BackgroundThe rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi.Methods and FindingsGovernment-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths.ConclusionThis first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs.

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.

Health surveillance assistants (HSAs) in Malawi have provided community case management (CCM) since 2008; however, program monitoring remains challenging. Mobile technology holds the potential to improve data, but rigorous assessments are few. This study tested the validity of collecting CCM implementation strength indicators through mobile phone interviews with HSAs. This validation study compared mobile phone interviews with information obtained through inspection visits. Sensitivity and specificity were measured to determine validity. Using mobile phones to interview HSAs on CCM implementation strength indicators produces accurate information. For deployment, training, and medicine stocks, the specificity and sensitivity of the results were excellent (> 90%). The sensitivity and specificity of this method for drug stock-outs, supervision, and mentoring were lower but with a few exceptions, still above 80%. This study provided a rigorous assessment of the accuracy of implementation strength data collected through mobile technologies and is an important step forward for evaluation of public health programs.

ObjectivesFew developing countries have the accurate civil registration systems needed to track progress in child survival. However, the health information systems in most of these countries do record facility births and deaths, at least in principle. We used data from two districts of Malawi to test a method for monitoring child mortality based on adjusting health facility records for incomplete coverage.MethodsTrained researchers collected reports of monthly births and deaths among children younger than 5 years from all health facilities in Balaka and Salima districts of Malawi in 2010–2011. We estimated the proportion of births and deaths occurring in health facilities, respectively, from the 2010 Demographic and Health Survey and a household mortality survey conducted between October 2011 and February 2012. We used these proportions to adjust the health facility data to estimate the actual numbers of births and deaths. The survey also provided ‘gold-standard’ measures of under-five mortality.ResultsAnnual under-five mortality rates generated by adjusting health facility data were between 35% and 65% of those estimated by the gold-standard survey in Balaka, and 46% and 50% in Salima for four overlapping 12-month periods in 2010–2011. The ratios of adjusted health facility rates to gold-standard rates increased sharply over the four periods in Balaka, but remained relatively stable in Salima.ConclusionsEven in Malawi, where high proportions of births and deaths occur in health facilities compared with other countries in sub-Saharan Africa, routine Health Management Information Systems data on births and deaths cannot be used at present to estimate annual trends in under-five mortality.

BackgroundMalawi ratified a compulsory birth and death registration system in 2009. Until it captures complete coverage of vital events, Malawi relies on other data sources to calculate mortality estimates. We tested a community-based method to estimate annual under-five mortality rates (U5MR) through the Real-Time Monitoring of Under-Five Mortality (RMM) project in Malawi. We implemented RMM in two phases, and conducted an independent evaluation of phase one after 21 months of implementation. We present results of the phase two validation that covers the full project time span, and compare the results to those of the phase one validation.Methods and FindingsWe assessed the completeness of the counts of births and deaths and the accuracy of disaggregated U5MR from the community-based method against a retrospective full pregnancy history for rolling twelve-month periods after the independent evaluation. We used full pregnancy histories collected through household interviews carried out between November 2013 and January 2014 as the validation data source. Health Surveillance Agents (HSAs) across the 160 catchment areas submitted routine reports on pregnancies, births, and deaths consistently. However, for the 15-month implementation period post-evaluation, average completeness of birth event reporting was 76%, whereas average completeness of death event reporting was 67% relative to that expected from a comparable pregnancy history. HSAs underestimated the U5MR by an average of 21% relative to that estimated from a comparable pregnancy history.ConclusionsOn a medium scale, the community-based RMM method in Malawi produced substantial underestimates of annualized U5MR relative to those obtained from a full pregnancy history, despite the additional incentives and quality-control activities. We were not able to achieve an optimum level of incentive and support to make the system work while ensuring sustainability. Lessons learned from the implementation of RMM can inform programs supporting community-based interventions through HSAs in Malawi.

AbslraclThe paper applies the travel cost method (TCM) to estimate the value that rural households in the Steelpoort subbusin ot" South Africa place on river and collective tap water. While the TCM calculalion.s are based on the (ipportuniiy cost ot the time household members spend on water collection, tbe resulting weltare values are close in magnitude to tbe estimates obtained using a contingent valuation method (CVM) on tbe same sample. The paper shows thai in die absence ot price data, the TCM providessatisfactoryestiniatesot benefits where direct estimation of demand elasticity would otherwise be impossible. According to botb metbods. households consuming river water attribute higher value to the resource than collective tap users. The income elasticity of ibe irip generating function is mucb higher than that of tbe opportunity cost of time (price), implying that household's water use behaviour would be more responsive to factors affecting household income than lo price incentives. Comparing Ibc esiimaled values witb actual operating and maintenance cost of water provi.sion in tbe study area suggests that policies promoting cost-covering water tariffs bave a potential to succeed.

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Fruits and leaves of Persia americana are used in traditional medical practices. This study was carried out to determine the antibacterial, antifungal, and antidiabetic effects of the leaf extracts from P. americana. The antibacterial activities of the leaf extracts were evaluated against Klebsiella pneumoniae and Staphylococcus epidermidis while antifungal activities were determined against Candida albicans and Candida tropicalis. The antidiabetic potential of the extracts was determined against mammalian α-glucosidase in vitro. The broth microdilution method was used to investigate the antibacterial and antifungal susceptibility of the microbial strains towards the leaf extracts. S. epidermidis was the most susceptible microbe out of the tested microorganisms. The acetone extract was the most potent extract against S. epidermidis with a minimum inhibitory concentration (MIC) of 50 μg/mL. At 100 μg/mL, the ethanol:water extract 18% of K. pneumoniae cells remained viable. Cell viability after exposure to the dichloromethane (DCM) and methanol extracts was 28% against C. albicans and 8% against C. tropicalis, respectively. The DCM:methanol and acetone extracts caused membrane damage in S. epidermidis exhibited by protein leakage. Only the acetone extract effected nucleic acid leakage. Screening of extracts’ potential to inhibit the activity of α-glucosidase was carried out spectrophotometrically following the production of p-nitrophenol from p-nitrophenol-glucopyranoside (substrate) at a wavelength of 405 nm. Out of all the tested extracts, the methanolic extract showed the best inhibitory activity on α-glucosidase enzyme in a time-dependent and dose-dependent manner. K i and K inact values were found to be 1.4 mg/mL and 2.4 U/min, respectively, after incubation for 1 hour. It was concluded that the leaf extracts of P. americana contain phytochemicals with antibacterial, antifungal, and α-glucosidase inhibitory effects. Further studies are required for the identification of the active compounds in the leaf extracts responsible for these observed effects.