Beyond distance: an approach to measure effective access to case management for sick children in Africa

Disrupted Service Delivery? The Impact of Conflict on Antenatal Care Quality in Kenya

Introduction: African countries facing conflict have higher levels of maternal mortality. Understanding the gaps in the utilization of high-quality maternal health care is essential to improving maternal survival in these states. Few studies have estimated the impact of conflict on the quality of health care. In this study, we estimated the impact of conflict on the quality of health care in Kenya, a country with multiple overlapping conflicts and significant disparities in maternal survival.

Materials and Methods: We drew on data on the observed quality of 553 antenatal care (ANC) visits between January and April 2010. Process quality was measured as the percentage of elements of client–provider interactions performed in these visits. For structural quality, we measured the percentage of required components of equipment and infrastructure and the management and supervision in the facility on the day of the visit. We spatially linked the analytical sample to conflict events from January to April 2010. We modeled the quality of ANC as a function of exposure to conflict using spatial difference-in-difference models.

Results: ANC visits that occurred in facilities within 10,000 m of any conflict event in a high-conflict month received 18–21 percentage points fewer components of process quality on average and had a mean management and supervision score that was 12.8–13.5 percentage points higher. There was no significant difference in the mean equipment and infrastructure score at the 5% level. The positive impact of conflict exposure on the quality of management and supervision was driven by rural facilities. The quality of management and supervision and equipment and infrastructure did not modify the impact of conflict on process quality.

Discussion: Our study demonstrates the importance of designing maternal health policy based on the context-specific evidence on the mechanisms through which conflict affects health care. In Kenya, deterioration of equipment and infrastructure does not appear to be the main mechanism through which conflict has affected ANC quality. Further research should focus on better understanding the determinants of the gaps in process quality in conflict-affected settings, including provider motivation, competence, and incentives.

Utilization of Integrated Community Case Management and Its Factors in Southern Ethiopia: Facility Based-Cross-Sectional Study

Background. An integrated community case management (ICCM) program fosters child health care seeking and access to appropriate treatment for illnesses in children at the community level in Ethiopia. There is paucity of evidence to the utilization of ICCM services by mothers/child caregivers in rural Sothern Ethiopia. Hence, the aim of this study was to determine the utilization of integrated community case management (ICCM) and its factors among mothers/child caregivers in rural Southern Ethiopia. Methods. A multistage sampling technique was used to select study participants in health care facilities offering child health care services. An exit interview was conducted on 574 mothers/child caregivers in randomly selected public health centres. Data were entered using Epi Info and transported to SPSS version 20 for analysis. Results. Only less than a quarter of participants visited health posts for ICCM services during the study period. Those study participants who have not heard about ICCM service before the survey were about 6.53 times more likely not to use the services as compared to those who have heard about the service. Participants who were not members of the women’s development team were about 2.23 times more likely not to utilize ICCM services when compared to their counterparts. Conclusion. The study shows low utilization of ICCM service by children less than five years. Prior information about ICCM services and membership in the health development army was significantly associated with ICCM use. Therefore, our finding may suggest the need for advocacy to increase participation in the health development army and information education to increase the level of awareness and formal education efforts.

Health service delivery and political trust in Nigeria

Do improvements in health service delivery affect trust in political leaders in Africa? Citizens expect their government to provide social services. Intuitively, improvements in service delivery should lead to higher levels of trust in and support for political leaders. However, in contexts where inadequate services are the norm, and where political support is linked to ethnic or religious affiliation, there may be weak linkages between improvements in service delivery and changes in trust in political leaders. To examine this question empirically, we take advantage of a national intervention that improved health service delivery in 500 primary health care facilities in Nigeria, to estimate the impact of residence within 10 km of one or more of the intervention facilities on trust in the president, local councils, the ruling party, and opposition parties. Using difference-in-difference models, we show that proximity to the intervention led to increases in trust in the president and the ruling party. By contrast, we find no evidence of increased trust in the local council or opposition parties. Our study also examines the role of ethnicity and religious affiliation in mediating the observed increases in trust in the president. While there is a large literature suggesting that both the targeting of interventions, and the response of citizens to interventions is often mediated by ethnic, geographic or religious identity, by contrast, we find no evidence that the intervention was targeted at the president's ethnic group, zone, or state of origin. Moreover, there is suggestive evidence that the intervention increased trust in the president more among those who did not share these markers of identity with the president. This highlights the possibility that broad-based efforts to improve health services can increase trust in political leaders even in settings where political attitudes are often thought to be mediated by group identity.

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The intervention was not targeted at the president's ethnicity or state of origin.

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Service improvements led to increases in trust in the president and ruling party.

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Trust increased among respondents outside the president's ethnicity or state of origin.

Armed conflict and maternal health care utilization: Evidence from the Boko Haram Insurgency in Nigeria

Retention in maternal health care is essential to decreasing preventable mortality. By reducing access to care, armed conflicts such as the Boko Haram Insurgency (BHI), contribute to the high maternal mortality rates in Nigeria. While there is a rich literature describing the mechanisms through which conflict affects health care access, studies that estimate the impact of conflict on maternal health care use are sparse and report mixed findings. In this study, we examine the impact of the BHI on maternal care access in Nigeria. We spatially match 52,675 birth records from the Nigeria Demographic and Health Survey (NDHS) with attack locations in the Armed Conflict Location and Event Dataset (ACLED). We define BH conflict area as NDHS clusters with at least five attacks within 3000, 5000 and 10,000 m of BH activity during the study period and employ difference-in-differences methods to examine the effect of the BHI on antenatal care visits, delivery at the health center and delivery by a skilled professional. We find that the BHI reduced the probability of any antenatal care visits, delivery at a health center, and delivery by a skilled health professional. The negative effects of the BHI on maternal health care access extended beyond the Northeastern region, that is the current focus of humanitarian programs. Systematic efforts to identify and address the mechanisms underlying reductions in maternal health care use due to the BHI, and to target the affected populations, are essential to improving maternal health in Nigeria.

Cost-effectiveness analysis of revised WHO guidelines for management of childhood pneumonia in 74 Countdown countries

Background

Treatment of childhood pneumonia is a key priority in low–income countries, with substantial resource implications. WHO revised their guidelines for the management of childhood pneumonia in 2013. We estimated and compared the resource requirements, total direct medical cost and cost-effectiveness of childhood pneumonia management in 74 countries with high burden of child mortality (Countdown countries) using the 2005 and 2013 revised WHO guidelines.

Methods

We constructed a cost model using a bottom up approach to estimate the cost of childhood pneumonia management using the 2005 and 2013 WHO guidelines from a public provider perspective in 74 Countdown countries. The cost of pneumonia treatment was estimated, by country, for year 2013, including costs of medicines and service delivery at three different management levels. We also assessed country–specific lives saved and disability adjusted life years (DALYs) averted due to pneumonia treated in children aged below five years. The cost-effectiveness of pneumonia treatment was estimated in terms of cost per DALY averted by fully implementing WHO treatment guidelines relative to no treatment intervention for pneumonia.

Results

Achieving full treatment coverage with the 2005 WHO guidelines was estimated to cost US$ 2.9 (1.9–4.2) billion compared to an estimated US$ 1.8 (0.8–3.0) billion for the revised 2013 WHO guidelines in these countries. Pneumonia management in young children following WHO treatment guidelines could save up to 39.8 million DALYs compared to a zero coverage scenario in the year 2013 in the 74 Countdown countries. The median cost-effectiveness ratio per DALY averted in 74 countries was substantially lower for the 2013 guidelines: US$ 26.6 (interquartile range IQR: 17.7–45.9) vs US$ 38.3 (IQR: US$ 26.2–86.9) per DALY averted for the 2005 guideline respectively.

Conclusions

Child pneumonia management as detailed in standard WHO guidelines is a very cost–effective intervention. Implementation of the 2013 WHO guidelines is expected to result in a 39.5% reduction in treatment costs compared to the 2005 guidelines which could save up to US$ 1.16 (0.68–1.23) billion in the 74 Countdown countries, with potential savings greatest in low HIV burden countries which can implement effective community case management of pneumonia.

Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso District, Uganda

BACKGROUND

Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda.

METHODS

A qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the 'Health Access Livelihoods Framework'.

RESULTS

iCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs' free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence - factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits.

CONCLUSIONS

In peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage.

Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua

Objective.

To describe Nicaragua’s integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data.

Method.

This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007–2013 in 120 remote Nicaraguan communities where brigadistas (“health brigadiers”) offered iCCM services to children 2–59 months old. The study used program monitoring data from brigadistas’ registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported.

Results.

Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25–0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21–0.81).

Conclusions.

The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

Niger's Child Survival Success, Contributing Factors and Challenges to Sustainability: A Retrospective Analysis

BACKGROUND

Household surveys undertaken in Niger since 1998 have revealed steady declines in under-5 mortality which have placed the country 'on track' to reach the fourth Millennium Development goal (MDG). This paper explores Niger's mortality and health coverage data for children under-5 years of age up to 2012 to describe trends in high impact interventions and the resulting impact on childhood deaths averted. The sustainability of these trends are also considered.

METHODS AND FINDINGS

Estimates of child mortality using the 2012 Demographic and Health Survey were developed and maternal and child health coverage indicators were calculated over four time periods. Child survival policies and programmes were documented through a review of documents and key informant interviews. The Lives Saved Tool (LiST) was used to estimate the number of child lives saved and identify which interventions had the largest impact on deaths averted. The national mortality rate in children under-5 decreased from 286 child deaths per 1000 live births (95% confidence interval 177 to 394) in the period 1989-1990 to 128 child deaths per 1000 live births in the period 2011-2012 (101 to 155), corresponding to an annual rate of decline of 3.6%, with significant declines taking place after 1998. Improvements in the coverage of maternal and child health interventions between 2006 and 2012 include one and four or more antenatal visits, maternal Fansidar and tetanus toxoid vaccination, measles and DPT3 vaccinations, early and exclusive breastfeeding, oral rehydration salts (ORS) and proportion of children sleeping under an insecticide-treated bed net (ITN). Approximately 26,000 deaths of children under-5 were averted in 2012 due to decreases in stunting rates (27%), increases in ORS (14%), the Hib vaccine (14%), and breastfeeding (11%). Increases in wasting and decreases in vitamin A supplementation negated some of those gains. Care seeking at the community level was responsible for an estimated 7,800 additional deaths averted in 2012. A major policy change occurred in 2006 enabling free health care provision for women and children, and in 2008 the establishment of a community health worker programme.

CONCLUSION

Increases in access and coverage of care for mothers and children have averted a considerable number of childhood deaths. The 2006 free health care policy and health post expansion were paramount in reducing barriers to care. However the sustainability of this policy and health service provision is precarious in light of persistently high fertility rates, unpredictable GDP growth, a high dependence on donor support and increasing pressures on government funding.

Independent Evaluation of the integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design

We evaluated the impact of integrated community case management of childhood illness (iCCM) on careseeking for childhood illness and child mortality in Malawi, using a National Evaluation Platform dose-response design with 27 districts as units of analysis. “Dose” variables included density of iCCM providers, drug availability, and supervision, measured through a cross-sectional cellular telephone survey of all iCCM-trained providers. “Response” variables were changes between 2010 and 2014 in careseeking and mortality in children aged 2–59 months, measured through household surveys. iCCM implementation strength was not associated with changes in careseeking or mortality. There were fewer than one iCCM-ready provider per 1,000 under-five children per district. About 70% of sick children were taken outside the home for care in both 2010 and 2014. Careseeking from iCCM providers increased over time from about 2% to 10%; careseeking from other providers fell by a similar amount. Likely contributors to the failure to find impact include low density of iCCM providers, geographic targeting of iCCM to “hard-to-reach” areas although women did not identify distance from a provider as a barrier to health care, and displacement of facility careseeking by iCCM careseeking. This suggests that targeting iCCM solely based on geographic barriers may need to be reconsidered.

Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial

BACKGROUND

While community health workers are being recognized as an integral work force with growing responsibilities, increased demands can potentially affect motivation and performance. The ubiquity of mobile phones, even in hard-to-reach communities, has facilitated the pursuit of novel approaches to support community health workers beyond traditional modes of supervision, job aids, in-service training, and material compensation. We tested whether supportive short message services (SMS) could improve reporting of pregnancies and pregnancy outcomes among community health workers (Health Surveillance Assistants, or HSAs) in Malawi.

METHODS AND FINDINGS

We designed a set of one-way SMS that were sent to HSAs on a regular basis during a 12-month period. We tested the effectiveness of the cluster-randomized intervention in improving the complete documentation of a pregnancy. We defined complete documentation as a pregnancy for which a specific outcome was recorded. HSAs in the treatment group received motivational and data quality SMS. HSAs in the control group received only motivational SMS. During baseline and intervention periods, we matched reported pregnancies to reported outcomes to determine if reporting of matched pregnancies differed between groups and by period. The trial is registered as ISCTRN24785657.

CONCLUSIONS

Study results show that the mHealth intervention improved the documentation of matched pregnancies in both the treatment (OR 1.31, 95% CI: 1.10-1.55, p<0.01) and control (OR 1.46, 95% CI: 1.11-1.91, p = 0.01) groups relative to the baseline period, despite differences in SMS content between groups. The results should be interpreted with caution given that the study was underpowered. We did not find a statistically significant difference in matched pregnancy documentation between groups during the intervention period (OR 0.94, 95% CI: 0.63-1.38, p = 0.74). mHealth applications have the potential to improve the tracking and data quality of pregnancies and pregnancy outcomes, particularly in low-resource settings.

The indirect impact of antiretroviral therapy: Mortality risk, mental health, and HIV-negative labor supply

To reduce the burden of the HIV/AIDS epidemic, international donors recently began providing free antiretroviral therapy (ART) in parts of Sub-Saharan Africa. ART dramatically prolongs life and reduces infectiousness for people with HIV. This paper shows that ART availability increases work time for HIV-negative people without caretaker obligations, who do not directly benefit from the medicine. A difference-in-difference design compares people living near and far from ART, before and after treatment becomes available. Next we explore the possible reasons for this pattern. Although we cannot pinpoint the mechanism, we find that ART availability substantially reduces subjective mortality risk and improves mental health. These results show an undocumented economic consequence of the HIV/AIDS epidemic and an important externality of medical innovation. They also provide the first evidence of a link between the disease environment and mental health.

Access to integrated community case management of childhood illnesses services in rural Ethiopia: a qualitative study of the perspectives and experiences of caregivers

BACKGROUND

In 2010, Ethiopia began scaling up the integrated community case management (iCCM) of childhood illness strategy throughout the country allowing health extension workers (HEWs) to treat children in rural health posts. After 2 years of iCCM scale up, utilization of HEWs remains low. Little is known about factors related to the use of health services in this setting. This research aimed to elicit perceptions and experiences of caregivers to better understand reasons for low utilization of iCCM services.

METHODS

A rapid ethnographic assessment was conducted in eight rural health post catchment areas in two zones: Jimma and West Hararghe. In total, 16 focus group discussions and 78 in-depth interviews were completed with mothers, fathers, HEWs and community health volunteers.

RESULTS

In spite of the HEW being a core component of iCCM, we found that the lack of availability of HEWs at the health post was one of the most common barriers to the utilization of iCCM services mentioned by caregivers. Financial and geographic challenges continue to influence caregiver decisions despite extension of free child health services in communities. Acceptability of HEWs was often low due to a perceived lack of sensitivity of HEWs and concerns about medicines given at the health post. Social networks acted both to facilitate and hinder use of HEWs. Many mothers stated a preference for using the health post, but some were unable to do so due to objections or alternative care-seeking preferences of gatekeepers, often mothers-in-law and husbands.

CONCLUSION

Caregivers in Ethiopia face many challenges in using HEWs at the health post, potentially resulting in low demand for iCCM services. Efforts to minimize barriers to care seeking and to improve demand should be incorporated into the iCCM strategy in order to achieve reductions in child mortality and promote equity in access and child health outcomes.

How Can Childbirth Care for the Rural Poor Be Improved? A Contribution from Spatial Modelling in Rural Tanzania

Introduction

Maternal and perinatal mortality remain a challenge in resource-limited countries, particularly among the rural poor. To save lives at birth health facility delivery is recommended. However, increasing coverage of institutional deliveries may not translate into mortality reduction if shortage of qualified staff and lack of enabling working conditions affect quality of services. In Tanzania childbirth care is available in all facilities; yet maternal and newborn mortality are high. The study aimed to assess in a high facility density rural context whether a health system organization with fewer delivery sites is feasible in terms of population access.

Methods

Data on health facilities’ location, staffing and delivery caseload were examined in Ludewa and Iringa Districts, Southern Tanzania. Geospatial raster and network analysis were performed to estimate access to obstetric services in walking time. The present geographical accessibility was compared to a theoretical scenario with a 40% reduction of delivery sites.

Results

About half of first-line health facilities had insufficient staff to offer full-time obstetric services (45.7% in Iringa and 78.8% in Ludewa District). Yearly delivery caseload at first-line health facilities was low, with less than 100 deliveries in 48/70 and 43/52 facilities in Iringa and Ludewa District respectively. Wide geographical overlaps of facility catchment areas were observed. In Iringa 54% of the population was within 1-hour walking distance from the nearest facility and 87.8% within 2 hours, in Ludewa, the percentages were 39.9% and 82.3%. With a 40% reduction of delivery sites, approximately 80% of population will still be within 2 hours’ walking time.

Conclusions

Our findings from spatial modelling in a high facility density context indicate that reducing delivery sites by 40% will decrease population access within 2 hours by 7%. Focused efforts on fewer delivery sites might assist strengthening delivery services in resource-limited settings.

Demand generation and social mobilisation for integrated community case management (iCCM) and child health: Lessons learned from successful programmes in Niger and Mozambique

AIM

We present the approaches used in and outcomes resulting from integrated community case management (iCCM) programmes in Niger and Mozambique with a strong focus on demand generation and social mobilisation.

METHODS

We use a case study approach to describe the programme and contextual elements of the Niger and Mozambique programmes.

RESULTS

Awareness and utilisation of iCCM services and key family practices increased following the implementation of the Niger and Mozambique iCCM and child survival programmes, as did care-seeking within 24 hours and care-seeking from appropriate, trained providers in Mozambique. These approaches incorporated interpersonal communication activities and community empowerment/participation for collective change, partnerships and networks among key stakeholder groups within communities, media campaigns and advocacy efforts with local and national leaders.

CONCLUSIONS

iCCM programmes that train and equip community health workers and successfully engage and empower community members to adopt new behaviours, have appropriate expectations and to trust community health workers' ability to assess and treat illnesses can lead to improved care-seeking and utilisation, and community ownership for iCCM.

Stakeholders' perceptions of integrated community case management by community health workers: a post-intervention qualitative study

Background

Integrated community case management (iCCM) involves delivery of simple medicines to children with pneumonia, diarrhea and/or malaria by community health workers (CHWs). Between 2010 and 2012, an iCCM intervention trial was implemented by Healthy Child Uganda. This study used qualitative tools to assess whether project stakeholders perceived that iCCM improved access to care for children under five years of age.

Methods

The intervention involved training and equipping 196 CHWs in 98 study villages in one sub-county in Uganda in iCCM. During the eight-month intervention, CHWs assessed sick children, provided antimalarials (coartem) for fever, antibiotics (amoxicillin) for cough and fast breathing, oral rehydration salts/zinc for diarrhea, and referred very sick children to health facilities. In order to examine community perceptions and acceptability of iCCM, post-intervention focus groups and key respondent interviews involving caregivers, health workers, CHWs and local leaders were carried out by experienced facilitators using semi-structured interview guides. Data were analyzed using thematic analysis techniques.

Results

Respondents reported increased access to health care for children as a result of iCCM. Access was reportedly closer to home, available more hours in a day, and the availability of CHWs was perceived as more reliable. CHW care was reported to be trustworthy and caring. Families reported saving money especially due to reduced transportation costs, and less time away from home. Respondents also perceived better health outcomes. Linkages between health facilities and communities were reportedly improved by the iCCM intervention due to the presence of trained CHWs in the community.

Conclusions

iCCM delivered by CHWs may improve access to health care and is acceptable to families. Policymakers should continue to seek opportunities to implement and support iCCM, particularly in remote communities where there are health worker shortages.

Effect of community based interventions on childhood diarrhea and pneumonia: uptake of treatment modalities and impact on mortality

Introduction

Diarrhea and pneumonia are the two leading causes of mortality in children under five. Improvements have occurred over the past two decades but the progress is slow to meet the MDG-4.

Methods

We conducted a systematic review of the randomized controlled trials, quasi-experimental and observational studies to estimate the effect of community based interventions including community case management on the coverage of various commodities and on mortality due to diarrhea and pneumonia. We used a standardized abstraction and grading format and performed meta-analyses for all the relevant outcomes. The estimated effect of community based interventions was determined by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.

Results

We included twenty four studies in this review. Community based interventions led to significant rise in care seeking behaviors with 13% and 9% increase in care seeking for pneumonia and diarrhea respectively. These interventions were associated with 160% increase in the use of ORS and 80% increase in the use of zinc for diarrhea. There was a 75% decline in the unnecessary use of antibiotics for diarrhea and a 40% decrease in treatment failure rates for pneumonia. Community case management for diarrhea and pneumonia is associated with a 32% reduction in pneumonia specific mortality, while the evidence on diarrhea related mortality is weak.

Conclusion

Community based interventions have the potential to scale up care seeking and the use of essential commodities and significantly decrease morbidity and mortality burden due to diarrhea and pneumonia in children under the age of five years.

Overcoming health systems barriers to successful malaria treatment

The success of malaria control programmes is recognised to be handicapped by the capacity of the health system to deliver interventions such as first-line treatment at optimal coverage and quality. Traditional approaches to strengthening the health system such as staff training have had a less sustained impact than hoped. However, novel strategies including the use of mobile phones to ease stockouts, task-shifting to community health workers, and inclusion of the informal sector appear more promising. As global health funding slows, it is critical to better understand how to deliver a proven intervention most effectively through the existing system.