How ASRI eliminated malaria and prevented TB patient dropout

Guest blog by Clare Wolfowitz, Ph.D.

What works? Carefully designed community outreach works. And community capacity-building works. Here’s how.

Outreach: introducing mosquito bed nets

In 2009, Health In Harmony's partner Alam Sehat Lestari (ASRI) obtained 4,000 mosquito nets from the Against Malaria Foundation, to combat persistent malaria in the region, as one of their most common diagnoses. What followed is a remarkable success story. The mosquito net distribution — like all ASRI programs — integrated health care with both conservation AND education outreach.

ASRI’s Community Outreach Coordinator, Etty Rahmawati, led two distribution meetings, in each of 23 villages. At the first meeting, she explained the importance of using bed nets; and she distributed polybags to each household for growing small tree seedlings, to be returned to ASRI as payment for the bed nets. (While health care should be accessible to all, the ASRI team understood that such payments play a role in the perceived value of health care, as well as representing an important contribution.) Then, two months later, Etty held a second meeting in each village, where community members had the opportunity to exchange their tree seedlings for bed nets. After demonstrating how to use the nets, Etty used her storytelling gifts to explain the importance of forest conservation — and tree-planting — in combating malaria. (A study in Brazil had found that just a 4 percent decrease in forest cover led to a 50 percent increase in malaria rates.)

The result of this intensive outreach was dramatic. The nets were indeed properly used, and malaria cases sharply decreased - in 2010 and 2011, the clinic did not see a single local case of malaria. And today ASRI's Executive Director, Monica Nirmala, reports that malaria diagnosis has essentially disappeared.

Distributing bed nets to community members | Photo: Ted Ullrich

Capacity-building: mobilizing community health workers

How did ASRI achieve close to 100% compliance in tuberculosis treatment? And why is this critically important?

Treating tuberculosis is notoriously difficult. But effective treatment is critical not only to prevent the development of resistant strains but also to reduce the rate of infection of family members and others in the community. Treatment requires each patient to continue taking daily medication for six months — long past the point when they are symptom-free. Therefore, the established protocol is “directly observed treatment,” by either giving medications directly at a treatment center or having a family member give the medication. But these two approaches have not proven to ensure sustained patient compliance.

So — ASRI adopted the “Avon calling” approach. In 2007, Health In Harmony Founder, Dr. Kinari Webb, recognized that tuberculosis was endemic in the region and that treatment presented a challenge. Thus, as almost its first program, ASRI hired and trained someone in each village to (1) visit tuberculosis patients in their homes, on a daily basis, and (2) report accurately on medication compliance. Moreover, in order to keep their jobs, these community health workers were required to have perfect performance records themselves, since a single missed dose might jeopardize the treatment’s success.

As a result, in the first year, the patient dropout rate declined from 50 to 18 percent. It continued to drop each year, to eventually reach less than one percent — even while treating hundreds of tuberculosis patients every year.

Community health care workers who treat patients with TB | Photo: Kinari Webb

Thank you for making this amazing progress possible!


About Clare Wolfowitz

Clare is the Vice President of the Health In Harmony Board of Directors. She spent several years living in Indonesia but currently resides in Washington, DC.


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