P RO J E C T   P ROPO SA L  Prepared for: Designing Disease Control Programmes in Developing Countries (3457) Prepared by: Craig Bonnington, Margaret Gani-Ikilama, Leyla Hernandez, Franck Shembo, Lisa Woods Team: Team A2 Date: 23 March 2011 Proposal: SO-Malaariya – Brought to you by a consortium of multidisciplinary professionals in early

retirement from profit earned on corporate shares and dividends. The group works pro bono to design disease control projects in Africa and Asia. NGO officers will actively participate from London, England and Silicon Valley, California.

 

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Table of Contents

Acronyms........................................................................................................................................................... 3

Executive Summary........................................................................................................................................... 3

Introduction........................................................................................................................................................ 4

SOMALIA HEALTH PROFILE........................................................................................................................... 4

The public and private health systems.............................................................................................................. 4

Health Information Management System........................................................................................................... 4

Malaria control policies ...................................................................................................................................... 4

Key stakeholders............................................................................................................................................... 6

BAY REGION..................................................................................................................................................... 6

Malaria prevalence........................................................................................................................................... 6

Political instability and violence ........................................................................................................................ 6

OPTIONS APPRAISAL: BEST PRACTICES IN THE PREVENTION & CONTROL OF MALARIA………..… 7 Microscopy.........................................................................................................................................................

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Rapid Diagnostic Tests (RDTs) ......................................................................................................................... 7

Shopkeeper training........................................................................................................................................... 7

Home-based Fever Management (HBFM) ........................................................................................................ 7

Rectal artesunate.............................................................................................................................................. 8

Health systems strengthening for malaria......................................................................................................... 8

LLIN distribution.................................................................................................................................................. 8

Intermittent Preventive Treatment (IPT) ............................................................................................................ 9

Insecticide Treated Plastics Sheeting (ITPS) ................................................................................................... 9

Indoor Residual Spraying (IRS) ....................................................................................................................... 9

Zooprophylaxis ................................................................................................................................................ 9

Larval control.................................................................................................................................................... 9

RECOMMENDED STRATEGIES FOR MALARIA PREVENTION & CONTROL - BAIDOA TOWN................ 9 Mother2Mother (M2M) Peer Initiative...............................................................................................................

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Shopkeeper Training......................................................................................................................................... 10

LLIN distribution................................................................................................................................................ 10

Zooprophylaxis................................................................................................................................................. 10

Appendix A, B, C………………………………………………………………………………………………………… 17

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ACRONYMS AHW Animal Health Worker AHWT Animal Health Worker Trainer AMFm Affordable Medicines Facility-malaria ARPCT Peace and Counter-Terrorism in Somalia AS+SP Artesunate and Sulphadoxine-pyrimethamine AUC African Union Commission AU-IBAR African Inter-African Bureau for Animal Resources COOPI Cooperazione Internazionale DREA Department of Rural Economy and Agriculture FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition GFATM Global Fund for AIDS, Tuberculosis and Malaria HSM Harakat al-Shabaab al-Mujahideen M2M Mother to Mother MM Mother Mentors PfPR P. falciparum Parasite Rate PMR Private Medicine Retailer RBM Rollback Malaria RDP Reconstruction and Development Plan RRA Rahanweyn Resistance Army TFG Transitional Federal Government U5 Global Acute Malnutrition UIC Union of Islamic Court EXECUTIVE SUMMARY The disease burden of malaria has a detrimental effect on the health and prosperity of the people of Somalia as people with malaria typically have bouts of chills, fever, and sweating. These fevers interact with malnutrition, and Somalia has an U5 Global Acute Malnutrition (GAM) score of 16.2 per cent. Malaria can leave an affected person bedridden so that they cannot work or otherwise contribute to the household’s well being and malaria in synergy with malnutrition is associated with an increased risk of morbidity and mortality. Malaria endemicity in Baidoa ranges from four to six months out of the year, and in Baidoa district alone, malaria prevalence is estimated at 22 per cent. The socio-economic factors that influence malaria morbidity and mortality include the health-seeking behaviour of sufferers and mothers, a war-affected health system that has low capacity for malaria diagnosis and case management and the prescription practices of private medicine retailers. This project will seek to improve early detection and effective treatment by training shopkeepers to diagnose and treat simple malaria, and to refer complicated cases of malaria to public and private health facilities during 2011-2012. This initiative will work increasing shopkeeper knowledge on the rational use of medicines and the importance of prescribing a full course of first-line anti-malarial medications only in combination with antipyretics. To improve access to prompt and effective treatment of malaria in the home and community, influential mothers will be trained as Mother Mentors (MMs) to diagnose and treat clinical fevers in the home. The MMs will then train neighbouring mothers on HBFM. The LLIN distribution will aim to reduce mortality in pregnant women, in under-fives (U5s) and amongst 15,000 households in Baidoa town. The LLINs will be distributed together with the UNICEF Expanded Immunization Programme (EPI) as UNICEF distribution networks are well established. The correct usage of LLINs will be emphasised with “Hang up” campaigns conducted two weeks after distribution. Finally, the project will seek to increase community protection through insecticide zooprophylaxis, sponging livestock with delamethrin. Vectors who bite the treated animal will die and this treatment will provide a protective effect to livestock and communities.

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INTRODUCTION1 Somalia is located on the Horn of Africa and is bordered by the countries of Djibouti, Kenya, Ethiopia and Yemen. Population figures are contentious as the last official census took place in the 1970s, but 2009 estimates put the population at about 8.5 million. Households typically consist of about 5.8 people and nearly 50 per cent of the population is younger than 18-years old. The urban-rural split is 38:62 and the population literacy rate is an estimated 80 per cent. A lack of a central government and economic sanctions has left the country isolated from the international community and global trade, and about 43 per cent of the population lives on less than US $1 per day.2

Somalia has been in a protracted civil crisis for 20 years and has ceased to operate as a unitary State since 1991. The South Central Zone (SCZ) has minuscule political infrastructure despite efforts to unite warring factions in the SCZ, Somaliland and Puntland through the development of a parliament and Transitional Governments. Parliament appointed the current Transitional Federal Government (TFG) in 2004, but fierce opposition and attacks from warring groups and militias mostly in the SCZ has crippled TFG governance. The humanitarian space contracted in 2010 when eight humanitarian organisations were banned from working in the south. Agencies have responded through 'remote implementation’ or the use of national staff and local implementing partners.

In addition to armed conflict, persistent droughts threaten the stability of the country. Presently, about 2 million people are in crisis from delayed, insufficient rains. The crisis-affected people comprise the urban poor and pastoralists yet to recover from a six-season drought, the flood-affected riverine, and the internally displaced. Drought leads to food insecurity and malnutrition due to the death of livestock and camels. Malnutrition and hunger increases malaria morbidity and mortality amongst all drought-affected peoples. Spiritual beliefs greatly influence parents’ health seeking practices regarding sick children. For example, there is a general belief that regardless of what health care is sought, whatever God wills will transpire.3 In the case of malaria, serious malaria with convulsions is attributed to “evil eye,” while mosquitoes are believed to be responsible for malaria without convulsions. Health facilities are viewed as a last option for child malaria treatment especially among the pastoralists. For urban dwellers, modern drugs are sought for malaria treatment most commonly from local shops or pharmacies. Health seeking behaviour is affected by cultural understandings of health and illness, which has implications for diagnosis and control.

Somalia Health Profile Somalia has some of the worst health indicators in the world and is ranked 161 out of 163 countries in the last Human Development Index ranking in which it was included (2004).4 The dearth of vital statics has precluded Somalia’s inclusion in later Human Development Reports but UNICEF (2010) statistics report that its maternal mortality ratio is amongst the highest in the world. Diarrhoeal diseases, acute respiratory infections (ARIs) and malaria – in synergy with malnutrition – account for more than half of all child deaths (UNICEF, 2010).5 In 2008, the Somali Health Management Information System reported 45,826 uncomplicated and 4,456 severe cases of malaria. A 2007 modelled approach estimates this to be much higher at 770,000 annual clinical attacks of Plasmodium falciparum.6 The high burden of disease threatens Somalia’s MDG progress and serves as a stumbling block to national peace and reconciliation.

Health Indicators – UNOCHA Consolidated Appeals Process Somalia (2011) Adult mortality 416/1,000 WHO World Health Statistics 2009/2010 Maternal mortality 1,400 /100,000 WHO World Health Statistics 2010 Under-five mortality 200/1,000 WHO World Health Statistics 2009/2010 Measles immunization coverage among one year olds

24% WHO World Health Statistics 2010 and UNICEF 2006

% households w/at least one ITN 12% UNICEF State of the World’s Children (2011) % U5s sleeping under ITNs 11% UNICEF State of the World’s Children (2011) % U5s with fever receiving anti-malarial drugs 8% UNICEF State of the World’s Children (2011) Number of medical doctors per 10,000 population >0.5/10,000 WHO World Health Statistics 2009/2010 Number of nurses/midwives per 10,000 people 1/10,000 WHO World Health Statistics 2009/2010

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The public and private health systems A majority of health facilities were damaged or looted during the civil conflict and only a fraction has been reconstructed. I/NGOs have supported the public health system but the coverage is quite low. Most health facilities are located in major towns or in areas that have relatively safe operating environments. Service provision is therefore uneven and intermittent. The patient load is also extraordinarily high with one health post for every 13,000 people and one Maternal and Child Centre (MCH) for every 35,000 people.7 There is a severe shortage in health staff with a ratio of three doctors and 11 nurses per 100,000 people.8 While the hospital rosters indicate that doctors are on staff, many work in the private sector to earn a living. This leaves the hospital staffed by non-medically trained volunteers.9 These challenges impact on the viability of the public health system and constrain the quality of malaria prevention and control services. Reports assert that the public relies on the private sector for malaria diagnosis and case management needs. A report found that the average Somalilander visits a health facility once every 11.8 years, while she visits a pharmacy 3.8 times per year.10 Distance, transport costs and more reliable drug stocks perpetuate this health-care seeking behaviour. While health posts can be located up to 6 km from a household,11 a report estimated that at least 200 pharmacies operate in Baidoa town alone.12 More than 30 per cent of all pharmacies provide parasitological diagnosis services using RDT (18%) or microscopy (25%). Pharmacists prescribe, SP monotherapy (8% to 37%); up to 53 per cent routinely provides Chloroquine (CQ) as a first line anti malarial. Only 31.4 per cent of pharmacists prescribe an Artemsinin Monotherapy (AMT). The prescribing practices of pharmacists have implications for malaria-related mortality and the threat of drug resistance in Somalia. Health Information Management System The Health Management Information System (HMIS) serves as the main data source for monitoring the Somalia National Malaria Control Program. It is a health-centre based system where each facility records clinical and suspected malaria cases, diagnosis using laboratory and RDTs, frequency of RDT/slide positives, confirmed in-patient malaria patients, antenatal care (ANC) attendance and administration of Intermittent Preventative Therapy (IPT). Problems in the Somali HMIS are associated with access to health facilities, human resources, and varying data demands for particular programmes from multiple partners. Sustained efforts have resulted in improvements in data but additional strengthening is still required. Sentinel districts were created in 2008 to monitor HMIS indicators through the monthly collection of data. The original plan was for three pilot regions – Northwest Zone (NWZ), Northeast Zone (NWZ) and South Central Zone (SCZ) – but due to limited access to the NWZ, there are only two sentinel districts in Somaliland that house three specialists. Malaria control policies The defined aims of the Somali National strategic plan for Malaria are to achieve the following by 2015:13

• Near absent malaria transmission in particular geographical locations which historically have had low malaria transmission

• Constant, uninterrupted control in the other malarious parts of the country (Southern parts of Central South Zone)

The previous strategic plan focused on the provision of interventions at the health facility level. Community engagement and mobilization is envisaged to support diagnosis and case management; prophylaxis; epidemic preparedness; early detection and response; and health systems strengthening. It should be acknowledged that while the initial plan – taking into cognizance the Somalia situation – was modest in its aspirations, this current plan is ambitious in specifying a particular timeline of 2015 for most areas in all three zones to have attained sustained control. With respect to first-line anti-malarial medications, a policy was adopted (2004) to introduce ACTs for uncomplicated malaria.14 In 2005, Somalia revised its national malaria treatment policy, abandoning CQ as its first line treatment for Artenusate and Sulphadoxine-pyrimethamine (AS +SP).15

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Key stakeholders The technical Malaria Working Group in Nairobi works with partners interested in Rollback Malaria (RBM) initiatives, and those with a mandate for malaria prevention and control activities. UNICEF, WHO and the Ministry of Health and Labour (MoHL) from the different regions of Somalia are part of this group.16 There are a variety of organizations executing various aid programs in the Bay region.17 This project however will particularly focus on working with the following organizations to achieve the specified aims, as they have proven expertise and experience:

• UNICEF: Training, LLIN distribution, interface with local authorities • WHO: Storage of supplies, security of personnel and supplies, training, coordination • FSNAU: Surveys, zoo-prophylaxis, LLIN distribution • Somali Doctors Association: Advocacy, training, networking with stakeholders • The African Inter-African Bureau for Animal Resources (AU-IBAR): A department of Rural

Economy and Agriculture (DREA) of the African Commission (AUC) livestock condition and price UNICEF is also the prime recipient of the GFATM grant for Somalia and disburses funds to 12 recipients and three Somalia health authorities (NE, NW and TFG). The WHO serves as the technical focal point for various health programmes, and works towards strengthening Somalia’s health care delivery system. It is the lead agency of the Health Cluster, which coordinates the health sector of the ongoing emergency response, and works to build the capacity of local government and partners.18 Bay Region The Bay region is located in the SCZ, about 245 km from Mogadishu. The population is estimated to be 250,330 – about 75,000 of who live in Baidoa town.19 Agriculture and livestock sustain the Baidoa rural economy, and represent 65 per cent of the workforce and more than 50 per cent of the export earnings. 20The two dry seasons are July-September and January-March. These are the periods for harvest and trade while the remaining months of the year (wet season) are dominated by agricultural labour.21

Malaria prevalence22 Food Security and Nutrition Analysis Unit (FSNAU, 2004-2007) surveys show that the prevalence of P. falciparum in various regions of Somalia is “unstable.” There is “epidemic transmission” in Somaliland and Puntland “moderate transmission” in Central Somalia and “high transmission” in the south. A summary of P. falciparum parasite rate (PfPR) data amongst 21,436 Somalis representing 363 communities, carried out between 2004 and 2007 showed the following for Bay region: 121 surveys (the highest done for any region) produced a mean PfPR rate of 21.92 per cent, with a PfPR range of 0-78. Only15 studies showed a PfPR = 15; and for a total of 6,248 slides examined, the PfPR was 21.90 per cent. The dominant malaria species in Somalia is believed to be P. falciparum. The prevalence of P.vivax has however not been adequately investigated, an important observation as this has been described as the dominant Plasmodium species (40 per cent) in bordering Ethiopia (2009a). P vivax has also been reported among US soldiers in Somalia.23 See Malaria prevalence map in Appendix A.

Political instability and violence The Bay region has been the site of political instability for decades.24 The Rahanweyn Resistance Army (RRA), a rebel faction fighting for independence of southwest Somalia, is controlled by the TFG, which is allied to Ethiopian troops due to a shared concern over Islamic power in the south among several rebel groups.25,26 A more extremist Islamic militant group, the Harakat al-Shabaab al-Mujahideen (HSM), is also fighting for control, and is responsible for promoting instability throughout the south. In July 2009 the UN suspended its operation in Baidoa when the security situation deteriorated after the withdrawal of Ethiopian troops. Violence in Mogadishu, where the TFG is based, has led to outmigration and displacement of people fleeing into Baidoa district. The security situation has led to the following: dependence on humanitarian assistance; access and security difficulties with pockets of stability; increased IDP and food insecurity; and minimal quality frameworks.27

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OPTIONS APPRAISAL: BEST PRACTICES IN MALARIA PREVENTION AND CONTROL About one million African children die each year from malaria, most of who live in sub-Saharan Africa. Malaria is most dangerous to U5s who have not had the opportunity to build up immunity. In malaria-endemic areas, about a quarter of all child mortality is attributable to malaria (RBM, 2010).28 Pregnant women are another high-risk group as malaria in pregnancy causes anaemia, low birth weight and miscarriages. Simple prevention strategies such as sleeping under a LLIN, or accessing a full course of ACT can be out of reach for the socially disadvantaged. The RBM Partnership goal is to “eliminate malaria as a public health problem and obstacle to socio-economic development.” RBM has grounded its strategy on four pillars of action: 1) Prompt access to treatment; 2) insecticide treated nets; 3) prevention and control of malaria in pregnant women; and 4) malaria epidemic and emergency response. The Millennium Development Goal and targets related to malaria include:

• Goal 6: Combat HIV/AIDS, malaria and other diseases • Target 8: To have halted by 2015 and begun to reverse the incidence of malaria and other major

diseases ⇒ Indicator 21: Prevalence and death rates associate with malaria ⇒Indicator 22: Proportion of population in malaria-risk areas using effective malaria prevention, treatment measures

In light of the Somalia National Strategic Plan for Malaria, the RBM Partnership goal, and the MDGs, the following options have been appraised for malaria control in the South Central Zone of Somalia:

Microscopy Microscopy – the gold standard in malaria diagnosis – has the advantages of quantifying malaria through total parasite counts and species differentiation.29 This is important as treatment for malaria varies between parasite species and level of parasitaemia.30 Due to limited number of properly trained technicians, and a lack of quality assurance mechanisms, there is increased risk of incorrect diagnosis with microscopy. The WHO has reported from 60 to 90 per cent misdiagnosis in public health facilities were microscopes are available.31 Misdiagnosis can lead to adverse consequences, including drug resistance. Rapid diagnostic tests (RDTs) The RDT was developed as an affordable alternative to microscopy. It is quick, easy to interpret, and can be performed in the absence of long training. RDT increases access to early diagnosis as it can be performed at all levels of the health system. While the cheaper RDTs can only detect Plasmodium falciparum, the more expensive RDTs can distinguish P. falciparum from P. vivax, P. malarae and P.ovale.32

Shopkeeper training A systematic review of shopkeeper trainings found evidence of effectiveness in Uganda, Tanzania and Kenya. In Kenya, shopkeepers were educated to counsel customers on how to treat malaria using dosage charts for CQ and antipyretics; how to use rubber-stamps that demonstrated age-appropriate doses of CQ to children; and how to recognize malaria cases that needed referral to a trained health worker. A cost-effectiveness analysis found that each additional appropriately treated case cost USD $4.00.33 A limitation of shopkeeper training is the inherent difficulty in measuring shopkeeper and customer behaviour change. Buying and selling more drugs don’t guarantee correct use. It is therefore hard to predict the true effect that shopkeeper training has on malaria diagnosis and case management. Home-based fever management (HBFM) Most childhood malaria cases in Africa are treated at home, and from 50 to 70 per cent of children who die from febrile illnesses do not come into contact with the formal healthcare sector.34 HBFM is one way to increase access to prompt and effective malaria treatment. Community health workers (CHWs), drug suppliers and

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private medicine retailers (PMRs) typically support HBFM initiatives with advice, supervision and the provision of appropriate anti-malarials. An Ethiopian RCT trained mothers in HBFM who then trained neighbouring mothers in HFBM. This intervention resulted in 40 per cent ([95% CI 29.2-50.6]; P=<0.003) less U5 mortality, but may have limited applicability because the intervention districts had ‘CQ-sensitive falciparum malaria’ and strong social cohesion. A similar initiative in Burkina Faso resulted in less malaria morbidity. Rectal artesunate A large 2002 RCT in Africa and Asia found that pre-referral treatment with rectal artesunate can decrease death and disability in complicated malaria cases who experience treatment delays [RR 0.49 [95% CI 0.32-0.77].35 People treated with rectal artesunate experience a rapid decrease in fever. But the disadvantages are that rapidly “cured” patients might not seek the required second dose. Furthermore, the use of rectal artesunate outside of a trial setting has not been explored, so the benefit of delivering this intervention at the community level is unknown. Health systems strengthening for malaria The RBM Affordable Medicines Facility- malaria (AMFm) strengthens health systems through increased access to affordable ACTs. Core supporting interventions include provider training, public education and awareness campaigns, national policy and regulatory systems, and drug quality monitoring.36 In Tanzania, RBM-supported HSS has increased the quality of ACT provision, demand, and correct diagnosis due to health provider training.37 While the AMFm aims to improve drug procurement and distribution, rural pharmacies and clinics still experienced stock-outs. Moreover, private providers are not motivated to operate in rural areas and the disruption of ACT supply in the countryside represents a weakness in this approach. It also serves to increase the urban-rural healthcare access gap. LLIN distribution WHO recommends the use of LLINs as one of the main preventive measures to protect against malaria and reduce local transmission.38,39 Global consensus supported by RBM is to achieve 100% coverage in the targeted population and not only in vulnerable groups. A Cochrane review, concluded that full net coverage reduced malaria-related child mortality by about 18 per cent in sub-Saharan Africa.40 Free distribution with massive campaigns and the use of private sector to subsidize LLIN are part of the WHO strategies to improve coverage. Studies conducted in Kenya, showed a gap between the possession and use of nets. To be cost-effective, efforts should be done to complement the net distribution with behaviour change interventions and to integrate these activities with other health interventions such as immunization. Radio campaigns complemented with the assistance of community leaders has been proven to increase effectiveness of these programs.41

Intermittent Preventive Treatment (IPT) IPT, which is recommended during the second and third trimester of pregnancy, reduces morbidity and mortality; and increases birth weight with no serious side effects. However there have been reports on treatment failure and resistance. Other reports are about non-compliance due to negative community perceptions, issues with health action providers and the woman’s fear of adverse side effects. In some studies IPT is said to have impaired the development of naturally acquired immunity. 42 However, lack of access to ANC and therefore IPT is a greater in some African countries. Insecticide Treated Plastics Sheeting (ITPS) ITPS usually treated with pyrethroid insecticide, is a method of malaria vector control that has been used throughout Africa, though largely localised to refugee camps as an immediate solution for malaria control in semi-permanent dwellings. Evidence suggests ITPS reduces the longevity of mosquitoes by killing vectors upon landing on ITPS. There is an added benefit, as ITPS provides additional material for construction of shelters and physical barrier to non-anthropophilic vectors.43 However its exact impact is difficult to measure as it is most commonly used in humanitarian settings. They must also achieve high coverage as no evidence of reduction in mosquito blood-feeding of anthropophilic vectors been observed in some studies. Research has indicated that effectiveness of ITPS lasts for three months to a year depending upon the setting.44

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Indoor Residual Spraying (IRS) IRS is an effective vector control method for malaria and has resulted in near eradication of the disease in some areas. In Sri Lanka DDT reduced prevalence from 1.3 million to 17 cases over an 18-year programme. However the need for such extensive long-term coverage selected for resistance and 5 years later 600,000 cases were reported annually. Furthermore IRS is an expensive control strategy and requires careful planning, logistical framework, and suitable infrastructure. In Somalia its use has been largely restricted to epidemics in the north where more reliable infrastructure exists. IRS is now part of the Somalia National Strategic Plan for Malaria 2011-2015 in areas prone to epidemics. Indoor Residual Spraying has achieved mixed success in the relatively stable regions of Somalia. Furthermore, IRS will only be effective in areas where the dominant vector displays endophilic (rests indoors) behaviour.10

Zooprophylaxis Insecticide zooprophylaxis involves treating livestock with insecticide in order to kill malaria vectors upon feeding. This is relatively cost effective and recommended in the malaria in complex emergencies, inter-agency handbook published by the WHO.45 Also preventing mosquito exposure to non-lethal residual levels of insecticide as is associated with Indoor Residual Spraying (IRS), which can select for resistance.46 This has been seen to be very effective in Afghan refugee camps where cattle treated four times annually with delamethrin reduced the incidence of Malaria as much as IRS using 20 per cent of insecticide volume and at a far reduced cost.47 The same method has also been successful in Kenya in conjunction with LLIN distribution.48 However this method of vector control requires the dominant vector species to display zoophilic behaviour as anthropophilic vectors will ignore livestock and feed upon humans. Compliance by livestock owners may be low if appropriate education of the benefits is not clearly conveyed. Larval control Larval control using chemical or bacterial larvicides, or predatory fish in stagnant water can be a successful measure to control malaria prevalence.49 A pilot study has shown it to be effective against larval abundance in 25 birkits (small reservoirs) in Somaliland, however impact on malaria transmission as a single intervention strategy is difficult to quantify. Use of insecticides over vast waterways can be expensive. Furthermore the WHO does not recommend larval control unless the population at risk is very high and permanent water bodies exist largely restricting treatment to urban settings.

RECOMMENDED STRATEGIES FOR MALARIA PREVENTION & CONTROL BAIDOA TOWN

1. Mother2Mother (M2M) Peer Initiative

The Somalia National Strategic Plan for Malaria asserts that behaviour change communication (BCC) and IEC support strategies should prioritise treatment-seeking behaviour. The M2M Peer initiative abandons traditional health communicators and uses social learning as way to promote correct diagnosis and prompt and effective treatment of malaria by mothers. This is needed as research shows that across all livelihood zones, health-seeking behaviour tends to follow a pattern of: Prayer >Traditional home health care >Traditional healer > Purchase medicine >Get religious leader to pray >Health facility. This delay can result in excess malaria morbidity and mortality in U5s in particular.50 The M2M Initiative will work to change the health-seeking behaviour of mothers by training influential mothers (Mother Mentors/MMs) to diagnose and treat clinical fevers in the home. The MMs will then train neighbouring mothers on HBFM. All mothers will be linked with the diagnosis, case management and referral services offered through the Baidoa Town ShopkeeperPlus initiative.

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2. Shopkeeper Training: Baidoa Town ShopkeeperPlus

In Baidoa there are about 200 pharmacies. The sheer presence of pharmacies on urban street corners, combined with convenient opening times of up 11 hours per day, makes private medicine retailers (PMRs) the “most accessible modern health care delivery point in Somalia.”51 Given the extensive coverage of the private sector, public health interventions to control malaria in Somalia should intervene at this basic, predominant level of public health service provision. This intervention is proposed in the form of shopkeeper training, which would serve to build the capacity of PMRs to diagnose and treat simple malaria, and to refer complicated cases of malaria to public and private health facilities. Shopkeepers will be given an opportunity to influence the curriculum on other areas that would be beneficial to them such as essential drug concepts and the rational use of drugs – with an emphasis on the importance of only selling ACT for suspected malaria, the counselling of customers on ACT use, and selling the correct dosage of ACT in combination with antipyretics. 3. LLIN distribution UNICEF distribution of LLINS has covered about 12 per cent of Baidoa households. Our program will complement this initiative by distributing WHO-compliant nets to households without nets, and assess the state of nets already present in households. For the allocation of strategies and resources, the baseline will be determined using extrapolated data from previous surveys. Our approach will include community leader engagement, identification and training of village field workers with an emphasis on the promotion of correct and consistent use, house-to-house distribution and follow-up.52

4. Malaria prevention using strategies of insecticide zooprophylaxis

Considering that Baioda district is in a state of conflict and has a population displaying nomadic behaviour more common effective methods of malaria prevention using insecticide such as IRS are less efficacious.9-10 This supports the cheaper more sustainable and practical use of insecticide zooprophylaxis. Furthermore it will also control sleeping sickness spread by the tsetse fly53 and rift valley fever a disease that causes loss of condition, death an abortion among livestock a disease responsible for 51 human deaths in 2006.54

Somalia has suffered a severe drought in 2011 due to lack of rainfall last year. Livestock including camels are dying leading to malnutrition and lack of income to agro-pastoralists in the south, thereby leaving such communities more susceptible to infection [malaria] associated mortality and morbidity. Improving nutrition and income for essential items including malaria prophylaxis is therefore required to ensure sustainable reductions in malaria incidence. Improving the quality of livestock and insecticide treatment of animals through training of local male animal care workers (ACW’s) would help to reduce malaria incidence and furthermore provide an early warning system for reduction in quality of livestock on which the lives of many communities are dependent. Somalia’s income is livestock driven and ensuring good quality will have positive effects both locally and nationally. Compliance is likely to be very high as livelihoods and nutrition are dependent on livestock condition especially in the Bulo Jameco of the Hawl Wadaag quarter where urban livestock ownership is high.

PROJECT DESCRIPTION

Goal & Purpose: To reduce malaria related mortality and morbidity in Baidoa town. Target population: 15,000 households in Baidoa Town Project implementation: The project will be implemented at the community level to promote ownership and sustainability. Due to the insecurity, the head office will be located in Nairobi and a satellite office in Baidoa town. A local coordinator, responsible for all operational aspects of the project will manage the satellite office. Other personnel will include three trainers, 50 local field workers, three field supervisors, two professional consultants – one entomologist and WHO technical malaria expert. We will work in close cooperation with the community to facilitate participation and empowerment the sustainability of the project.

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PROPOSED PROJECT OUTPUTS AND ACTIVITIES: Objective 1: To improve recognition of malaria and care-seeking behaviour by mothers within 24 hours of illness onset. Output 1: 60% of the town’s mothers recognise the symptoms of malaria and seek a full course of ACT for febrile children. Activities:

1.1 Neighbour groups formed from neighbouring houses with U5s.

Clusters of 20 HHs with U5s will be grouped in each Neighbour Group. One MM will be responsible for 20 HHs with children U5. There are 2,250 HH in the target area so there 110 MM will need to identified and trained.

1.2 Select 110 Mother Mentors (MMs).

Participatory methods will be used to identify mothers on quadrant blocks (urban) and village tracts (peri-urban) – who hold the most authority in the community. Influential mothers will be designed Mother Mentors and trained on IPC and HBGM. Incentives will be given based on WHO recommendations that community volunteers be remunerated for their time in a manner that is decided upon by the community.

1.3 MMs will receive a five-day training (and refresher training) on home-based fever management

(HBFM). UNICEF Somalia has agreed to allow the M2M refresher training to use its trained pool of female community-based trainers linked to the UNICEF Women to Women Initiative on HIV. MMs will also be eligible for non-formal education opportunities in numeracy and literacy. MMs will receive training to: (1) Recognize signs and symptoms of malaria (2) How to identify severe cases of malaria and counsel mother to take child to a health facility (3) The importance of compliance with a full course of ACT and the dangers of non-compliance. (4) Where to find a trained PMR.

1.4 MMs will train neighbour-group mothers in HBFM.

MMs will use pictorial aids and interpersonal communication (IPC) to communicate the essentials of HBFM to neighbour group mothers.

Objective 2: To improve the quality of malaria diagnosis and case management in Baidoa town’s PMRs. Output 2: 60% of community members have increased access to correct and prompt treatment of malaria. Activities:

2.1. Stakeholder meeting with the Ministry of Health and Labour (MoHL), WHO, UNICEF and I/NGOs. Legislation for the regulation of private medicine retailers (PMRs) in Somalia exists but oversight and enforcement is weak. MoHL permits are obtainable for three years but as PMRs are a business, they often apply for license from the local municipality without obtaining MoHL approval. A 2001 Proclamation of the National Pharmacy Regulatory Authority took place with no further establishment. In 2008 the MoHL began evaluating PMRs in Somaliland and MoHL staff expressed their value of the private sector role in public health provision. WHO also launched the Somalia Standard Treatment Guidelines and Training Manual on Rational Management and Use of Medicines at the Primary Health Care Level and is conducting training in public health facilities. Stakeholder meetings will be held to assess the opportunities to forge partnerships with key players in PMR regulation and oversight. Opinions on what critical issues training should suggest will be sought and integrated into project activities where possible.

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2.2. Mapping of PMRs in Baidoa town and invitation to participate in Baidoa Town ShopkeeperPlus training initiative. PMRs will be identified from the business license registry (urban) and existing PMR lists (peri-urban and rural) from previous surveys. Enumerators will undertake transect walks in urban areas to confirm the data, and to leave a flyer advertising the initiative to PMR owners.

2.3. Conduct formative research with PMR providers and local community.

Focus group discussions (FGDs) and one-to-one interviews will be conducted to understand what shopkeepers perceive their knowledge gaps to be in regards to malaria diagnosis and case management. Information will also be gathered on the perceived cost and benefits of participating, and to capture what is needed as motivation to get shopkeepers to act in the interest of public health (and sometimes against their profits). Perspectives on useful content will be sought and included in the training curricula. FGDs will be conducted with community leaders, women’s groups to understand personal experiences with PMRs and value place on service. This will also create a buzz about the initiative.

2.4. Based on stakeholder feedback and formative research, revise the WHO Somalia Standard Treatment Guidelines and Training Manual on Rational Management and Use of Medicines at the Primary Health Care Level based on feedback. A national consultant will be hired to review the existing training curricula and to field test the materials on randomly selected PMRs. In urban areas, the city will be divided into quadrants and an even number of PMRs will be allocated for the field-testing of the materials. Based on feedback, the training curricula will be revised and printed locally.

2.5. Develop referral network for complicated malaria by identifying closest clinics. Liaise with a delegate from the Somalia Doctor’s Association to create linkages with professional health providers of malaria case management. Establish firm links between Baidoa Town ShopkeeperPlus PMRs and health workers who can always (24/7) be accessed for prompt treatment of complicated malaria.

2.6. Create marketing, branding and reporting materials. Competition will be used to drive quality and promote quality service provision. Shopkeeper branding materials will include window logos, promotional items, and branded flyers that double as IEC materials on signs of complicated malaria with contact details and maps to nearby referral clinics, printed on the reverse. Branded referral forms will be printed and given to PMRs to use for complicated cases.

2.7. Conduct three-day PMR shopkeeper training. Participant PMR shopkeepers will be trained on these aspects: 1) Malaria diagnosis using RDT and recognizing the signs of malaria, 2) Using pictorial aids to give information to customers on correct ACT use, antipyretic use, and the importance of finishing anti-malarials, 3) How to recognize malaria cases that needed referral to a trained health worker 4) The rational use of medicine, and 5) Other useful content identified in stakeholder FGDs and meetings. Shopkeepers will also be trained on administrative aspects such as shelve management, RDT storage, safe needle disposal, filling out referral forms, and tracking ACT prescription. PMRs that track ACT prescriptions and referrals will have the opportunity to reach preferred provider status.

2.8. Individual training sessions, and refresher training. Where physically feasible individual training sessions will be conducted in PMRs to observe skills in his/her normal environment. Assessments will provide the initial evaluation of the effectiveness of the training. Refresher training workshops will be held every four months thereafter.

Objective 3: To improve the access and promote the correct use of LLINs in at least 80 per cent of Households from Baidoa district.

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Output 1: To raise awareness of the LLIN campaign distribution in the community. Activities:

3.1. Contact stakeholders from Baidoa to present the project and to identify potential community leaders and field workers from the village.`` Before starting the program a meeting between the program representatives, Unicef and the local opinion leader will be done to present the main aspects of the program: distribution strategies, use of filed workers from the community, collaboration with other ongoing programs and monitoring of activities. Promotional materials will be distributed.

3.2. Organize a promotion campaign for the distribution of LLIN at the local radio. Prepare a jingle with a key message about the importance of the use of the LLNI and the way and places for distribution.

Output 2: To increase the proportion of households using the LLIN that will be distributed to 80% from 2011- 2012. Activities: 3.3. Train the Field workers in the distribution and the use of LLIN.

Once identified in the community, at least 50 field workers will be trained. LLIN activities will be complemented with other program activities like identify Mother mentors and described in Objective 2.

3.3. Distribute two LLIN per household as maximum Using UNICEF mapping and feedback from mother mentors, clusters of Households will be assigned to each field worker, who will provide two LLINs per household. A short theatre demonstration by field worker will be performed at a central point to show installation of the net.

3.4. Coordinate the distribution of LLIN together with UNICEF in measles vaccination campaign and FSNAU nutritional surveys. A contact with EPI program organizer and FSNAU representative will be done to coordinate their activities with the LLIN distribution for children.

Output 3: To maintain the correct use of LLIN in 100% of intervention households. Activities:

3.5. Conduct “Hang up campaign” two weeks after distribution. Field Workers perform a home visit to ensure installation and good use of the LLIN.

3.6. Evaluation meeting with stakeholders and community leaders. One year after the initiation of the programme a new meeting with stakeholder will be conducted to collect feedback and show progress of the campaign.

3.7. Theatre performance 3 months after the first distribution. In order to reinforce the use of LLINs, a short presentation of net use will be performed in areas identified as meeting points for mothers and family (mosques, water-well, market, etc).

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Objective 4: To increase personal and community protection against malaria through the use of insecticide zooprophylaxis. Output 4: 60% coverage of delamethrin-treated livestock in Baidoa town and immediate surroundings. Activities: 4.1 Contract one entomologist:

Precise data on local prevalence of malaria vector species in the target population is not available although An. Arabiensis is assumed to be the dominant vector displaying exophagic, endophilic and zoophilic behaviour. One entomologist will be contracted to perform a survey of vector spp. prevalence, dominance and feeding, host seeking and resting behaviours before commencing the project. The entomologist will compile mid term reports on this data. Midterm reviews of performance will be assessed by the project co-ordinator coinciding with report submission.

4.2 Train animal health workers trainers (AHWTs) in general animal husbandry as well as insecticide

zooprophylaxis: The project will train 5 AHWT’s over a 10 day training course on basic animal husbandry and spraying techniques of insecticide zooprophylaxis of livestock legs in addition to methods of promoting these techniques among the community. Each AHWT will be provided with spraying equipment and Delamethrin (insecticide) for approximately 1,000 livestock under their responsibility. AHWT’s will record the equipments use and volume of insecticide used. Insecticide treatment will take place once a month.

4.3 Training of Animal Health Worker’s by AHWT’s

Further training will be provided by AHWT’s to 50 AHW’s in basic animal husbandry, insecticide zooprophylaxis and promotion of using AHW’s services among livestock owners using poetry as an oral form of teaching. AHW’s will be selected from low-income families from and will receive one cow every month bought collectively between all their clients. AHWs will also educate and promote livestock owners of the need for Delamethrin treatment and resulting improvement in animal condition. In addition AHW’s should encourage LLIN use. Education should be achieved through discussion groups and outreach activities of local livestock owners held every 2 months in each village.

4.4 Stake holder meetings Organise annual meetings with livestock owners in the programme, FSNAU representatives and The African Inter-African Bureau for Animal Resources (AU-IBAR) a department of Rural Economy and Agriculture (DREA) of the African Commission (AUC) concerned with reducing poverty through improving livestock condition and price.

4.5 Delamethrin treatment of livestock among community Each AHW will be assigned responsibility for the treatment of livestock within a specific geographic area. Re-treatment will take place at monthly intervals.

4.6 Delamethrin livestock treatment of nomadic populations.

A contingent of the AHW’s should specialise in promotion and implementation of insecticide zooprophylaxis among the nomadic populations. Ensuring nomads bring livestock to specific points for re-treatment at quarterly intervals.

4.7 AHWT’s and AHW’s problem identification and appropriate re-training.

AHWT’s will chair meetings for the villages they are responsible for with AHW’s once quarterly to identify problems with current promotion and implementation by AHW’s. Within 1 week AHWT’s will then meet and address these issues and produce appropriate solutions to identified problems. Each AHWT will then report back to their villages informing AHW’s of decided reformations to implementation along with re-training be

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over a one day training course within one week of AHWT’s meeting.

4.8 Production of AHW care advertisements for radio. Research by the RBM initiative has indicated that women are unlikely to use radios and therefore behaviour change communication is better given through other communication channels. However men, largely responsible for livestock ownership and management, are likely to be receptive to this form of media. Four 30-second adverts promoting monthly treatment of livestock will be produced using an advertising agency in Nairobi. This will enable promotion of AHW care and insecticide zooprophylaxis to high-risk groups not reached by AHW’s due to geographical and financial limitations of the project. Informing the community where to contact AHW services and the direct benefits associated with seeking treatment.

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