This report, from Strengthening Pharmaceutical Systems at Management Sciences for Health (MSH), details a supportive supervision for the implementation of artemisinin-based combination therapy (ACT) in Malawi. Carried out between August 18 and September 3 2008, the supervision follows a first review in March 2008 that first explored progress since ACT was introduced in Malawi in December 2007 in all government and Christian Health Association of Malawi (CHAM) health facilities. As suggested by National Malaria Control Program (NMCP), the August/September 2008 ACT supervision activity was combined with intermittent preventive treatment (IPTp) for pregnant women, which is conducted by Access to Clinical and Community Maternal, Neonatal, and Women's Health Services (ACCESS) programme.

Five supervisory teams visited 50 government and CHAM health facilities in 5 zones. During the visits, the teams collected information on malaria case management, drug management, and insecticide-treated nets (ITNs). In addition, they mentored the staff on key weaknesses and provided other support, if necessary.

Compared to the supervision in March 2008, improvements were observed in both case management and drug management, despite the increasing number of health workers untrained in new malaria treatment policy. For example, dispensers communicated correct key messages to patients, and improved patients' awareness of the use of and timely monthly reporting for lumefantrine-artemether (LA), which is a 6-dose regimen for treating uncomplicated malaria. The evaluators found that these improvements imply the positive outcome of case management training conducted by NMCP and district health officers (DHOs), particularly in the area of giving key messages to patients.

The challenges associated with training are as follows:

• There were increasing numbers of untrained health workers in the management of the new malaria treatment policy. In all the facilities visited, 76% (662/871) of the health workers were trained in ACT; this is slightly lower than the data in March (84%). Most of the untrained health workers are newly graduated medical assistants who might use malaria treatment guidelines to update their knowledge on case management.
• Because of a shortage of pharmacy technicians, most of the facility dispensers are auxiliary staff who did not receive formal training in dispensing and record keeping. (To avoid mistakes made by dispensers, some prescribers physically fill the dispensing registers in consultation rooms according to what was prescribed, instead of training dispensers in filling them based on what was dispensed.)
• It was observed that 23% (11/47) of the facilities that received treatment guidelines had misplaced or lost them. With regard to information, education, and communication (IEC) materials, patient posters and leaflets were not available in almost half of the facilities. Only 20% of the patients/caretakers interviewed saw the posters. The reasons for not seeing the posters include unavailability of posters, not interested in reading posters, and illiteracy. Poor orientation or handover was also observed in most of the facilities, which affects case management and drug management.

The challenges related to drug management and documentation include:

• Poor reporting rate in CHAM facilities, which is affected by factors such as lack of knowledge on reporting, shortage of reporting forms, and misunderstanding on reporting.
• Poor recording in the dispensing registers in busy facilities and low submitting rate of dispensing registers, which may be due to shortage of staff and lack of training.
• Misunderstanding or confusion in some facilities on how to make the necessary adjustment when substitution of LA packages is made - The adjustment is performed when some presentations of LA are out of stock. It includes the procedures of adjustment on stock cards, labeling on the adjusted packs and instructions to the dispensers, cutting the blister packs into ready-for-dispensing packs, and recording on dispensing registers. Almost all of those in charge of drugstores were reoriented on how to adjust LA; however, not all of them were able to perform properly.
• Poor record keeping on other essential drugs and medical supplies used in the management of malaria.
• Poor archiving of drug management documents - Documents were placed randomly in flat folders, scattered, misplaced, or lost. This could affect the accountability of drug management since records could not be traced for the purpose of auditing.

The following approaches are proposed to address the challenges facing the implementation of the new malaria treatment policy:

• Providing in-service training for untrained health workers and dispensers;
• Providing pre-service and refresher trainings in reporting, adjustment for substitutions, record keeping, archiving for LA, essential health commodities, and insecticide-treated nets (ITNs);
• Participating in revision of malaria treatment curriculum in health education facilities to ensure that the pre-service training is in line with the updated treatment policy; this training for medical assistants and nurses should include the documentation, reporting, and inventory management;
• Providing job aids for inventory management and ITN guidelines to health facilities; the job aids can be used as handover tools for relief duty or take-over staff;
• Strengthening handover and information sharing systems and supervision by District Health Management Teams. Evaluators suggest that the teams establish orientation or handover procedures for relief duty staff and pay supervisory visits to the facilities that are managed by relief duty or temporary staff. Skill transferring should also be strengthened by writing reports or holding briefing meetings.

Development Experience Clearinghouse (DEC) Express, May 29 2009; and email from Cynthia Kamtengeni to The Communication Initiative on July 9 2009.