Bridging the Care-Seeking Gap with ProAct

Sokhna lived in the village of Missira Dantilla nestled in the rolling hills of southeastern Senegal, where the Sahelian savannah climbs to the Guinean plateau. It was 2012 and her uncle Cheikh was a community health worker proud to have recently been trained by the Ministry of Health in the use of malaria rapid diagnostic tests and how to prescribe frontline malaria drugs. The Ministry had invested in training community health workers across the country and subsidized the services they provided – tests and treatment were free.

From time to time, someone from the village would knock on the rough-hewn wooden door to Cheikh’s mud hut complaining of a fever or chills. Occasionally, it was a mystery illness that left him feeling frustrated and useless, but more often it was malaria, and his eyes gleamed as he reached eagerly into his backpack for the little blister pack of the artemisinin combination therapy (ACT) that would make all the difference.

When Sokhna fell ill, her father (Cheikh’s brother) thought little of it. The rainy season brought fevers across the village as it had in this part of the world for thousands of years. As she worsened, it seemed to be the pattern that he had seen many times before – it has to get worse before it gets better. He was wrong. She died at the age of three despite having an uncle with the correct medicine in his hut less than 100 meters away. And that medicine was free.

Matt McLaughin with Peace Corps Volunteers Karin Nordstrom, Anne Linn, and Dr. Youssoupha Ndiaye presenting a poster on ProACT at the ASTMH conference.

We live in a time of unprecedented hope for the elimination of malaria worldwide. We have a fantastic toolkit with effective medications and simple, rapid, and accurate diagnostic tests. We have also made great strides in treatment availability in recent years, bringing testing and ACTs to rural clinics and community health workers. But bringing these tools ever closer to the patient isn’t enough. There is a reality that needs to be addressed – for the medicines to be effective they must get to those who need them, even though many people who desperately need treatment will not seek it. We have a Care Seeking Gap.

Part of the issue is cultural – in many parts of the world, malaria is considered akin to the flu, and even in the US the flu vaccine is woefully underutilized. Part of it is distrust in the system – despite truly heroic efforts on the part of many Ministries of Health, supply chain management remains a stubborn, persistent problem, and in many places stock-outs are still common.

The elephant in the room of malaria prevention is that, as an international community of practice, we have no consensus plan to bridge the Care Seeking Gap between treatment availability and epidemiological need – and we need to prepare one if we ever hope to get to zero.

Peace Corps Volunteer Ian Hennessee and Cheikh Tandian with a community health group.

Deaths in the family are a time of soul-searching. When Cheikh sat despondently on the bench in his family compound looking out through the fields of millet and corn thinking about what he could have done to prevent Sokhna’s death, the answer was obvious. He would change the script about what a community health worker is: instead of waiting passively for his sick neighbors to navigate the bamboo fence maze of Missira Dantilla’s footpaths to his front door, he would be proactive and go out on a regular basis to seek them. With the help of a Peace Corps Volunteer in his village, the President’s Malaria Initiative, and the Ministry of Health, the ProActive Community Treatment (ProACT) model was born.

Under ProACT, a community health worker does a weekly sweep of his or her village, visiting each household in turn and inquiring if anyone in the household has fever or other signs of malaria. If they do, testing and treatment is administered on the spot, for free. In the 2012 pilot, ProACT identified more malaria cases in one village in one month than the local clinic (which served five villages) did in three.

In 2013, ProACT was scaled up to 15 villages in a controlled trial that showed that not only did it detect more cases and earlier than the standard of care, but relative to the comparison villages the prevalence of symptomatic malaria decreased dramatically over the course of the project – we were seeing treatment as prevention.

 Best of all, contrary to our intuition that doing weekly sweeps might demotivate care seeking – why seek care when you know the doctor will come to you? – we found people were more likely to seek care when participating in ProACT. It was building trust in the community health workers.

With these results, the Government of Senegal scaled ProACT to an entire region in 2014 and is on track to implement it in two regions this year. Peace Corps and local partners are piloting ProACT in Togo and Madagascar and looking to expand. In parallel, other innovative organizations like Project Muso in Mali have come to the same idea and are pursuing very similar models of active case finding.

The road to zero is long, and as we travel down it, there will be many Sokhnas lost along the way. No child should have to die simply because their parents didn’t know to seek care, or didn’t trust the health system to have the medicines they need. We must invest in health care delivery models that are specifically designed to reach children like Sokhna who may not seek care. It is time for ProACT to be part of the larger malaria prevention conversation.

[This entry is part of the #DefeatMalaria World Malaria Day 2015 blog series]