Posts or Comments 28 January 2023

Monthly Archive for "September 2008"

Malaria in Pregnancy Bill Brieger | 12 Sep 2008

Malaria in pregnancy services need strengthening in Nigeria

We have discussed recently about the challenges of delivering malaria control services in Nigeria when the primary health care system is weak. Kayode Osungbade and colleagues have reinforced that concern in reporting on exit interviews among 390 women at 12 antenatal clinics in southwest Nigeria. Some key malaria-related findings included –

  • less than half of the participants, 167 (42.8%), had either haemoglobin or packed cell volume estimated
  • malaria prophylaxis were given to 25 (6.4%) pregnant women

In addition, “Majority of the respondents, 279 (71.5%), were in their second trimester at the time of booking, whereas 83 (21.3%) and 28 (7.2%) booked in their third and first trimesters, respectively.” No mention was made about pregnant women receiving insecticide treated bednets, but if such were available, this intervention would miss a crucial time for preventing malaria – the first trimester – when IPTp cannot be given.

Jhpiego recently completed a malaria in pregnancy household survey of over 1,000 recebtly pregnant women in seven local government areas of Akwa Ibom State in the southeastern part of Nigeria. Those preliminary results were not encouraging either.

  • 5.1% of ANC clients received two doses of IPTp under direct observation

  • Only six (15.4/%) ANC providers reported having seen the national MIP guidelines at their facilit

  • 23.4% women who delivered in the past six months reported they slept under an ITN during their most recent pregnancy

The challenges of integrating malaria control into pregnancy remain high in Nigeria.  Better collaboration is needed between malaria control and maternal and child health staff at local, state and national levels to ensure lives of women and their unborn children are saved.

Coordination &Treatment Bill Brieger | 11 Sep 2008

When ACT supplies fall between grants

A colleague in Bamako – home of the famous Bamako Initiative – shared an experience with one of the staff members in her organization who sought malaria treatment for a sick 3 and 1/2 year old child at a front line community health clinic.  center-sante-communitaire.JPGOn the first visit the child was prescribed quinine injection for that cost about US 28 cents.  After three days the child was still sick and returned to receive ACTs at a cost of $10.07.

This raised a few questions. Why were RDTs not used? Why were ACTs not the first line of treatment? Why did the family have to pay for the medicines?

One can answer the first question with the concern that children under 5 years can benefit from prompt and presumptive treatment as a life saving measure.  When the presumptive treatment is NOT the first line drug, one senses that the value of prompt treatment may be negated. Even though the Ministry of Health has printed and circulated malaria treatment guidelines, when one looks at the cost differences, one can get an idea of what the health worker might have been thinking – and it was unlikely to be the guidelines.

The Bamako Initiative is a community based and community managed cost recovery mechanism. The program has been working in Mali for over 15 years. This makes sense for inexpensive essential drugs. So why was the family charged what appears to be the cost of an adult dose for a small child? The ultimate answer may be that the community health service has had to buy ACTs for resale because Mali is what one might call “in between grants”.

treatment-simple-act-guidenlies.JPGThe Round 1 Global Fund Grant for Malaria wrapped up almost two years ago. The Round 6 Grant is just taking off. PMI support is available, but also in a start-up phase.

Fortunately the child ultimately got the correct ‘presumptive’ treatment, and also fortunately the parents could afford it.  This scenario may repeat itself in other countries. Therefore all partners must coordinate their efforts in a country and work together to close the “ACT gap.”

Drug Quality &Treatment Bill Brieger | 05 Sep 2008

Preserving efficacy of ACTs

Although we have been advocating for continued research into new antimalarial drugs, David Smith of the University of Florida’s Emerging Pathogens Institute says that, “We don’t have anything in the pipeline after ACTs, and it’s basically just a matter of time until drug resistance evolves and artemisinin also fails. So the question becomes how do we keep ACTs in our arsenal for as long as effectively possible?”

dscn0253.JPGSmith, a co-author on a study that is scheduled to publish online this week in the Proceedings of the National Academy of Sciences pointed out that, “The models indicate that we can slow the evolution of resistance to current artemisinin-based therapies if nations use them in combination with two or more partner drugs. Currently, most nations don’t do this. They use one therapy at a time, wait for it to fail, and then switch to a different therapy.”

Issues of cost, logistics and policy implementation are at the root of the problem. In Nigeria, for example, monotherapy artemesinin-based drugs are still available in shops, although the National Agency for Food and Drug Administration is no longer granting new licenses for monotherapies. Some of the old licenses have a few years left, unfortunately.  ACTs brought in through donor programs like the Global Fund have been targeted free for children, which leaves the door open for ‘leakage’ to the adult population who may take lower than effective doses and promote drug resistance.

The upcoming article in PNAS will explain that, “The researchers’ models also show that cycling through single drugs accelerated the rate at which malaria parasites evolved drug resistance. Smith said this occurred because cycling a single drug degraded the parasite’s average fitness, which made it easier for drug-resistant genes to spread throughout the parasite population.”

The contrast still persists with free or subsidized ACTs in the public sector, often aimed only at children and expensive ACTs in the private sector for adults. Unless a comprehensive national malaria drug policy can be implemented throughout all elements of the health sector, the threat of developing resistance to aretesinim-based medicines will persist.

Burden &Health Systems Bill Brieger | 02 Sep 2008

Health systems and high burdens

Nigeria has been classified as one of the main high burden malaria endemic countries.  The World Bank Booster program notes that the per capita investment in malaria is disproportionately low in largest high burden countries, and this threatens progress across the continent.

The results of this low level of per capita investment were highlighted by Oresanya and colleagues recently when they reported that, “Household ownership of any net was 23.9% and 10.1% for ITNs.” Furthermore, “Utilization of any net by children under-five was 11.5% and 1.7% for ITN.” The Abuja targets look a long way off from Abuja and environs.

One of the key “predictors of use of any net among under-five children … [was] the presence of a health facility in the community.” The implication is that the high burden malaria problem is not only characterized by low relatively investment in malaria control, but a similarly low level of investment in the health system through which malaria interventions can be delivered.

This assumption is reinforced in a report by Michael Reid in the WHO Bulletin stating that, “Despite several attempts at reform over the past 30 years, Nigeria still lacks a clear and coordinated approach to primary health care.” In only two years during the 30 years since the Alma Ata Primary Health Care (PHC) Declaration has the Nigerian budget for health exceeded 5% of the total, despite the formulation and reformulation of PHC policies and the training and re-training of front-line health care workers.

Recently we reinforced the point that malaria control must have a strong health system to reach all in need with life saving interventions. One wonders whether the challenge of high burden malaria countries can be addressed without major health care reform. Reid provides other disheartening documentary and interview evidence:

  • Nigeria has never learnt or developed any system of authentic and full-scale community health care before Alma-Ata or after it
  • The world health report 2000 ranked Nigeria 187 out of 191 countries for health service performance
  • Infant mortality rates have been deteriorating from 85 per 1000 live births in 1982, 87 in 1990, 93 in 1991 to 100 in 2003

Reid notes a tendency to blame the problem in part on a colonial legacy of two health systems – one for the elite and the other for the poor.  Other countries with fewer resources than Nigeria have overcome this legacy. Is it a matter of political will?

“Peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources,” according to Schellenberg et al. (2008). These peripheral facilities in Nigeria and primary health care for that matter, are the constitutional responsibility of local government in Nigeria. A visit to many of these in Akwa Ibom State last month found shortages of staff and medicines, lack of basic furniture, damaged roofs, abandoned rooms, lack of water supply and light, and staff quarters overgrown by weeds. It would appear that in high burden countries the neglect of PHC is the same as the neglect of malaria control.

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