Strengthening Primary Health Care in Rural Malawi using the Community-Directed Intervention Approach

Access to health interventions continue to be a major challenge for many people in rural settings in low income countries of the world including Africa. The revitalization of Primary Health Care (PHC) was placed high on the agenda of several international fora, and was also highlighted in the 2008 World Health Report addressing issues of poverty, equity and access to health care in rural areas. Health systems in Sub-Saharan Africa continue to be weak and suffer from inadequate mechanisms for delivering PHC services to those in most need. This has maintained the high burden of infectious diseases prevalent among the rural population. A well-functioning health system is the backbone to supporting health programmes, and creating healthy populations. Health systems’ strengthening was recognized as a vital element in the global health agenda to achieve the Millennium Development Goals (MDG) and now evolved to Sustainable Development Goals (SDG). Community participation in health programmes has shown that it enhances their sustainability and affordability compared to non-participatory programmes. Initiatives such as community-directed interventions (CDI) the community takes charge of the process of planning and implementing the interventions. The CDI approach was used to distribute Vitamin A and insecticide treated nets (ITN) as well as in home management of malaria (HMM) by community volunteers in areas with prior experience with the community-directed treatment with ivermectin (CDTi) for onchocerciasis control. CDI has recently been used in control and treatment of schistosomiasis and soil transmitted helminths (STH) in rural Kenya. However, limited knowledge is available about its added value for strengthening PHC services in geographical areas with no experience in CDTi. This implementation research project was aimed to study how best and in which way the CDI approach could be used to strengthen identified areas of PHC in a rural setting. Designed as a comparative two-arm study, where intervention CDI/PHC strategy at community level in addition to EHP/PHC; and comparison EHP/PHC strategy only were respectively implemented and evaluated over a period of 12 months. The findings have shown that implementation of CDI strategy at community level in addition to EHP/PHC is both feasible and acceptable with no significant differences in intervention coverage between the arms. The CDI strategy can complement the regular EHP efforts especially where personnel and geographical barriers exist. Faced with acute shortage of trained health workers in many healthcare systems, CDI is a viable alternative for the delivery of essential health services in rural hard to reach areas. However, for maximum outcomes, the design and implementation of interventions have to take into consideration the critical factors and adapted to suit with local conditions.