Click on the photograph of each training centre to see a summary of recent activities

Centre for Innovation Against Malaria (CIAM) hosted by MRC Laboratories, The Gambia
OR visit CIAM's own site http://www.ciam.gm
 

Centre for Innovation against Malaria, The Gambia
Visit CIAM site

An alligator's advice: begin with basics: "If you cannot swim, you will never gate crash an alligator's christening party".
This old West African proverb is in line with the mandate of the Centre for Innovation Against Malaria (CIAM): the recognition that there are processes that must first be addressed before individuals and communities can be equipped to take action to reduce the burden of malaria. CIAM's innovative stance is based on the belief that it is necessary to move from demonstrating effectiveness to setting policy and practice, a process which begins with individuals taking responsibility for malaria control. It is into this arena, the interface between academia and implementers, that CIAM plans and carries out its activities.
In the period June 2003 and December 2004, major activities included:
-Training of community health nurses in participatory planning of malaria interventions at community level
n Evaluation of a malaria module integrated into a national peer health education programme for youth empowerment
-The launch and evaluation of a radio soap opera series on malaria control called the Power of Radio
- Conducting a quantitative survey to evaluate the implementation of Intermittent Preventive Treatment (IPT) of malaria in pregnancy in two out of six health divisions.
Each project is designed to include two aspects that are essential for future success: the integration of the project when it comes to an end into other activities and the rigorous demonstration of the impact of the project.

Project Design and sustainability
The project design process begins with addressing felt needs. One example is the training course for Community Health Nurses (CHNs), conducted between August and September 2004. This was designed to bridge the gap in the existing curriculum on participatory planning with communities for the implementation of community-driven malaria control activities. A long period of consultation, in the case of the CHN course, over 12 months, took the form of periodic dialogue and discussion with curriculum and malaria experts, health decision makers and CHN tutors.
42 CHNs were interviewed and completed a computer test to determine their learning preferences and their expectations for the course. The majority wanted to:
-know more about malaria issues;
-design more responsive malaria activities and
-help move community members from awareness about malaria to taking appropriate actions
These findings were important in guiding the development of a 19 module course and the accompanying interactive CD Rom.
Several approaches were adopted to facilitate future sustainability. These included building on the existing CHN curriculum; the early identification of the CHN school; and the careful selection of individuals who have a stake in the project, to form a technical group to oversee the design and implementation of the project. The active involvement of each of the selected individuals ensures the continuation of the methods/strategies introduced by the project beyond the lifetime of the project.
The challenge of addressing socio-behavioral aspects of malaria control
Although the importance of socio-behavioural aspects of malaria control is increasingly being recognised as pivotal to the future control of the disease, determining whether projects have led to a demonstrable change in behaviour remains a challenge. The radio soap opera series developed by CIAM in collaboration with the National Malaria Control Programme, TESITO, a UK based NGO, and the MRC, The Gambia, illustrates some of these issues. In developing countries, radio is seen as an appropriate tool to raise awareness of the management of malaria because it reaches more people in rural areas than any other medium. Building on this and in the light of a felt need in a review of the national malaria control programme for more communication materials relevant to the prevention and control of malaria, a 26 episode radio soap opera called the Power of Radio (or Bolonghodala in Mandinka), was produced and launched on 28th July 2003. It ran initially for six months and created widespread enthusiasm among listeners.
Radio programmes such as the Power of Radio that combine entertainment with education have proved in other settings to have the greatest impact on behavioural change. This was tested in a series of evaluation studies using qualitative and quantitative assessments following the end of the six months broadcast of the Power of Radio. The evaluation, which took place in the pilot village Julangel in the east of the country, first aimed to design and develop rigorous tools to measure malaria knowledge and reported behaviour. Secondly, it concentrated on selected aspects of the radio series, in particular the effectiveness of the Power of Radio to communicate malaria messages and the documentation of change in knowledge and reported behavioural practices following the broadcast of the radio series. Initially, 75 mothers with children under five years of age were interviewed. In the second survey conducted in April 2004, 81 mothers were interviewed. These mothers had not previously been interviewed. In addition, a group of 49 mothers who had previously been interviewed were re-interviewed to determine if prior interviewing resulted in better performance. Among these mothers who were re-interviewed, prior administration of the questionnaire did not significantly influence knowledge scores. Although there were no significant differences in acquired knowledge before and after the broadcast, marked differences in reported behavioural practices were noted (see table)
If these reported behavioural changes are sustained and the radio series achieves a higher coverage than its current 170,000 Mandinka speaking listeners then re-broadcasting the programme in other languages could result in a significant impact on the adoption of positive behavioural practices thereby leading to a reduction in morbidity. This is an exciting prospect to pursue.
The school-based Peer Health Education programme aimed at empowering young people to transfer knowldge and skills to communities. An evaluation of the impact of this approach on behavioral practices of caregivers of children under five has been conducted and data is currently being analysed.

Operational Research
CIAM is increasingly moving towards building a niche on the design and implementation of operational research studies in collaboration with external partners such as DBL in Denmark. In December 2004, a quantitative survey was conducted in two health divisions where suphadoxine-pyrimethamine (SP) had been provided since September 2003 for the IPT of malaria in pregnancy. Contrary to national guidelines stating that two doses of SP should be provided for effective IPT of malaria in pregnancy, preliminary findings from one of these divisions indicate that in the five health centres offering IPT services, out of a total of 3,706 IPT doses given, SP was administered as a second dose in only 30% of cases. This was due to several factors including poor training of health workers; inadequate assessment of gestational age; late booking by mothers and lack of awareness of IPT among pregnant mothers. A more detailed and comprehensive analysis of both qualitative and quantitative assessment of the service delivery related to IPT delivery is underway and the findings will be used to inform policy and implementation plans for expanding access to IPT nationally.
In the Future
CIAM aims to continue strengthening the capacity of decision makers such as parliamentarians, and to expand further its work in operational research to address health systems constraints for the scaling up of effective malaria interventions.

Want to know more? Visit CIAM

Centre for the Enhancement of Effective Malaria Interventions, Tanzania visit CEEMI web site

CEEMI's mission is to promote the application of effective and appropriate interventions in the prevention and control of malaria in Tanzania and to strengthen capacity at district, national and regional levels.
Launch of the CEEMI and NMCP building
Construction of the NIMR building to house CEEMI and the NMCP started in March 2003 and was handed over to NIMR/CEEMI on 8th March 2004. The building was co-funded by the GMP, DFID and the MoH and provides excellent office, conference and library/internet facilities. As CEEMI works to respond to the capacity strengthening needs of the NMCP in-country and at the regional level, there are many obvious advantages to housing the two organisations together.

Evaluation of a Seminar for members of parliament
A seminar for members of the Tanzanian parliament was organised by CEEMI in November 2003. The main objective of the seminar was to support the RBM initiative to reduce morbidity and mortality due to malaria by 50% by 2010. 204 out of 295 MPs attended the seminar, which was opened by the Vice President of Tanzania, Dr. Ali Mohamed Shein. In his speech, Dr. Shein reiterated the Government's commitment to malaria prevention and control.
The MPs were given an overview of the malaria situation in the country by the manager of the NMCP, highlighting the value of ITNs and the vulnerability to malaria of pregnant women and children under five years of age. There were presentations on net manufacture and social marketing of ITNs. The economic impact of malaria was stressed and the need for tax relief for bednet manufacture. A short drama focussing on the problems associated with morbidity and mortality due to malaria was presented by the"CHAHALESA" drama group, and a radio presentation was based on the resource pack given to the MPs during the seminar.
An evaluation in the first quarter of 2004 indicated that the seminar had been influential in catalysing various positive changes: greater knowledge of malaria prompted more informed discussion within parliament on the socio-economic effects of the disease on the nation's development; and evidence showed that MPs became involved in various local initiatives to improve environmental sanitation as a preventative measure. Perhaps most significant was the development of more supportive malaria policies and an increase in the pace of implementation of existing policies for malaria, An initiative to establish new posts, 'district malaria focal persons' was set in motion (see section below), and a new policy which increases availability of malaria control measures by waiving taxes for products such as ITNs and insecticides was developed and ratified.

Training of District Malaria & IMCI Focal Persons
As part of the MoH's initiative to strengthen the capacity of the districts to control malaria and implement Integrated Management of Childhood Illnesses (IMCI) strategies, the MoH in Tanzania plans to train 121 newly recruited District Malaria/IMCI Focal Persons by the end of 2005.
The first course for 20 District Malaria/IMCI Focal Persons, designed and conducted on behalf of the MoH by CEEMI in collaboration with partners and experts within Tanzania, commenced in November 2004. In addition to support from the MoH, additional funding was secured from the Malaria Consortium (Uganda) and WHO Country Office for the development of training modules and field work evaluation, respectively. The training course spans 12 weeks divided into theory, practical and field work and covered areas of: (i) Basic Epidemiology and Statistics (ii) Malaria & IMCI implementation (iii) Health Information, Management and Research (iv) Managerial Skills, Planning, Monitoring and Evaluation; and (v) Information, education and communication/Behaviour change communication. The relevance and effectiveness of the course will be assessed by following the work and progress of the participants as they take up the full responsibilities of their roles in their respective districts viewed against districts where personnel have not yet been trained. The curriculum is already under review for future implementation.
IPTp in Muheza district
CEEMI is playing a lead role in the development of a cascade training model to ensure the appropriate expertise and knowledge are available for effective and efficient delivery of IPTp at health centre level for replication country-wide at a later stage. To date, a pilot study has been conducted in Korogwe district and the baseline protocols and training materials reviewed and improved by the stakeholders. Robust monitoring systems are currently being designed prior to the implementation of the training in the intervention district of Muheza.

Activities under consideration
n Informing traditional birth attendants of the beneficial effect of intermittent preventive treatment in pregnancy in Muheza district, Tanga region, north-eastern Tanzania
n Training of Council Health Management Team on Surveillance System for effective management of malaria control activities in Muheza District.

Ghana Malaria Centre

Ghana Malaria Centre was established under the School of Public Health (SPH), University of Ghana, Legon.

Mother-Caregiver Advocates Programme
GMC has built capacity for malaria control at the community level in Asante Akim North District and Shama Ahanta East Metropolitan Area. This was done through a Mother-Caregiver Advocates Training Programme that is based on the principles of advocacy, empowerment and community mobilisation. The programme is now being monitored and efforts to integrate it into the District Health Systems are under way.
The Mother-Caregiver Advocates continue with their community-based training activities supervised by staff from the District Health Management Team (DHMT), District Assembly Officers, and Community Health Officers based at the sub-district level in the implementing districts.
In addition to the group and house-to-house training sessions run by the Advocates, they also organise community durbars to inform a wider group of community members on malaria and its prevention. Emphasis is placed on the causes of malaria and its effects on children under five. The need to keep the environment clean, use mosquito proof netting on windows, sleep under bed nets and wear protective clothing outside at night is stressed. The Advocates emphasize the importance of seeking early treatment for malaria. They also urge pregnant women to attend ante-natal clinics to be advised on malaria prophylaxis. Opinion leaders and Assemblymen in the communities attend these durbars and contribute to the effectiveness of the programmes. They encourage citizens to follow the advice given.
The Advocates report monthly on their activities to the DHMT, through their supervisors. The reports are collated by DHMTs and sent to GMC quarterly. Statistics on capacity development at different levels in the operational areas and the output from the advocates training activities in the districts are collated. A comprehensive Logical Framework for monitoring and evaluation of the MCA programme was developed and consensus established with key stakeholders in the implementing areas. This is guiding the programme monitoring and will be the basis for evaluation at the end of 2005. Discussion is currently in progress with the district and regional stakeholders to integrate the programme further into the district health system operations with support from the District Assemblies. The DHMT already use the information gathered from the advocates’ activities in their routine reporting system to the Ghana Health Service. Thus the outputs from the MCA programme contribute to determination of achievement of health targets and indicators at the district level.

TDR Seminar
GMC participated in a seminar organised by UNICEF/UNDP/World Bank/WHO/TDR in collaboration with SPH, Noguchi Memorial Institute of Medical Research and the Faculty of Science University of Ghana, Legon. The theme for the symposium was: "Social, economic and biological determinants of the emergence and spread of drug and insecticide resistance". The symposium took place at the Noguchi Memorial Institute of Medical Research, Legon. Presentations were made on scientific work in progress in the control of tropical diseases including malaria.
SPH/GMC collaboration with Partnership for Social Science in Malaria Control (PSSMC) and Ghana Health Service (GHS) to build capacity for social science inputs into malaria control
Effective malaria control relies on understanding the complex interplay of factors (socio-cultural, economic, political and environmental) that influence the behaviour of both those who suffer from malaria as well as those who provide health care for the disease. The contributions that social science and social scientists can make to understanding these issues are critical.
The overall purpose of the planned course is to contribute towards a reduction in malaria related morbidity and mortality by enhancing the appreciation and application of social science approaches in malaria control. For example, taking scientifically proven effective anti-malaria interventions, such as the use of insecticide treated nets (ITNs), to scale requires an understanding of the social, cultural, economic and political factors that affect the availability, access to, and use of ITNs. However, the applied social science capacity required to provide such information is frequently lacking in sub-Saharan Africa. The aim of the training programme is to strengthen the social science input to multidisciplinary approaches designed to achieve the National Malaria Control Programme/Roll Back Malaria (RBM) goals.
One of the objectives of the proposed course is to train non-social scientists together with junior level social scientists who have little applied field experience in malaria, and, in line with RBM and GMP goals, to develop partnerships between these groups which result in the design and implementation of innovative approaches to malaria control. A unique feature of the proposed programme is that participants will be expected to apply as part of a multidisciplinary team (including for example, national malaria control personnel, district level health officers, junior level social scientists, planners etc), rather than as individuals. The program will consist of training (classroom and fieldwork) at the GMC in Ghana during which the teams will develop malaria control proposals. The teams will then be encouraged to return to their own localities to implement their plans. This approach to training will contribute to developing multidisciplinary teams and the type of social science capacity that is required for the development and implementation of appropriate and sustainable interventions necessary to achieve the local RBM objectives.

Malaria Alert Centre, Malawi
MAC is now operating from its new centre built by GMP. The Minister of Health, the Honourable Yusuf Mwawa, officially opened the centre building during a colourful ceremony held on 15 March 2004, soon after a MAC training programme for media personnel.

Current training activities
Since the beginning of its programme MAC has focused on the district health structure and has targeted primary health care workers and rural communities. Specifically, MAC has worked with districts to improve the management of childhood severe malaria, strengthen district health capacity to collect, manage and utilize community based malaria data for district health planning, and improve the capacity of rural communities to contribute towards malaria control through home based management of fever cases presumed to be malaria. The aim is to scale-up nationally once these strategies have been evaluated.
The centre has been involved in the audit of ongoing health programmes, and building capacity for improved health care, using malaria as the entry point in three districts. In Mwanza, the new village health register developed with MAC support was launched by the District Health Management Team (DHMT) on 1st January 2004. Lately, MAC and the department of Community Health in the College of Medicine have finalized discussions with the Ministry of Health to implement a Centres for Disease Control (CDC) sponsored large scale study in three districts, linking the delivery of free insecticide treated nets (ITNs) with district EPI services, which in Mwanza will utilize the village register as a monitoring tool.
In Ntcheu, MAC continues to monitor use of the Critical Care Pathways which were introduced for the management of very sick children at the district hospital, including those with severe malaria. Lessons learnt from this on-site training for the health care team have been incorporated into the implementation of the national Paediatric Hospital Care Improvement Programme in eight districts. This programme is being implemented as part of a QA project with the Department of Paediatrics in the college.
In Blantyre district, 15 drug revolving fund structures became operational during the malaria season for communities around Mpemba health centre catchment area, covering a population of about 30,000. Preliminary results of community-based surveys following their introduction indicate their acceptability. Mpemba catchment area is a possible site for future studies on drug access issues, especially in relation to use of antimalarial combination therapies at community level.
Within the COM structure, MAC is hosting the post-basic malaria training for the MPH programme, which was started in 2003. In addition, MAC’s proximity to research on severe malaria in Blantyre has made it an ideal regional centre for malaria case management training programmes coordinated by WHO/AFRO, for the SADC region. Through international partnerships with CDC and the LSTM, MAC has been able to conduct annual training courses in basic entomology for programme and research assistants. This training has proved valuable during the ongoing evaluation of the ITN programme for the Malawi National Malaria Control Programme (NMCP).
For malaria advocacy, MAC organized the training of 25 media personnel with support from the GMP Technical Advisor and the Commonwealth Broadcasting Association in March 2004. Thereafter, it set up a committee that includes the media, to support implementation of national malaria programme activities.

For the future:
MAC was developed with a view to providing some innovative training initiatives for malaria control. It has incorporated Information and Communication Techology (ICT) facilities and the availability of ICT skills within the core team will enable the centre to embark on computer based learning programmes, especially in support of district health teams who are addressing the malaria problem, often with limited mentorship from traditional training institutions. The establishment of a VLE scheme to be shared amongst the four training centres is being planned (see page 39). With GMP support, MAC hopes to use more of its computer based learning facility in its training programmes in the coming year.
During the past year, MAC has been actively involved in discussions between the Ministry of Health, the COM and the Bill and Melinda Gates Foundation on the establishment of a Malaria Control and Evaluation Programme in Africa (MACEPA) in Malawi. If finalized as part of the next five-year national scale-up malaria plan for Malawi, MAC will participate in its implementation. MAC will also work on ongoing training activities and will develop proposals that will enable the institution to access funding that Malawi will have secured through the Global Fund to fight AIDS, Tuberclosis and Malaria.