Scale-up of community-based malaria control can be achieved without degrading community health workers' service quality: the Village Malaria Worker project in Cambodia

Abstract

BackgroundMalaria control has been scaled up in many developing countries in their efforts to achieve the Millennium Development Goals. Cambodia recently scaled up their Village Malaria Worker (VMW) project by substantially increasing the number of VMWs and expanding the project's health services to include treatment of fever, diarrhoea, and Acute Respiratory Infections (ARI) in children under five. This study examined if the scale-up interfered with VMWs' service quality, actions, and knowledge of malaria control, and analysed VMWs' overall achievements and perceptions of the newly added health services.MethodsStructured interviews were conducted pre scale-up in February-March 2008 with 251 VMWs and post scale-up in July-August 2010 with 252 VMWs. Comparing the pre and post scale-up survey results (n = 195), changes were examined in terms of VMWs' 1) service quality, 2) malaria prevention and vector control actions, and 3) knowledge of malaria epidemiology and vector ecology. In addition, VMWs' newly added health services were descriptively analysed based on the post scale-up survey (n = 252).ResultsVMWs' service quality and actions significantly improved overall during the scale-up of the VMW project (mean index score: +0.805, p < 0.001; +2.923, p < 0.001; respectively). Although most of knowledge areas also showed significant improvement (between +0.256 and +0.499, p < 0.001), less than half (10.3%-47.7%) of the VMWs correctly answered a set of questions on malaria epidemiology and vector ecology, even in the post scale-up survey. About 70% of the respondents reported that their health services to control malaria remained the same or that they were more active after the scale-up. Two-thirds (66.3%) had become more enthusiastic about serving as a VMW since the scale-up, and all but one respondent reported being willing to continue the new services.ConclusionsThe Cambodian experience clearly demonstrated that a nationwide scale-up of community-based malaria control can be achieved without degrading community health workers' service quality. The government's strategy to expand VMWs' health services, while providing sufficient training to maintain the quality of their original malaria control services, could have contributed to the improvement of VMW's service quality, actions, and knowledge in spite of the rapid scale-up of the project.

Integrating child health services into malaria control services of village malaria workers in remote Cambodia: service utilization and knowledge of malaria management of caregivers

“…Independent variables included VMW’s service quality, which was measured by using a quality index [26,33] based on VMWs’ answers to survey questions. The quality index composed of five items: active detection, diagnosis and treatment, perception of anti-malarials, follow-up, and dissemination of preventive measures.…”

“…Data on VMWs’ characteristics and experience including age, sex, occupation, length of education, and working experiences were collected using a VMW survey questionnaire developed with reference to previous relevant studies [26,33]. Distance from the nearest health centre to each village was obtained from the official records collected by the VMW project.…”

“…The VMWs are then trained in malaria control interventions including prevention, diagnosis, and treatment. The CNM staff members and district health officers supply essential items, such as rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT), and they supervise and monitor VMW activities monthly [4,26]. …”

“…VMWs in M villages only provide malaria control services, but villagers visited VMWs to seek care for childhood illnesses [4]. With respect to service providers, initial findings suggested that the integration has increased VMWs’ motivation and improved the quality of their malaria control services [26]. However, no study has yet been conducted to focus on the experience of service users after the introduction of the new child health services elements.…”

Plasmodium vivax Malaria in Cambodia

“…With support from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), the CNM successfully extended access to insecticide-treated bed nets and diagnosis and treatment. In 2004, CNM piloted the Village Malaria Worker (VMW) program (community health volunteers trained by the CNM and partners to deliver malaria prevention and treatment services to remote hyperendemic villages), which was expanded in 2009 to all at-risk villages located beyond 5 km from the nearest health facilities 4–6. After initial confirmation of artemisinin resistance in 2008,7,8 a containment project was launched in 2009 along the Cambodian–Thai border (in an area defined as Zone 1, see Figure 1B for details) to increase coverage of control interventions, especially vector control (long-lasting impregnated nets [LLINs] and hammock nets) and case management, and limit factors contributing to the spread of resistance 9.…”