Using community health workers for malaria control: experience in Zaire

Abstract

The potential for using community health workers (CHW) for administering timely and effective treatment for presumptive malaria attacks was evaluated in the Katana health zone in Zaire. In each of the 12 villages of an intervention area (area A) with 13000 inhabitants, a CHW was trained in the use of a simple fever management algorithm. The CHWs performed their services under the supervision of the nurse in charge of the area's health centre (HC). Malaria morbidity and mortality trends were monitored during 2 years in area A and in an ecologically comparable control area (area B), where malaria treatment continued to be available at the HC only. Health care behaviour changed dramatically in the intervention area, and by the end of the observation period 65% of malaria episodes were treated at the community level. Malaria morbidity declined 50% in area A but remained stable in the control area. Parasitological indices showed similar trends. Malaria-specific mortality rates remained, however, at essentially the same levels in both areas. The non-comprehensiveness of the CHWs' care and their ambiguous position in the health care system created problems that compromise the sustainability of the intervention.

PIP: Along the western shore of Lake Kivu in eastern Zaire, Katana health zone's primary health care (PHC) development plan established a pilot community trial in 1987 in 12 villages. It concerned community health workers (CHW) who provide chloroquine phosphate (25 mg/kg) treatment over 3 days for episodes of fever (i.e., presumed malaria attacks). A socioeconomically comparable area about 30 km south of the intervention area with the same malarial ecology and malariometric indices served as the control area. Malaria treatment continued to be offered at the health center only in the control area. Both areas were peninsulas. Villagers selected a literate volunteer to serve as the malaria CHW. CHWs received 2 weeks of in-service training in the area's health center. They charged no consultation fees. Malaria prevalence and incidence fell 50% in the intervention area, a significant decline. The crude parasitological index and high parasitemia index declined by 5- and 6-fold, respectively, in the intervention area compared to 2-fold in the control area. Even though mortality rates fluctuated in both areas, they remained essentially the same in both areas. The population in the intervention area had adopted important health care behavior. For example, the number of malaria episodes that remained untreated decreased 7%, while it increased 8% in the control area. In the intervention area, the number of cases treated at home and by the CHW increased 16% and use of the informal private sector fell markedly (-23%). Thus, more than 65% of malaria episodes were treated at the community level. There were problems revolving around the non-comprehensiveness of CHWs' care and their unclear position in the health care system. The major problems concerned the lack of a long-term commitment to CHWs on the part of the health care system and the failure to achieve real community participation. Even though malaria morbidity and parasitological indices were reduced and health care behavior improved, the problems compromised the sustainability of the intervention.