Ten years ago we took the challenge to scale up home based management of malaria using Rapid Diagnostic Test (RDT) and Artemisin Combination Therapy (ACT) in Senegal. Senegal was among the first countries to introduce these new tools nationwide at community level through a project called “PECADOM”. Today we celebrate the success of this intervention that has contributed to reduce dramatically the malaria burden in our country. Furthermore the DSDOMs (Home Care Providers) are now part of the health system and they play a critical role in improving health in their communities through a comprehensive package of activities. Looking back at this initiative, I would like to share here a few lessons, that I think, important to consider in developing and implementing large scale health programmes.
1. ALWAYS START WITH A CLEAR VISION
The vision underlying the initiative was very clear and this helped bringing stakeholders on board and getting their “buy in”.
2. LEADERSHIP SHOULD COME FROM THE MINISTRY OF HEALTH AND EMBEDDED AT EVERY LEVEL OF THE HEALTH SYSTEM (NATIONAL, REGIONAL ET PERIPHERAL)
The decision to implement the initiative was a made at central level by the Ministry of Health (MOH) in response to low access to malaria services in hard to reach areas, without any push from partners. The leadership of the MOH to direct and guide the process at each level of the health system, fostered the “buy in” and the ownership of the project by district health teams and local partners.
3. INVOLVEMENT IS NOT ENOUGH, GIVE ROLES AND RESPONSIBILITIES TO LOCAL AUTHORITIES ACCORDING TO THEIR MANDATE
Local administrative authorities were involved from the beginning with clear roles and responsibilities. In our case they chaired the local governance body, participated to activities and acted as champion.
4. POPULATIONS ARE NOT ONLY BENEFICIARIES; THEY HAVE THEIR PART TO PLAY
The selection of DSDOMs/Home Care Providers was done by communities themselves on the basis of a set of criteria and through a rigorous process led by the village chief, otherwise beneficiaries will not adhere to the intervention.
5. DEVELOP AND REGULARLY ADAPT GUIDELINES AND PROCEDURES
Clear guidelines and procedures were developed for stakeholders at various levels and they were revised on annual basis during the first two years to adapt the tools using lessons learnt from the field, new knowledge and new orientation.
6. BUILD A MANAGEMENT STRUCTURE THAT LASTS
The project’s management structure was built around the health system enabling regional and district teams to implement the initiative in close collaboration with others sectors and local partners, under the coordination of the National Malaria Control Programme (NMCP)
7. HAVE PASSION AND COMPASSION
The compassion and the passion that led to the design and implementation of this initiative by the NMCP were deeply felt by hard to reach communities who largely took ownership of the project and initiated by themselves measures to improve the service delivery. For instance a village built a hut for the DSDOM to perform his duties and keep his equipments and drugs in a safe place.
8. TAKE TIME TO REFLECT AND DO THINGS.
The long process of maturing the project before implementation minimized errors and increased the chances of success. Indeed, between the time the decision was made and the beginning of the pilot project, more than one year have passed. This period was used by the NMCP team to review the litterature, document other successful experiences in Africa and around the world and develop the project’s document.
9. START WITH A PILOT PHASE
It is not wise to implement such initiative at once nationwide, because if you make a mistake it will be a big one. You need to move step by step, learn and adjust. We started a pilot phase in 2008 with 20 villages and we scaled up gradually by including 100, 408, 861, and 1000 villages between 2009 and 2010. Afterwards thousands of villages were added to the list.
10. DON’T BE AFRAID TO MAKE MISTAKES AND TO RECEIVE CRITICS
As soon as the decision to start is made go ahead and implement your actions. You will never be ready at 100%, things will never be perfect. But listen, observe and follow every aspect to detect errors and weaknesses. Also be open to constructive criticism, but most importantly be very proactive in identifying challenges and finding solutions. For instance at the beginning of the project we did not provide a suitcase to keep drugs and other commodities, this was done six month later after we received feedback from the DSDOM themselves.
11. BE INNOVATIVE: TELL A NEW STORY EVERY YEAR
From a passive model of community case management of malaria an innovation called “PECADOM plus” transformed the approach to a community-based proactive malaria case detection model in 2013. Prior to that in 2012, the DSDOM’s package of activities increased with the integration of management of pneumonia and diarrhea for children under five years. Other innovations were introduced such as “PECA-Dara” i.e home management of malaria in informal Koranic residential schools.
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Dr Sylla Thiam
Public health expert