In total, eight FGDs and 20 IDIs were conducted. Five FGDs were carried out with adults (parents, guardians and teachers), and three FGDs conducted with school children who had recently sought care from an LTK dispenser.
Social demographic characteristics of participants
Of the 32 children involved in the FGDs, the youngest child was 11 years old and 75% were aged between 11 and 15 years. An equal ratio of male to female children participated in the FGDs to address any potentially diverging views relating to treatment seeking behaviour, due to a priori observation that girls appeared to be seeking significantly more LTK consultations than boys. For the adult FGDs, 32 female and 28 male individuals participated. Half of the participants were aged between 31 and 40 years, and almost 40% of participants (predominantly teachers) had obtained tertiary education. The remaining participants (60%) (predominantly parents and guardians) were primarily subsistence farmers or engaged in small-scale business. The results of the FGDs and IDIs are presented by key themes. In general, the responses of participants (teachers, parents and guardians, and children) from schools with different levels of uptake did not significantly differ, and are therefore presented together.
Understanding of the LTK by different stakeholders
Teachers, parents and guardians, school children, and healthcare workers as well as key stakeholders generally understood that the purpose of the LTK was to provide care for basic illnesses and injuries for children enrolled at that particular school during school time, rather than for other children or the wider community as a whole. The majority of community members were also aware that if a child became sick at home after the end of the school day, during weekends, or during the school holiday, it was still the responsibility of a parent or guardian to take the child to the health facility for treatment rather than to wait for the LTK to be available.
“[The LTK] It is mainly concerning the treatment of learners when they are sick at school especially on the part of malaria; we have LTK dispensers who are doing that job, they were trained by Save the Children”.
IDI with head teacher.
Teachers and education officials reported that children had developed a trusting relationship with the LTK dispensers in their capacity as both a healthcare provider as well as an educator, and that these roles were perceived as complementary rather than contradictory.
“The learners trust us more than their class teachers. Sometimes when the learner is sick, quietly s/he leaves the class for LTK room without the knowledge of their class teacher. When you tell the learner to wait for you at break time so that you can treat them, they feel that you are taking long. They want to be treated right away. They view us as teachers and doctors at the same time.”
LTK dispenser FGD.
However, it was frequently reported by teachers that parents and guardians had not initially understood the specific target and scope of the LTK, in addition to initial concerns arising from uncertainty in the teachers’ ability. Schools reported that they had commonly used community sensitization meetings to resolve these challenges, but also that once community members saw the programme in action it had been enthusiastically accepted and supported.
“There was a day when my child was sick and I was passing by. Then I had to escort my child to the LTK room, I saw exactly what the dispenser did. I did not see any problem with testing and treatment of my child. We have confidence in the dispensers because they were trained, therefore if they say that my child has malaria, I believe the results.”
FGD with parents and guardians.
Nevertheless, at times it was still difficult for parents and guardians to appreciate that the LTK was not an extension of the “village clinic”, community case management (CCM) or a component of the integrated management of childhood illnesses programme (IMCI) conducted by a salaried community health worker known as a Heath Surveillance Assistant (HSA). LTK dispensers reported that at times it was not only sick school going children who were brought to the school out of hours, but that parents and guardians themselves had also requested treatment.
“Yes, people approach us, and plead with us, that we should assist them because the health facilities where they can be tested and treated for malaria are very far. They have heard that at school, we do have malaria test kits and treatment, therefore they request us to assist them but we refuse.”
FGD, LTK dispenser.
Benefits of the school-based malaria programme
A number of benefits of the LTK were reported by children, parents and guardians, and teachers. Teachers described that apart from acquiring additional skills with regard to malaria testing and treatment, school absenteeism and the number of school drop-outs had reduced. These perceived benefits to school attendance and performance, rather than directly to an outcome in terms of health, were also shared by district and national officials as well as by children themselves. School children, parents and guardians also highlighted the fact that the LTK had relieved some of the economic burden (both opportunity and financial cost) of taking a child to the health facility.
“When you are sick, you do not have to be absent from school you still come; you go to the LTK room, receive medication and go back to class. Our parents are very happy because they are not having any problem with taking us to the health facility to receive treatment so they say they are able to save money.”
School children FGD.
“It is a great relief to us, instead of us parents taking the sick learner to the health facility for treatment, we are spared that task. The burden is lifted from us. The learner is assisted at school and attends classes.”
FGD with parents and guardians.
District and national level key stakeholders reported that the LTK was consistent with the Malawi’s School Health and Nutrition (SHN) 2008–2018 strategic plan, which aims to have “healthy school-age children who can fulfil their optimum learning potential” [10]. They recognized that school children had not previously been addressed with specific malaria interventions, and that the LTK had raised greater awareness of the burden of malaria in this age group.
“Yes, because that (school) is the contact point with children. You know previously we used to say that the most affected are the under-fives, but what we are seeing now, with this coming data: you find a nine years old, eight years, these are maybe in class 5, class 4, class 3, they are equally affected. So this study is an eye opener because it is like a shift from our previous belief that it is only the under-fives that we should focus on—those who are really greatly affected.”
IDI with NMCP official.
Additionally, stakeholders also reported that LTK dispensers had been observed providing relevant behaviour change communication messages around malaria control while conducting a consultation with a child. This was perceived to be a public benefit of the LTK to the broader community, as children were acting as message carriers into the wider community.
“There are several people that have received mosquito nets and they have misused. Since teachers are also emphasizing the use of bed nets, the child will pass on this information to the parents and we might see changes in bed net use. I think it is the right channel to pass this information.”
IDI with official from MOEST.
Healthcare workers reported that the LTK had reduced workload at the local health facilities, since some of the children who would have sought treatment there were now being managed at school. Moreover, policy makers expressed strong support for the LTK, and expressed provision for scaling up should it prove feasible.
“I think schools are the appropriate place for this mainly because it will reduce attendance at the health facilities, if we prevent these clients coming to the facilities, that means even the work load at the facility will be lessen.”
IDI with official from MOEST.
Perceived roles of different stakeholders
It was appreciated that while the roles and responsibilities of each stakeholder was different, they were broadly supporting and complementary. In particular, it was understood that teachers were now responsible to test and treat sick learners, while head teachers supported and supervised them. The MoH provided drugs and supplies, whilst the District Health Office supported teachers through supervision and mentorship. The MoEST and Save the Children Malawi provided technical support.
“We supply the schools with the malaria kits, we can supervise, train and also involve our malaria focal person. So I think it starts from the supplies, supervision and review meetings and in future we can incorporate them into our programmes.”
IDI, Senior District Health Official.
Relationship between healthcare workers and LTK dispensers
One major barrier to implementation frequently raised by participants from both the education and health sectors, particularly LTK dispensers and healthcare workers, was that there had sometimes been poor working relationships between the two groups, especially in the early stages of implementation. This had ultimately led to a common perception amongst LTK dispensers that the LTK was of low priority to healthcare workers, most notably during the collection of drugs and supplies. However, some healthcare workers expressed that this was rather due to the fact that they had been inadequately orientated.
“Initially we did not know what to do with the new programme and some teachers were sent back without supplies but after they included us in the training, teachers were supported accordingly.”
IDI, healthcare worker.
LTK dispensers expressed an expectation that they should have been supervised by healthcare workers from the nearest health facility, but that this had rarely occurred in practice. This resulted in concerns that a lack of supervision could lead to a detrimental loss of both knowledge and skills.
“Normally when you are doing an activity outside your area of expertise, you need to have mentors close. Teachers went to health facilities for mentorship but no health worker visited the schools as was required.”
IDI with MOEST official.
In the event where an LTK dispenser was unable to assist a child and had referred them to a health centre, LTK dispensers were trained to fill a referral form that would be completed by the receiving healthcare worker and subsequently returned to the LTK dispenser once the child returned to school. However, LTK dispensers frequently reported that they did not always receive feedback from healthcare workers regarding the referred children, and that parents and guardians were often not given the referral form back by health workers after having sought care. This prevented LTK dispensers from knowing what, if any, action had been taken regarding the child’s original health complaint.
‘The other problem we see is on referral, you find that our friends at the health facility, they do not give the mothers the feedback slips, we do not know whether the child we referred was assisted or not.”
LTK dispenser FGD.
Supply chain management and collection of supplies
At times where only limited supplies were available at the health facility, or where certain supplies were persistently stocked out, LTK dispensers often perceived this to be the result of health workers prioritizing the supply chain requirements of community case management of integrated childhood illnesses over the LTK. Recognizing the broader challenges experienced in effective supply management to the health sector, senior health officials expressed concern over maintaining the supply chain for the LTK without external support.
“I think this programme at school level will be difficult to run…it is a major problem to keep the LTK supplies adequate because currently government supplies are meant for health facility or village clinics.”
IDI with senior health officer.
In addition, LTK dispensers frequently raised problems regarding the availability, costs incurred or appropriateness of transport to collect supplies from the health facility. Some LTK dispensers reported incurring personal costs undertaking this task, and called for additional financial or in-kind (e.g., a bicycle) support.
“We do use bicycles but there is a challenge in the sense that if the LTK dispenser does not have a bicycle, she or he has to borrow and in cases where the borrowed bicycle is broken, the LTK dispenser should mend it at his or her cost.”
LTK dispenser FGD.
Increased workload and demand for incentives
A common challenge regarding the LTK from the perspective of implementers was the high workload created by attending to sick children, especially during the peak malaria season when the number of children seeking care was relatively high, and a perceived lack of adequate compensation for the additional work. Teachers reported that the short duration of break time (usually fewer than 30 min) was often insufficient to attend to all the children seeking care, causing teachers to be delayed in returning to their teaching duties. While some reported that the head teacher would call in another teacher to attend to the class when this occurred, it was not necessarily effective as the substitute teacher had not prepared for the lesson, and would be limited to simply supervising the class.
“We also assist by making learners quiet as they wait for their teacher who is at LTK room.”
FGD with non-LTK dispensers.
“I visited schools implementing this programme in the district and the challenge that I noticed is the workload. Teachers have to attend to their classes and the sick learners.”
IDI with Senior Ministry of Education official.
“LTK dispensers do not rest. We do not have time to rest. The moment you have gone to LTK room to treat learners you do not have time to rest because sick learners come one after the other especially from January to March when malaria cases are at a peak. Therefore, there is a huge workload it would be good if all teachers were trained to share the workload.”
LTK dispensers FGD.
All stakeholders expressed a need to increase the number of LTK dispensers trained per school from an average of three up to six, depending on the total school enrolment. This was intended as a strategy to address conflict between the LTK dispensers and non-dispensers resulting from the perception by non-LTK dispensers that LTK dispensers were not fulfilling their core duty of teaching; but also to relieve LTK dispensers of their individual workloads and hence reduce some of the dissatisfaction that they were undertaking additional work without additional pay.
“The number of trained teachers and the size of the school, that should be looked into critically otherwise they will be just treating pupils than teaching and that can create chaos in schools.”
IDI with Senior District Health Official, Zomba.
Because of the perceived increase in workload, many stakeholders expressed a need for appropriate and adequate remuneration as crucial for the LTK to be sustained. This was most commonly framed as a motivation for teachers to undertake the role, but also as a justification that the treatment of children was an additional responsibility for a teacher and should therefore be compensated as an addition to their regular salary. The most commonly suggested methods of remuneration were financial, such as monthly allowances or review meetings and training.
“My comment is that the programme planners should give dispensers incentives as you know that this work is very involving.”
LTK dispensers FGD.