The introduction of rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs) dramatically expanded access to prompt and effective case management of malaria in sub-Saharan Africa. However, inhabitants of remote, rural areas still face substantial challenges in accessing care, including geographical, educational, and financial barriers, resulting in reduced effective malaria case management . In rural Senegal prior to the introduction of community case management for malaria, roughly 90% of fever cases were first treated at home, and only 20% of cases received formal care . Introduction of community case management has been an attempt to address these obstacles. In many scenarios, community case management has improved outcomes for childhood malaria, diarrhea, and pneumonia, and for all-cause child mortality [3–5].
Senegal was one of the first countries to bring diagnosis with RDTs and treatment with ACTs to scale at the community level . The country has a long-standing system of informal community-based health huts (cases de santé), begun in 1977, supported by a network of non-governmental organizations and staffed by several cadres of community health volunteers. ACTs were introduced at the health facility level in 2006, followed by RDTs in 2007 . In health huts, ACTs and RDTs were introduced in 2008. To further address barriers to care, the Senegal National Malaria Control Program (NMCP) introduced home-based management of malaria for individuals all ages, known by its French acronym of PECADOM (prise en charge à domicile). Selected villages at least 5 kilometers away from a health facility and not served by a health hut chose a community member to be trained on case management of fever with RDTs and ACTs. This cadre of community health worker (CHW) is known as a DSDOM, or dispensateur de soins à domicile. After a 20-village pilot in 2008 , the program was scaled up to 408 villages in seven of Senegal’s 14 regions in 2009 and 861 villages in nine regions in 2010 . Since then, it has been scaled up to over 2,000 villages in 10 (of the 14) regions with higher transmission considered to be remote (≥ 5 kilometers from a health facility) or with other difficulties in access to health facilities. In 2012, after extensive discussions with other divisions of the Ministry of Health and Social Welfare and with financial and technical partners, the NMCP and partners piloted the integration of management of diarrhea and pneumonia for children under five years into the program, and trained existing CHWs over the next three years to diagnose and treat diarrhea and pneumonia among children under five years .
Despite improvements in access to care , limits were noted in the PECADOM strategy, especially due to low utilization. Even with the presence of trained health volunteers in communities, care seeking was sub-optimal. Inadequate supervision and frequent stock outs were additional challenges noted during the first four years of PECADOM [10, 11].
The Kedougou region of Senegal provides an excellent example of the challenges facing remote, rural areas. Situated in the southeast of Senegal, with a regional capital 685 kilometers from the capital city of Dakar, bordered by Mali to the west and Guinea to the south, Kedougou region had a population of 151,715 in 2013, with 9 inhabitants per km2 . Most inhabitants are subsistence farmers, though artisanal gold mining provides a livelihood for many. While Senegal reported a national annual malaria incidence in 2016 of 24 per 1000 inhabitants, reported annual malaria incidence was 300 in Kedougou region . In 2010, Kedougou region had the highest all-cause child mortality and malaria parasite prevalence in Senegal .
In 2012 and 2013, the health district of Saraya (in Kedougou), in partnership with the U.S. Peace Corps, the President’s Malaria Initiative, and the NMCP, piloted a proactive case management component to the PECADOM program during the approximately 20 weeks of malaria transmission season. In the proactive model of PECADOM, known in Senegal as PECADOM Plus, CHWs and their communities chose one day each week to conduct household visits, or “sweeps”. Some community members (usually women)were trained to identify symptoms of malaria and assisted CHWs in identifying residents in need of care. During the sweeps, CHWs attempted to visit every household in the community to identify residents with fever or history of fever during the previous two days. Every resident identified with fever or history of fever was tested by RDT, and those with positive RDTs received an ACT. In 2012, during the high transmission season (from August to November), PECADOM Plus was piloted in the five villages of the catchment zone of one health post; 563 symptomatic people received RDTs during active sweeps, of which 404 were positive (71.7%), and all positives were treated with ACT. While sweeps started in five villages, unfortunately, shortages of RDTs and ACTs shortly after sweeps began necessitated limiting weekly active sweeps to a single particularly remote village for the majority of the transmission season. Adequate supplies of RDTs and ACTs were secured shortly before the end of transmission season to carry out an end of season sweep in all the villages. During the end of season sweep, the prevalence of symptomatic, RDT-confirmed malaria cases was six times higher in the neighboring villages in which a CHW was present but not conducting active sweeps than in the village in which sweeps had occurred weekly .
A 2013 trial included 14 intervention and 15 comparison communities (one CHW per community) in which sweeps were conducted at baseline, midline, and endline, and in which a CHW was present for consultation through the standard passive PECADOM model, but not conducting active sweeps. During the 21 weeks of the trial, CHWs in the 14 intervention communities performed 1,036 RDTs during active sweeps, of which 62.4% were positive and treated with ACTs. The prevalence of symptomatic, parasitologically confirmed malaria infection during the weekly sweeps was comparable at baseline in intervention (1.88%) and comparison (1.58%) villages, but at endline, during the 21st week of sweeps, this prevalence was 16-fold higher in comparison than intervention villages . In addition, the number of RDTs performed by CHWs between sweeps (indicative of care seeking) more than doubled in the intervention villages. With these results, the NMCP adopted PECADOM Plus as a strategy, and introduced it to all the PECADOM villages in the region of Kedougou (132 villages) in 2014, adding the neighboring similarly high transmission Kolda region in 2015 (total 246 villages), and the remaining high transmission regions of Tambacounda and Sedhiou in 2016 (total 708 villages) (Fig. 1). While the NMCP considers Tambacounda and Sedhiou to be part of the highest transmission zone, along with Kedougou and Kolda, transmission is lower in Tambacounda and substantially lower in Sedhiou (Fig. 2). Diagnosis and treatment of diarrhea and pneumonia among children under five years was incorporated into the active sweeps in 2014. Other interventions also took place during this period: long lasting insecticidal nets (LLINs) were distributed in Kedougou in July 2013, in Kolda in November 2013, and in Tambacounda and Sedhiou in May 2014, and again in all four regions in March 2016. The Ministry of Health adopted a policy of free care for children under five years in 2014. Seasonal malaria chemoprevention (SMC), which in Senegal targets children aged 3 to 120 months, was fully implemented in all four regions starting in 2014; with four rounds in Kedougou (July – October) and three rounds in Kolda, Tambacounda, and Sedhiou (August-October).
This case study describes the implementation process of the PECADOM Plus model in Senegal, results from the 2014–2016 scale up, lessons learned, and recommendations for future study and implementation. Data collected from both the active sweeps and the regular passive case detection and case management activity of the CHWs are presented, with a focus on the malaria data. The impact of the program on the number of malaria cases diagnosed at the health post level was not measured, as it was not possible using programmatically collected data to differentiate cases from PECADOM Plus and non-PECADOM Plus communities.
PECADOM Plus model and implementation
Successful implementation of this strategy required a comprehensive approach to training, supervision, supply chain, and communication, and included the following activities:
Orientation of the regional health management teams (RHMT) and district health management teams (DHMT) in a regional workshop to share the guidelines of the strategy. This orientation equipped the management teams to organize their personnel at the level of the district for implementation and monitoring.
Training of health post chief nurses (HPCN): The DHMT, supported by representatives of the RHMT and a representative of the central level, organized workshops to train the HPCN who supervised the CHWs on the guidelines and the implementation of PECADOM Plus.
Selection of community supervisors: Usually experienced CHWs, these individuals liaised between the CHWs and health posts, provided supervision, and facilitated both reporting and supply chain management.
Training of community supervisors and CHWs: The CHWs and community supervisors, the key players in the implementation, were trained by the DHMT, supported by a member of the RHMT and a representative of the NMCP. The classroom training included modules on the PECADOM Plus approach, malaria, diarrhea, acute respiratory illness (ARI), and monitoring and evaluation.
Practical training of CHWs at health posts: After the classroom-based training at the district level, CHWs participated in 15 days of practical training at the health post supervising them. This internship allowed CHWs to practice RDT performance and breath counting for pneumonia diagnosis, as well as correct treatment. (Of note, CHWs not participating in the proactive component receive the same training.)
Supplies for CHWs: After the practicum, the CHWs were provided with equipment (timer, thermometer, bag, cap, vest, T-shirt, case register, badge) and supplies (RDTs, ACTs, oral rehydration solution (ORS), zinc, and dispersible amoxicillin) to enable them to carry out the planned sweeps.
Communication / awareness: Each HPCN met with community leaders to inform them about the work of the CHWs and the weekly sweeps, and to obtain their support. CHWs educated community members on the services provided through PECADOM Plus, prevention, early treatment seeking, and adherence to treatment. The CHWs selected community members (usually women) in each cluster of households, whom they trained on malaria symptoms and danger signs, and who assisted the CHWs in identifying people needing care.
Weekly household sweeps: Once every week during the malaria transmission season, the CHWs went door to door to every household in their respective villages to detect, test, and treat or refer suspected cases of malaria, diarrhea or ARI. Any suspected case of malaria (determined by a fever or history of fever in the last 48 hours) received an RDT. A thermometer was used to measure the temperature. All cases of uncomplicated malaria without indication for referral were treated with ACTs. Patients with negative RDT, temperature greater than 39.5 °C, signs of severe disease, children under 2 months, pregnant women in the first trimester, or in case of stock-out, were referred to the closest health facility. Children diagnosed with diarrhea were treated with ORS and zinc and those diagnosed with pneumonia were treated with amoxicillin. If the CHW had a stock out of tests or any treatment, weekly sweeps continued, and residents were referred to the health post if the RDT or medication needed was not on hand.
Supervision: Supervision was planned to be conducted every week by the community supervisor, every month by the HPCN, and quarterly by the DHMT. Community supervisors were requested to visit each CHW weekly, or in areas where larger distances separate their CHWs, every two weeks, observing their weekly sweeps, giving feedback, recording summary data, and making sure they had supplies. Community supervisors often brought supplies to CHWS.
Remuneration: Both CHWs and community supervisors received a stipend for each day of work ($5 for CHWs and $10 for community supervisors), similar to what was paid for similar level of effort for a day of work during public health campaigns. They also received funds for transportation to coordination meetings and telephone credit to facilitate communication.
Supply chain: Needs for RDTs and ACTs were estimated for PECADOM Plus villages prior to the transmission season, and the NMCP worked to assure that districts ordered and received sufficient quantities of RDTs and ACTs for the community level for the transmission season. Other sections of the Ministry of Health and partners were responsible for medications to treat pneumonia and diarrhea. Community supervisors mentored CHWs in monitoring their supplies and often facilitated resupplying CHWs. Supplies were received from the supervising health post.
Coordination: Monthly coordination meetings included the CHWs, community supervisors, and HPCN. At the district level, the district medical officer (DMO) met with the DHMT and the HPCNs monthly. At these meetings, the status of the implementation, constraints and difficulties encountered, and proposed solutions were discussed. The NMCP PECADOM focal point participated in these meetings by remote conferencing, and was responsible for reporting to the NMCP Coordinator any constraints noted in the implementation and proposed solutions.
Monitoring and evaluation: Monitoring was done at three levels: by community supervisors, HCPN, and DHMT. An evaluation meeting was held after the malaria transmission season to share experiences among the various stakeholders. During these workshops, districts presented the results of the PECADOM Plus program, analyzed the implementation, and identified the strengths, weaknesses, lessons learned, and recommendations. In addition to these workshops, the results of PECADOM Plus program were annually published in the NMCP bulletin and have been disseminated internationally at scientific meetings [17, 18].
Integration of development partners and non-governmental organizations (NGOs): While led by the NMCP, RHMT, and DHMT, PECADOM Plus benefitted from the involvement and support of development and NGO partners. In the early scale-up of PECADOM Plus in Senegal, Peace Corps Volunteers played integral roles in training, supervision and mentoring of CHWs, facilitating communication and supply chain, and participating in the monitoring and evaluation component.