When Benin recorded its first case of COVID-19 on March 16, 2020, the country’s health authorities understandably pivoted to pandemic preparedness and response activities to protect people from the coronavirus.
But the pandemic threatened progress in the fight against malaria. According to the 2018 Benin Service Availability and Readiness Assessment (SARA 2018), the mosquito-borne illness remains the leading cause of mortality among children under five years and of morbidity among adults in Benin, accounting for more than 39 percent of adult medical consultations. Disruptions to primary healthcare and malaria prevention and treatment efforts could have deadly consequences.
Prior to the pandemic, there was already a gap in the provision of malaria interventions. Although health facilities had supplies like rapid diagnostic tests (RDTs) and intermittent preventive treatment in pregnancy, the percentage of health workers who adequately provided malaria prevention, diagnosis, and treatment services was 38 percent in 2018, the latest year for which data is available (SARA 2018).
As COVID-19 began to spread in Benin, the Integrated Health Services Activity, led by Management Sciences for Health with support from the U.S. Agency for International Development through the U.S. President’s Malaria Initiative, mobilized financial and technical support to Benin’s health zones to ensure that essential health services and malaria interventions continued throughout the pandemic. In particular, the activity continued working with the Ministry of Health (MOH) and partners on a process called On-site Training and Supportive Supervision (OTSS), which aims to improve staff performance in health service delivery.
Addressing performance gaps at health facilities
In health facilities across the departments of Ouémé, Plateau, Alibori, and Atacora, OTSS began with an assessment of the steps health workers took in providing health services, from registering incoming patients to diagnosing and treating malaria. By randomly selecting patient cases, the activity evaluated the way health workers analyzed their malaria samples and performed their work.
Following this initial assessment, the activity supported health zones to establish Quality Improvement Teams (QITs), which coach and mentor health facility staff responsible for addressing performance gaps. Alongside the QITs, the activity coached health workers on reaching national standards for malaria case management, including the correct use of RDTs and microscopy and the appropriate administration of treatments. In the context of COVID-19, these coaching and mentoring sessions were shortened and socially distanced and required the use of masks and hand sanitizer.
The visits were helpful for raising the quality of healthcare for malaria, said Dr. Félicienne Founkè Tayéwou, Head Doctor in the commune of Kétou, Plateau.
“For the integrated management of malaria, the coaching implemented by the activity and use of the OTSS tool helped stakeholders to effectively respect the national protocol for malaria care, from welcoming patients to performing each step of rapid diagnostic tests and providing a definitive diagnosis, whether the patient is suffering from uncomplicated or severe malaria. With OTSS, we see how each step is important, it makes us more attentive to the expiry date of RDTs and helps us to better supervise our staff. We really find this support helpful to improve the quality of care provided in Kétou.”
Following the initial coaching visits, the QITs jointly developed quality improvement plans with health facility staff. These plans identify gaps, propose time-bound solutions, and assign tasks to individuals, allowing QITs to monitor progress over time. The QITs also made ongoing phone calls to health workers to provide additional support while reducing physical contact during the pandemic.
Targeting underperforming health facilities, the activity reached 61.7 percent (184 out of 298) of all health facilities in the four departments. In 2021, the activity will implement OTSS in the remaining health facilities and provide at least one follow-up visit to 90 percent of the facilities targeted in 2020.
Better staff performance results in better health services
This year’s efforts to improve staff performance and the quality of malaria services contributed to several important results:
70 percent of activity-supported health zones met the minimum standard of clinical malaria care across the four departments;
The percentage of health zones meeting the minimum standard of malaria diagnostic test performance increased from 68 percent in December 2019 to 91 percent in September 2020; and
The number of children under five years receiving artemisinin-based combination therapy without a confirmed diagnosis using a malaria diagnostic test decreased from 40,092 in 2019 to 13,442 in 2020.
Mireille Keira, a midwife at the health center of Adjarra, Ouémé, who benefited from the activity’s coaching visits, observed, “My commune faces many challenges regarding the quality of care. All indicators were very low, including for the care of uncomplicated malaria. After the activity provided a first round of coaching, indicators slowly started to improve. We implemented QITs that now meet to discuss the indicators and how to improve them.”