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In general, community members indicated a good level of satisfaction with community level care, despite the gaps and inconsistency in service provision. However, health facility and other higher level stakeholders raised a lack of appropriate training among community health volunteers, low access to diagnostic tests, a lack of support for referral and inconsistent availability of ACT.

A subtle mistrust of community health volunteers was also apparent which appeared to arise from an overlap of roles with facility level staff, and a lack of clarity in supervision arrangements see below :. Even when we go to their houses, they are very friendly and nice to us. The quality of care at the community level depends on their capacity. I think it is just satisfactory.

In some areas, health facility staff support to community health volunteers appeared limited to drug distribution whilst in others, there appeared to be some additional supervisory components. Health workers at both state, health facility and community levels emphasized an inefficient data flow system as well as unclear reporting requirements, with many claims of either a lack of community level reporting duties, unclear reporting lines, or infrequent or irregular reporting by community health volunteers to health facility or state levels:.

They only supervise us as when they give us drugs — that is what it is about. Referral linkage between community and health facility levels appeared to be weak, with respondents across target groups mentioning poor documentation referral notes are not routinely available , a poor feedback mechanism, prohibitive costs borne by patients for transportation and food requirements, and bad roads:. There is very poor quality in referring. The system lacks proper and clear documentation across the board. Some communities appeared to have access to a public ambulance for which patients are required to cover the cost of fuel, whilst others relied on private transport for referral.

Community-initiated fundraising efforts for which funds can be channelled towards referrals appeared to be relatively widespread. On a general level, there was existing precedence and support for the provision of incentives to support community health volunteer activity, though specific stipend amounts have varied by campaign. There was however a difference of opinion across target groups as to whether incentives should be given to CCGs for their role in the SMC drug distribution. They can be saying why the incentive and they can begin to suspect. The most important thing is that to educate the people let them understand, this malaria is there and everybody has experienced it.

Communities appeared to have a good general understanding of the signs and symptoms of malaria and the groups most at risk. Care-seeking decisions were seemingly led by knowledge of drug availability, perceived effectiveness of drugs, proximity to household, trust in the provider and associated costs of seeking treatment. The majority of community respondents said they would ideally first seek care from community health volunteers given their close proximity and familiarity, followed by chemists or other private vendors and finally health facilities or hospitals.

Opinions of male household heads ultimately appeared to influence household care and treatment decisions, which was expected given the patriarchal society in Katsina state and the dominant role of men as custodian of household financial resources. Interviewer: Like in this town, whom do you trust much and listen to?

C1: He is the one to grant the permission on everything. There appeared to be little community level demand for malaria diagnosis, with the focus remaining on access to free drugs whether malaria was confirmed or suspected. Findings indicated a high acceptability of ACT and injections for treatment of severe malaria. It was indicated that malaria prevalence can be proportionately higher among these groups compared with settled communities, yet their health-seeking at formal health facilities tended to be lower:. Y es, we know the [nomadic] population here is about people. We have about ten settlements.

Generally malaria affects nomadic population because they are living near the small ponds where they give their animals drinks. They access health care through mobile and outreach activities. Health facility worker, IDI, Baure. All groups emphasized that community support for the intervention would be encouraged by the involvement of key community stakeholders, in particular community health volunteers in this case CCGs as well as traditional and religious leaders, in the mobilization and sensitization pre-delivery as well as the actual delivery of drugs.

They frequently play a role in supporting community level dissemination of health information by health workers:. You know, it is our tradition here that our people do not disrespect their leaders, and they are living in peace, that is why it is very difficult for them to disobey them, especially when they give them certain information about something…Honestly, they trust their leaders right from district head, village and ward heads. Community leader, IDI, Baure. The masses always believe in their traditional and religious institutions, because they are the ones that are always closer to the people and they know their problems and most people do solve their financial and social problems from their advice.

Town criers, village development committees, public functions such as weddings and naming ceremonies, and media such as radio and television were also mentioned across target groups as key communication channels for announcing plans for forthcoming community activities. The majority of people listen to radio so it is important especially — the FM and state radio, it is good, a lot of jingles, a lot of message should be passed through these media houses and secondly, there is need when you see the community leaders, they should call their own village heads to have meeting so that they can disseminate information given to them, down to the grassroots.

While the data indicated lower levels of community literacy than expected, particularly among women, literacy appeared to be highest for Hausa written in Arabic script and it was suggested that materials available with this writing would likely raise acceptability. It was suggested that support would be boosted if the drugs were distributed at the most opportune time, specifically when the malaria burden is highest at the onset of the rainy season, and if efforts were taken to effectively engage with community members and leaders.

However, some informants felt that the negative experience of the polio campaign could override any positive programmatic efforts and enthusiasm for the project:. Malaria is a serious sickness, distorting the smooth running of our lives, and we are all sick and tired at the same time looking for a solution. Household head, FGD, Dutsi.

Background

The community leaders, policy makers should be involved — do you know why? This polio has spoiled everything, so any programme you have, people will suspect it. Some people will think that it is just business as usual due to their previous experience of unfulfilled promises with other organizations. The importance of emphasizing SMC as a complement to other malaria control efforts i.

Requests for clear messaging on dosages, timing of doses and possible danger signs were commonly made:. So, we can encourage the community through telling them the importance of this project. They need to understand. You see, they have to live in a very good environment, no stagnant water, no refuse dumping, using the net. They need to understand all the ways of keeping malaria down.

There was broad consensus across target groups that a community level SMC drug delivery system would better enable a high coverage of beneficiaries and garner wider community support, as compared with a health facility distribution system. Concerns were raised across informant groups however about the storage capacity and security of drugs at the community level. There were divergent views though on the most effective drug distribution method. House to work will work because the one we are doing now is house to house.

It is better. We will enlighten women that this medicine is very useful to them. The experience of the polio campaign appeared to work as both a supportive and hindering factor. Some respondents felt that familiarity with the household-to-household approach adopted under this campaign would be likely to raise acceptance of the SMC programme if the same delivery approach was used, whilst other warned of negative connotations given the high refusal rates under the polio campaign:. For me, it is house to house approach, because it has been tested and trusted during fighting for polio campaign.

The secret here is that some view it that, if they go to the hospital, they have to buy this and that, so they may likely not go. They may think it is something else, just like the case of polio… So I will not suggest house to house unless [it is] with very good promotion. A minority of respondents thought that health facilities should take the lead in the distribution of drugs, in particular where clinics are close to communities, seemingly due to assumptions of the higher technical competence of health facility staff and as a means of further encouraging health-seeking behaviour towards established clinics.

Interestingly, most health facility staff supported a community level distribution. They will be able to monitor any problems that may arise as a result of dispensing the drug. When drugs are made available, hand them over to the head of personnel in the hospital, after which people should be made aware of the availability of the drugs in question. People should be told on the days and times they are supposed to be coming for such drugs. It is important they get used to going to the facilities.

A few respondents across community, LGA and state level groups suggested a combination delivery system, with areas adopting either a health facility or community level delivery system, depending on the proximity of health facilities to their target communities:. I think from the experience two - way will help, one by delivering these drugs to the facilities, like in Dutsi LGA where they have quite a number of facilities that are closer and can take care of the communities.

Secondly, where communities are far from the facilities, you make outreach, or select an area and a village head and supply them. While respondents agreed that community leaders should play a pivotal role in the delivery of the programme, there were differing views on the most effective management and supervision of the distribution process.

Higher-level stakeholders state, LGA, health facility tended to propose management by health facility personnel so as to maintain quality control and reduce the risk of onward sale of drugs or distribution on political grounds. They have to go to CCGs and what is important is to make the community aware and sensitize them that something is coming and it is for their own good. You cannot work without the facilities at community level but, if I will advise, you have to use the traditional leader to monitor the facilities, for example, if you have drugs to be distributed for a given community, so that drugs should be channel through the facility because it is drugs and people know that anything that has to do with drugs is from the facilities they will value it most.

Then use the community leaders to put an eye on what the facilities are doing…to ensure that what is meant for the community has really gotten to them. It was emphasized by state and LGA level informants that programme planning and delivery should be integrated as far as possible into the public health system, particularly at the LGA level, so as to access critical local knowledge, to promote ownership and support for the programme, as well as to build local capacity.

Involving the community will be one of the most important steps.

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