USAID Health Care Improvement Project Mali Anemia Case Study

Kathleen Hill & Evelyn Kamgang CORE Spring Meeting May 2012

Many Actors One Goal:
Actors,
Tackling Anemia in Mothers & Children
A Country Case Study: Mali

Kathleen Hill & Evelyn Kamgang

USAID Health Care Improvement Project
University Research Co., LLC
CORE Spring Meeting May 1st, 2012

1

Session Outline

I. Presentation: Mali Case Study
• HCI Mali anemia project objectives
• Anemia prevalence & causes in Mali (women & children)
• Anemia control best practices: what, when & where?
• Findings from a baseline assessment in Mali’s Sikasso region
2. Group work: Moving to Implementation
• Many actors, One goal: achieving inter-sectorial implementation
in a complex environment
• Models to support implementation planning: CFIR; Program
Assessment Guide (PAG); Breakthrough Series Improvement
Collaborative
3. Plenary Discussion: Putting it all together

2 USAID HEALTH CARE IMPROVEMENT PROJECT

USAID Health Care Improvement Project./URC 1


Acknowledgements

• USAID Mali Mission (funding & technical support)

• USAID Washington Staff (Nutrition, Malaria, MNCH)

• Consultant: Dr. Halimatou Alaofe

• HCI Project staff in Mali & Niger: Dr. Maina Boucar, Dr.
Karim Sangare, M S b Djib i
K i S Mr. Sabou Djibrina, D Z k i S l
Dr. Zakari Saley


HCI Mali Anemia Project Goal and Objectives

Program Goal: To reduce anemia prevalence in pregnant
women, mothers and young children in Mali’s Sikasso
region (one district)
Program Objectives:
1. To improve household and community uptake of anemia
prevention/control best practices for pregnant women,
mothers and young children
2.
2 To achieve broad coverage and quality of high impact MOH
anemia prevention/control interventions for mothers and
children within essential lifecycle windows of opportunity
(pregnancyearly post-partuminfancyearly childhood)




Mali Context
 Total population: 14.2 million (Feed the
Future)
 73% of population rural; 64% li on < 1
f l ti l live
USD per day
 ANC rate: 72% (one visit); 63% (2 or
more visits)
 Skilled birth attendance rate: 49%
(UNICEF 2010)
 Infant mortality rate: 131 per 1000
(UNICEF 2010) Sikasso region: 2nd most
 Under 5 mortality rate: 178 per 1000 live populous & poorest region;
births (WHO/UNICEF 2010) most agriculturally productive;
highest stunting rate; Feed the
 Moderate-severe underweight < 5 years: Future priority region
About 27% (UNICEF)
 Moderate to severe stunting < 5 years:
about 38% (UNICEF)
USAID HEALTH CARE IMPROVEMENT PROJECT




Main Direct & Indirect Causes of Anemia
for Women & Children in Mali
Direct Causes:
 Micronutrient Deficiency: primarily iron deficiency; also
vitamin A & zinc (decreased production red blood cells)
 Malaria: hemolytic anemia (destruction red blood cells)
 Other parasitic infections: mainly schistosomiasis &
hookworm (excessive loss red blood cells)
Indirect Causes:
 Lack of childbirth spacing
 Food insecurity, malnutrition, poverty
 Poor sanitation & access to potable water
 Weak access to health services
 Early childhood feeding practices (e.g., delayed breastfeeding)


How Big is the Problem?
Anemia & Related Prevalence Rates in Mali
Other
Anemia
Iron- Malaria parasite
Prevalence
deficiency prevalence prevalence
(Any & severe) anemia (Schisto.)
(S hi t )
76% 73% 23% Schisto.
Pregnant (FAO 2010) (Aguayo, 48% 8% Hookworm
women 2005) (Ayoya 2006)
85% (Mali)
Children 91% (Sikasso) ?? 38% Mali 51% Schisto.
6-59 mos 26% severe (Mali)
mos. (Dabo 2011)
35% severe 59% Sikasso
(Sikasso)
39% 12-17 months (EA&P 2010)
(EA&P2010)

USAID HEALTH CARE IMPROVEMENT PROJECT



Critical Lifecycle Windows for
Uptake and Delivery of Anemia Best Practices
for Mothers & Young Children
Early Post- Infancy Early
partum Childhood
Pregnancy (0-6
(Mother & (6 mos-5
Newborn) months)
years)
Focused ANC Early & exclusive EEBF Complementary feeding
breastfeeding from 6 months
Iron/folate (EEBF)
suppl. Diversified feeding
Micronutrient Vit A suppl.
Deficiency Nutrition best Active feeding sick
practices Iron suppl. mother child

Nutrition best Vit A suppl (2x/year);
practices (mother) Zinc for diarrhea
IPTp x 2 (SP) LLITN use (mother LLITN use (mother LLITN use (mother &
Malaria & newborn) & infant) newborn)
Long-lasting
insecticide-trtd Prompt care Prompt care seeking
bednet (LLITN) seeking fever fever
use
Accessible/quality Accessible/quality care
care febrile illness febrile illness
Hygiene Food & personal Food & personal Food & personal
Parasitic
9 hygiene USAID HEALTH CARE IMPROVEMENT PROJECT
hygiene hygiene
Infections Systematic de-

Main Delivery Venues for
MOH Anemia Control Best Practices

• Community- and home-based: antenatal, early post-
partum & early childhood services via community health
workers (“Agents de Sante Communautaire” ASC) and
( Agents Communautaire”,
community-based health volunteers (“Relais
Communautaire” , RC)
• Facility-based antenatal & early post-partum
consultations: community health centers (CSCOM) &
district referral health centers (CSRef)
• Facility-based well-child and sick-child consultations
(CSCOM & CSRef)
• Quarterly regional MOH-sponsored “Week of Intensive
Nutrition Actions” (SIAN)



Current Status of Selected Anemia Control
Best Practices in Mali

• Breastfeeding within 1st hour of birth: 46% (DHS)
• Exclusive BF until 6 months: 38% (DHS)
( )
• Complementary feeding from 6 to 11 months (fruits,
vegetables, meat): 11-12% (DHS)
• Bednet use previous night: 75-80% (children 0-4 yrs;
however < 10% used pre-treated net)
• Intermittent Preventive Therapy for Malaria in Pregnancy
(IPTp): 2 SP doses in pregnancy: 4% (DHS 2006)
• Care-seeking w/in 24hr onset of fever in children: 23%
• Treatment of febrile illness with ACT: 7.8%
Sources: EA&P Survey, 2010; DHS 2006

Preparing for Implementation :
Baseline Evaluation in Mali’s Sikasso Region

Baseline Assessment Objectives:
1. Assess anemia-related knowledge, attitudes & practices
among beneficiaries & providers
2. Assess implementation of community- and home-based
anemia control interventions
3. Assess implementation of high-impact MOH Health
Center-based
Center based anemia control interventions including
interventions,
cross cutting health system service delivery supports





Data Collection Sites:
12 Communes (household/ community) & 15 Health Centers
in Kadialo & Bougouni Districts (Sikasso Region)
District 15 Health Centers 12 Communes
(CSCOM & CSRef)
1 CSCOM Urban Kadiolo
Kadiolo
K di l 1 CSR f
CSRef
Missenu
3 CSCOM Rural Nimbougou
Dyou
3 CSCOM Urban Bougouni
1 CSRef
Bougouni Koumantou
Bladié
6 CSCOM Rural Banimonotié
Bladiè Tièmala
Koumantou
Koumantou
Défina



Data Sources & Sample Sizes
Community Interviews (12 communes) :
• Community leaders (n=42)
• C
CHW ( C/ SC) (
(RC/ASC) (n=30; 75% RC)
% C)
• Household (pregnant women & mothers) (n=480)
• Observation of 1 SIAN
Health Center (15 centers)
• Interviews managers (n=12) & providers (n=30)
• Client exit interviews: antenatal, sick & well child
consultations (total n=459 )
• Chart audit (n=550)
• Inventory of inputs & service organization (n=12)

Selected Results

• Household
• Community
• SIAN (Week of Intensive Nutritional Activities)
• Facility





Household & Client Exit Interviews: % Pregnant Women
Who Correctly Identified 3 Main Causes of Anemia
(n=688; n=359 household interviews; n=329 client exit interviews)




Household & Client Exit Interviews: % Pregnant Women
Who Correctly Identified Anemia Prevention Measures
(n=688)





Household & Client Exit Interview Results: % Pregnant
Women Who Reported Selected Anemia Control Best
Practices (n=688)


Household Interviews: % Mothers of Young Children by
District Who Correctly Identified Pregnancy & Childhood
Anemia Control Best Practices
(n=251; n=121 household; n=130 client exit interviews)




Household & Client Exit Interviews: % Mothers and Pregnant
Women Who Report Specific Health Information Sources
(n=688 pregnant women; n=251 mothers)


Community Results

• Community Leader Interviews
• Community Health Worker Interviews
CHW Cadres in Mali:
• Agent de Sante Communautaire (ASC): Trained paid
CHW; provides health promotion, prevention & treatment
services; covers 1-3 villages (1,500 persons); helps
supervise RCs
• Relais Communautaire (RC): voluntary CHW recruited by
community; health promotion and prevention; 1 RC per
village (approx. 50 households; 300 persons)
• Traditional Birth Attendent (TBA)




Community Leader Interviews: % Community
Leaders Who Correctly Identified Anemia Causes
by District (n=42)


Community Leader Interviews: % Community Leaders
Report Recruiting ASC/RCs and Their Perceptions of Key
Services Provided by ASC/RCs (n=42 community leaders)

Leaders who report participating in ASC/RC recruitment: 67%
Community Leader reported Perception of Main Activities for
Leader-reported
ASC/RC:
– General health education: 60%
– Participation in SIAN: 62%
– Mosquito-net distribution: 52%
– Home or community-based ANC: 26%
y
– Home or Community-based PNC (post-natal Care):
21%




ASC/RC Interviews: % ASC/RC Who Correctly Identify
Anemia Causes (n=30)


% ASC/RCs in Urban vs. Rural Communes Who Correctly
Identify High-impact Anemia Control Interventions in
Pregnancy (n=20 rural; n=10 urban)




% ASC/RCs Who Correctly Identify Anemia Control
Interventions for Infants & Young Children (n=30)


ASC/RC Interviews: % ASC/RCs Who Report Prior
Training in Specific Technical Areas (n=30)




ASC/RC Interviews: % ASC/RCs Who Report to Routinely
Provide Specific Services as Part of Their Regular Work (n=30)


% ASC/RCs Who Report Specific Timing of Home-
based Post-natal Care Visits (# days after birth)
(n=30)




Week of Intensive Nutritional Activities (SIAN):
Key Findings by Direct Observation & Interviews

Data Collector Observation:
• Vitamin A & Albendazole (antiparasite) distribution occurs
via 3 primary avenues: Health Center (CSCOM), Village
Chief, mobile team (e.g., mosque or marketplace)
• Vitamin A distribution is much stronger than nutritional
education or anti-parasite treatment
• Nutritional Counseling activities were rarely observed as
p
part of SIAN activities
CSCOM Manager Self-reported Participation:
• 67% Kadiolo
• 29% Bougouni


% ASC/RC Who Report Participation in Specific
SIAN Activities (n=30)




Selected Health Center Results

• Manager & Provider Interviews
• Chart Reviews
• Client-reported high-impact interventions received during
antenatal, well-child, and sick-child consultations (client
exit and household interviews)





Provider Knowledge: % Skilled Maternal & Pediatric
Providers Who Correctly Identify Anemia Symptoms
& Causes (multiple choice question)
Pediatric Providers Maternal Providers
(n=5) (n=8)
Nurses, doctors Midwives, nurses,
doctors
d t
Anemia Symptoms:
Fatigue 20% (1) 50% (4)
Pale conjunctivae/skin 100 % (5) 100% (8)
(e.g., palms)
Shortness of Breath 60 % (3) 63% (5)
Anemia Causes:
Iron deficiency 20% (1) 63% (8)
Malaria 100% (5) 75% (6)
Parasite Infections 0% 25% (2)
(diarrhea/intestinal)


Maternal Provider Knowledge of Anemia Best Practices in
Pregnancy: % Providers Who Correctly Identify High-
impact Anemia Control Practices in Pregnancy
(n=8 providers)




Pediatric Provider Knowledge of Anemia Best Practices for
Infants/Children: % Providers Who Correctly Identify High-
impact Anemia Control Practices for Children (n=8 providers)


Availability Essential Anemia Control Inputs:
Laboratory, Micro-nutrient Supplements, Anti-malarial &
Anti-parasite Medications: % Facilities with Input (n=12)

% Facilities with
Essential Anemia Control Input
Input
Hematocrit Laboratory Testing 13%
Vitamine A 80%
Iron/Folic Acid (IFA) 100 %
Zinc 80%
Albendazole (de-worming medication) 87%
Sulphadoxine/Pyrimethamine (SP) for IPTp 80 %
Malaria Diagnosis & Medication
Quinine 400mg & 200 mg (Injectible) 100%
Quinine 300mg (oral) 73 %
ACT 100 %
Rapid Diagnostic Test (RDT) 100 %



ANC Chart Review Findings: % Antenatal Charts with
Anemia Control Best Practices Recorded
(n=300 Charts)

Anemia Best Practice Total
(n=300 dossiers)
Clinical Evaluation
Pregnant client questioned regarding +/- bleeding 2% (7)
Anemia symptom investigated (any) 32 % (95)
Laboratory Examination
Hemoglobin or Hematocrit recorded in chart (ever) 3% (8)
Malaria test noted ever (thick smear, RDT or other) 3% (8)
Anemia Prevention Interventions in Pregnancy
(per MOH policy )
SP prescription noted ever (IPTp) 83% (250)
Iron/Folic Acid prescription noted (ever) 87 %(261)
Deworming with Albendazole 7 %(20)
Distribution of insecticide-treated mosquito net 25% (75)




Clients Reporting Clinic ANC Anemia Control Best
Practices (n=329 ANC client exit interviews)
ANC Practice Reported by Client % Clients Who
Report Activity
Laboratory Testing
Hemoglobin level 12%
HIV test 3%
No laboratory Testing 84%
Nutritional Counseling 10%
Iron/Folic Acid Prescription/Distribution 98%

Malaria & Hookworm Best Practices
Deworming ((Albendazole) ) 8%
Bednet Counseling 30%
SP for Malaria prevention 54%
Follow-up Visit (when) 71%


ANC Chart Review Findings: % Antenatal Care
Charts/Patient Cards with Counseling Best Practices
Recorded (n=300)




Health Center Manager Interviews: % Managers Who
Report Regular Counseling/Education Activities
(n=12 managers)
Education Session Type Total Kadiolo Bougouni
(n=14) (n=4) (n=10)
Antenatal Care Consultations
(ANC) 14% (2) 0% 20% (2)
Individual Counseling only 50% (7) 25 %(1) 60 %(6)
Group Counseling only 36% (5) 75 %(3) 20% (2)
Individual & Group Counseling
Well-child Consultations (SPE)
Individual Counseling alone 7 %(1) 25 %(1) 0
Group Counseling alone 29% (4) 0 40% (4)
Individual & Group Counseling 50% (7) 75% (3) 40% (4)
No education/counseling g 14% (2)
( ) 0 20% (2)
( )
Sick-child Consultations
Individual Counseling 50% (7) 50 %(2) 50% (5)
Group Counseling 0 0 0
Individual & Group Counseling 29 %(4) 25% (1) 30% (3)
No education/counseling 21% (3) 25% (1) 20% (2)





Anemia Best Practices Received during Post-partum & Early Infancy
Clinic Visits As Reported by Mothers of Infants < 7 months (Recent or
Current) (n=66; 34 client exit & 32 household interviews)
Anemia Best Practice Reported by Mothers As % Mothers
Recieved During Post-partum & Routine Infancy Clinic Visits Reporting Best
Practice
FAF prescription (for lactating mother) 39%
Vit. A for mother post-partum 42%
Nutrition Counseling Reported by Client
Exclusive breastfeeding 39%
Nutritional best practices lactating mother 27%
Nutritional best practices infant (0-6 mos) 33%
Iron-rich foods 3%
Vitamin A –rich foods 3%
Vitamin A supplementation needs for infant 17%

Malaria & Hookworm Prevention Counseling Reported by
Clients 21%
Regular de-worming Infancy 3%
Use of insectide-treated nets
Danger Signs & Follow-up Counseling Reported by Clients 2%
Follow-up for infant (when & where) 17%
Newborn/infant danger signs

Well-child Visit Chart Review Findings: % SPE Charts (or
Patient Carnets) with Recorded Anemia or Anemia-related
Best Practice (n=100 charts; children 0-2 years)
Anemia Control Best Practice Average 2 Bougouni Kadiolo
Recorded During Routine Care Districts n=60 charts n=40 charts
n=100 charts
Growth Monitoring & Acute Malnutrition
Weight recorded 40 % 50 % 25 %
Height recorded 40 % 50 % 25 %
Weight/height % recorded 23 % 22% 25%
Mid upper arm circumference 20 % 17 % 25 %
Clinical examination for 0% 0% 0%
anemia
Vit. A Supplementation 17% 0% 43%
Child feeding status assessed 30% 17 % 43 %
(e.g., BF/not BF)
Any feeding problems noted 0% 0% 0%
Bednet counseling noted 20 % 0% 50 %
Deworming recorded 10 % 0% 25 %




Well-child Chart Review Counseling Results: % Well-child
Chart Visits (or Patient Cards) with Counseling Best
Practices Recorded (n=100 charts; children 0-2 years)


Sick-child Chart Review Findings: % Sick-child Chart (or
Patient Carnet) Visits with Recorded Anemia or Anemia-
related Best Practice (n=100 charts; children 0-2 years)
Anemia Best Practices % Charts Best Practice
General Evaluation
Weight recorded 9% (13)
Fever/temperature recorded 23% (34)
Anemia Evaluation & Diagnosis/Iron Suppl.
Anemia symptoms recorded (+ or -) 3 % (4)
Hemoglobin or hematocrit recorded (laboratory) 1% (2)
Anemia diagnosis recorded 4% (6)
Iron supplement prescribed 3% (5)
Vitamin A supplement last 12 months 16% (24)
De-worming last 12 months 18% (27)
Malaria Evaluation & Diagnosis
Thick smear or RDT recorded 59% (88)
Malaria treatment 49% (73)
Zinc if diarrhea 5% (7)



Anemia Counseling Best Practices during Well-child
Visits (7 mos-2 years): % Mothers Who Report Best
Practice (n=33 Client Exit Interviews Mothers)


Conclusions

Selected Challenges:
• Many anemia knowledge & practice gaps (beneficiaries; skilled and
unskilled providers)
• Many coverage gaps i d li
M in delivery of hi h i
f high-impact anemia control i t
t i t l interventions
ti
during critical lifecycle windows at community, household & health center
levels
• Many missed opportunities to deliver best practices (e.g., weak
counseling/BCC in established services; poor timing of post-partum visits)
• Differences between Kadiolo & Bougouni Districts (may be an opportunity if
positive deviance factors can be identified)
• Political context
Selected Opportunities:
• Defined MOH policy for anemia control & best practices
• Country initiatives: PMI, Feed the Future, etc.
• Many strong partners on the ground for many years (HKI, others)
• Many engaged community leaders & RC/ASC



THANK YOU

Expert Commentary

Questions
Q ti

Instructions for Small Group Work

53 53

Moving From Assessment to Implementation:
Group Work

• Applying Consolidated Framework for Implementation
Research (CFIR)

• Applying Breakthrough Series Collaborative Improvement
Methods (Systems-focused QI methodology)




Breakthrough Series Collaborative
Improvement Methodology



USAID Health Care Improvement Project Mali Anemia Case Study

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