women, the following is recommended:

• Seek funding from within MOH/National Malaria Control Centre and/or from partners to hire an MIP programme officer;
• Revive Malaria Task Force or initiate similar forum;
• Develop clear procurement plan for sulfadoxine-pyrimethamine and ITNs to include in the overall MOH procurement plan;
• Strengthen existing M&E systems and surveys to better capture key quality MIP data;
• Critically review malaria interventions, evaluating impact and cost-effectiveness;
• Strengthen comprehensive quality assurance programme;
• Develop guidelines for the role of community volunteers in line with the community health workers’ strategy being developed by the MOH; and
• Malaria campaigns should thus craft messages more carefully to
  avoid frequent misuse of malaria treatment, increased drug resistance, and negative health outcomes (in the event that other causes of fever are overlooked).