The study by Ayodele Jegede and colleagues “Evaluation of a capacity building intervention on malaria treatment for under-fives in rural health facilities in Niger State, Nigeria” provides a rigorous evaluation of a standard “cascade training” intervention.
The intervention followed the classic global health model where national experts trained state trainers who then trained local government area facilitators who were supposed to train frontline health workers.
The results expose deep structural flaws in this approach.
The most damning finding was the “reach gap.”
Despite the intervention being fully funded and implemented, the cascade broke down before reaching the frontline.
Only 54% of the health workers who actually treat febrile children reported receiving the training.
The transmission of knowledge stopped at the facility in-charge level and did not filter down to the lower-level cadres who manage the bulk of the patient load.
Consequently, the study found no statistically significant difference in appropriate treatment practices between the intervention and control groups.
The study also illuminated the persistence of the “know-do” gap.
Even where testing rates increased, appropriate treatment did not necessarily follow.
A critical finding was that while health workers in the intervention arm correctly withheld artemisinin-based combination therapies (ACTs) from children who tested negative for malaria, they frequently substituted them with other inappropriate antimalarials or antibiotics.
This suggests that the training taught them the technical rule (“no ACT for negatives”) but failed to teach the adaptive clinical skill of how to manage a negative diagnosis and patient expectations.
Finally, the study highlighted the futility of training in the absence of system support.
Significant stock-outs of Rapid Diagnostic Tests (RDTs) and ACTs occurred in the intervention facilities.
On many visit days, half the facilities had no ACTs available.
The authors conclude that capacity building cannot be an isolated activity and must be embedded within a functioning supply chain and health system.
Analysis through the lens of learning science
This study provides the empirical “counter-factual” that justifies TGLF’s evidence-based rejection of the cascade training model.
It illustrates precisely why a digital-first and direct-to-learner approach is necessary from an epidemiological and operational perspective.
Overcoming transmission loss
The finding that the cascade reached only 54% of workers is a powerful argument for TGLF’s networked learning approach.
By using digital platforms to connect directly with individual health workers on their own devices, TGLF bypasses the “frozen middle” layers of hierarchy where cascade training stalls.
TGLF does not rely on a facility manager to pass on a message but invites both the frontline worker and the manager to join the conversation directly.
From rote compliance to critical thinking
The behavior of the health workers who stopped giving ACTs but switched to other inappropriate drugs demonstrates the failure of “single-loop” learning.
They learned the what (do not give ACT) but not the why or the how (clinical reasoning and stewardship).
TGLF’s “double-loop” learning model addresses this by engaging workers in peer dialogue about why they feel compelled to prescribe drugs for negative cases.
This might include patient pressure or fear of complications.
The model helps them develop strategies to manage those pressures rather than just memorizing a guideline.
Resilience in the face of system failure
The study shows that stock-outs rendered the training ineffective.
In a traditional model, the health worker is a passive victim of these stock-outs.
In TGLF’s “challenge-based” learning model, a worker is likely to be the first one to identify “frequent stock-outs” as their primary challenge.
The network would then connect them with peers who have solved similar supply chain issues.
This might be through better forecasting, redistribution from nearby clinics or advocacy with district officials.
TGLF aims to transform the worker from a passive recipient of training into an active agent of system change who can navigate the very barriers that defeated the intervention in Niger State.
Reference
Jegede, A., Willey, B., Hamade, P., Oshiname, F., Chandramohan, D., Ajayi, I., Falade, C., Baba, E., Webster, J., 2020. Evaluation of a capacity building intervention on malaria treatment for under-fives in rural health facilities in Niger State, Nigeria. Malar J 19, 90. https://doi.org/10.1186/s12936-020-03167-y
Reda Sadki (2024). Why does cascade training fail?. Reda Sadki: Learning to make a difference. https://doi.org/10.59350/j8vg0-yng46
Reda Sadki (2024). What is double-loop learning in global health?. Reda Sadki: Learning to make a difference. https://doi.org/10.59350/s4xtw-b7274