Malaria Test, Treat and Track policy implementation in Angola: a retrospective study to assess the progress achieved after 4 years of programme implementation.

BACKGROUND: Malaria is one of the main causes of death in Angola, particularly among children under 5 years of age. An essential means to improve the situation is with strong malaria case management; this includes diagnosing suspected patients with a confirmatory test, either with a rapid diagnostic test (RDT) or microscopy, prompt and correct treatment with artemisinin-based combination therapy (ACT), and proper case registration (track). In 2011, the United States President's Malaria Initiative (PMI) launched a country-wide programme to improve malaria case management through the provision of regular training and supervision at different levels of health care provision. An evaluation of malaria testing, treatment and registration practices in eight provinces, and at health facilities of various capacities, across Angola was conducted to assess progress of the national programme implementation. METHODS: A retrospective assessment analysed data collected during supervision visits to health facilities conducted between 2012 and 2016 in 8 provinces in Angola. The supervision tool used data collected for malaria knowledge, testing, treatment and case registration practices among health workers as well as health facilities stock outs from different levels of health care delivery. Contingency tables with Pearson chi-squared (χ2) tests were used to identify factors associated with "knowledge", "test", "treat" and "track." Multivariable logistic regression models were used to assess factors associated with the defined outcomes. RESULTS: A total of 7156 supervisions were conducted between September 2012 and July 2016. The overall knowledge, testing, treatment and tracking practices among health care workers (HCWs) increased significantly from 2013 to 2016. Health care workers in 2016 were 3.3 times (95% CI: 2.7-3.9) as likely to have a higher knowledge about malaria case management as in 2013 (p < 0.01), 7.4 (95% CI: 6.1-9.0) times as likely to test more suspected cases (p < 0.01), 10.9 (95% CI: 8.6-13.6) times as likely to treat more confirmed cases (p < 0.01) and 3.7 (95% CI: 3.2-4.4) times as likely to report more accurately in the same period (p < 0.01). DISCUSSION: Improvements demonstrated in knowledge about malaria case management, testing with RDT and treatment with artemisinin-based combinations among HCWs is likely associated with malaria case management trainings and supportive supervisions. Gaps in testing and treatment practices are associated with RDT and ACT medicines stock outs in health facilities. Tracking of malaria cases still poses a major challenge, despite training and supervision. Hospitals consistently performed better compared to other health facilities against all parameters assessed; likely due to a better profile of HCWs. CONCLUSION: Significant progress in malaria case management in eight provinces Angola was achieved in the period of 2013-2016. Continued training and supportive supervision is essential to sustain gains and close existing gaps in malaria case management and reporting in Angola.

Community health workers: to train or to restrain? A longitudinal survey to assess the impact of training community health workers in the Bolama Region, Guinea-Bissau.

BACKGROUND: The shortage in human resources for health affects most dramatically developing countries which frequently use community health workers (CHW) as the basis for health programmes and services. The traditional definition refers CHWs as members of the community who are recruited and trained in health prevention and promotion to provide services within their community. In Guinea-Bissau, CHWs play a fundamental role in the diagnosis and treatment of childhood diarrheal diseases - one of the main health problems in the country. METHODS: This study is based on 22 CHW, 79% of the total number of CHW in the Sanitary Region of Bolama. The main goal was to assess how training CHW on diarrheal diseases impacted the accuracy of the diagnosis and treatment of these diseases in children under the age of 5 years. Three evaluations were made throughout time - one evaluation before the training and two follow-up evaluations.An observation grid was developed to evaluate the identified signs, symptoms, diagnosis and treatments prescribed by the CHW in consultations to children with a suspicion of diarrhoeal disease. A similar grid was filled by a medical doctor who took the role of the external validation standard.Friedman's variance analysis and Cochran's Q test were performed to compare the accuracy depicted by CHWs in identifying items throughout time. A logistic regression model was also used to check the possible influence of socio-demographic characteristics of CHWs on the accuracy of the diagnosis and treatment prescribed by the CHW. RESULTS: The results show that CHWs improve significantly their performance in identifying the correct diagnosis in the first follow-up moment after the training (P = 0.001, n = 22) but, 3 months later, the effectiveness decreases. No statistical evidence was found for the logistic regression models applied. This progressive loss of performance after training may occur because CHWs fail to apply treatment algorithms and guidelines over time. A limited set of socio-demographic characteristics of the CHWs can influence their performance and should not be disregarded when selecting CHW candidates. CONCLUSION: The selection, supervision, support and continuous training of CHW are as important as the training provided.