Tropical Health Matters

Philippa West and colleagues have demonstrated yet again that ownership of an insecticide treated bednet (ITN) does not guarantee that people are protected. Their study in Muleba District, one rural district in northwestern Tanzania points out the universal challenges of universal coverage.

In the study district the proportion of households (HH) owning ITNs increased from 63% to 91%.  The average number of ITNs per HH also rose from 1.2 to 2.1. The problem was that even with more nets in more homes, the proportion of residents actually sleeping under them did not rise to reach the desired target of at least 80%.  As an aside – statistical significance was achieved, but not program significance.

Here is what they found in the community from before and after universal coverage distribution:

• proportion of all residents sleeping under ITNs rose from 41% to 56%
• children under five years old – 56% to 63%
• pregnant women  – 55% to 63%

What was happening? One crucial finding was that 42% of households and fewer nets than the number of sleeping spaces and 20% had more than enough.  This speaks poorly to pre-distribution planning and HH registration or lack of care and verification during the actual distribution.

Another explanation documented by the researchers was that a fair number of HH did not redeem their net coupons at the distribution point – too busy, forgot, no transportation, etc. The program could have benefited from community directed distribution which guarantees that villagers take care of and ensure their own supplies of basic health commodities like ITNs.

These findings do not come as a surprise. Numerous reports from Demographic and Health or Malaria Indicator Surveys have shown a similar phenomenon – ownership of a net by the household does not guarantee that people actually use them.  In particular we can see this problem in the attached chart from the Tanzania 2010 DHS.

Fortunately the distribution in Muleba, though having problems, was equitable in terms of the economic status of recipients. Better planning, health education, community involvement and follow-up is required  if we are not to waste millions of dollars, not to mention lives, from poorly distributed nets.

The International AIDS Conference in Washington, DC, this week is attracting major media attention daily. The implications of the presentations go beyond one disease and address important health systems issues. Those presentations that address both HIV/AIDS and other infectious diseases like malaria are of particular interest when considering integration as part of health systems strengthening.

Integration in Service Delivery

Gebru and colleagues share experiences from Ethiopia. Community health extension workers integrated services at the household and showed that, “Integrating malaria program with HIV/AIDS at community level has brought health benefits among PLHIV. We have learned this project it is cost effective and advances efficient use of human and material resources. We also learnt that insuring active participation and involvement of HIV infected people is very instrumental for successful integration of Malaria activities with HIV care and support program.”

Efforts to re-energize integrated clinical care in Zambia were presented by Mugala et al. With PEPFAR support they expanded enrollment, conducted mobile outreach and ensured that HIV, malaria and other maternal health services were integrated throughout the district.

Researchers in Kenya reported on provision of integrated preventive services to people living with HIV/AIDS and noted that, “The provision of LLIN and a water filter in the context of routine HIV care is associated with a significant delay in C D4 decline and represents a simple, practical and cost-effective method to delay HIV-1 progression in many settings.”

Integration in Diagnostics

A Ugandan experience with integrated community HIV testing campaigns was shared by Chamie et al. A 5-day campaign provided point of care screening for HIV, malaria, TB, hypertension and diabetes. They were able to reach 74% of the adult population, found undiagnosed conditions and proved the feasibility of integrated testing.

Echete and co-workers shared experiences in strengthening rural health center laboratories in Ethiopia. Lab staff were trained on HIV, TB, and malaria diagnosis and received follow up supervision and performance checks. While they found integrated laboratory services could be brought to remote areas, they also cautioned on the need to guarantee sustainability.

From these few examples, we can see that integration helps improve quality of care, ability to reach out to communities and even improves quality of life for community members.  More operational research is needed to identify additional synergies that arise from integrating and malaria services.

Efforts to eradicate smallpox and guinea worm have taken generations.  In both cases there was a very clear and focal transmission pattern. Smallpox spread only among people and could be stopped with a very effective vaccine. Guinea worm again only infects humans and transmission can be stopped through safe water.

Unlike these other diseases malaria has no one silver bullet and transmission dynamics vary across many different environment types.  At present case containment that was successful in ending smallpox and is effective in guinea worm, is out of the question for malaria.  Malaria must deal with huge health systems challenges ranging from weak procurement and supply management systems to health workforce shortages.  Peak efforts at malaria control have also unfortunately coincided with a world economic downturn.

Documentation of malaria control progress is ongoing, if not perfect. A look at indicators from three national DHS/MIS surveys in Uganda make it possible to show how difficult it is to achieve and sustain coverage of the interventions we do have. To date the Roll Back malaria targets of 80% have not been achieved for any indicator, and in the cases of using insecticide treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp), there have been drops.

There are a number of ways to measure indicators.  For example, the figures for people who slept under any kind of net are better than those using only ITNs. On the other hand, if we used the data on taking Artemisinin-based combination therapy (ACT) within 24 hours of fever onset, then the figures would be worse.  Of course these figures do not even include whether treatment occurred after a positive rapid diagnostic test.

What we can see is that even with a little more positive nudge, the data are not encouraging.  The guinea worm eradication effort has shown that stakeholders do tire of maintaining disease control efforts year after year.  Many endemic countries are still much too dependent on external assistance to go it alone in eliminating malaria. What will it take to get malaria control and elimination back on track so we can achieve zero malaria deaths by 2015?

The World Bank has announced a project in Nigeria to map the location of high risk populations in order to target interventions more effectively. According to the Bank, “In Nigeria, populations at greatest risk for HIV comprise 3.4% of population but account for up to 40% of new infections.” We hope that such efforts will help decrease disease and not increase stigma and discrimination. But clearly, mapping is an important tool to understand a health problem.

Mapping on the broadest sense has been undertaken for malaria.  An earlier incarnation of African mapping was MARA, which was founded on the idea that mapping could help target resources.  More recently the Malaria Atlas Project (MAP) has tried to refine the mapping process drawing on a wide variety of epidemiological studies in endemic countries. MAP has moved beyond Africa and looks at both P. falciparum  and  P. vivax.

Detailed country maps from MARA and MAP on a country by country basis help us see different transmission and seasonal patterns of disease.  From this we can target regions in a country that may benefit more from indoor residual spraying or intermittent preventive treatment.

The interesting thing about malaria is that transmission can vary even on a micro level.  Urban malaria is a case in point, where there are fewer anopheles mosquito breeding sites in densely populated urban slums, and more in areas where people have gardens.

Even in rural areas transmission can vary by proximity to the watery breeding sources of mosquitoes. Factors ranging from deforestation to rice farming play a localized role in transmission mapping. This should lead to spatial targeting of interventions.

We need to carry mapping and thereby appropriate interventions to the community level to have the greatest effect. At present we are of lucky to get any supplies of malaria commodities into a country and distributed to the next administrative level.  Micro mapping and planning may sound like a dream in this context, but if we are to succeed in eliminating the disease, we may need to carry the fight from one neighborhood, hamlet or block to the next.  Such surveillance is the key to a malaria free future.

When the Affordable Medicines Facility malaria (AMFm) was conceptualized, designers clearly identified several ‘supportive mechanisms’ that would be needed at the country level. In particular guidance called for “RESPONSIBLE INTRODUCTION: IN-COUNTRY SUPPORTING INTERVENTIONS” [1] in five key areas:

• National policy and regulatory preparedness
• Wholesaler incentives and pricing/margin-control mechanisms
• Public education and awareness (IEC)
• Provider training
• National monitoring and quality preparedness (resistance monitoring, pharmacovigilance, and quality surveillance)

The planners envisioned the need to, “Train health professionals and private wholesalers/retailers to promote safe and effective use of ACTs, including diagnosis, prescription, and treatment,” since many of these would be in the private and/or informal sector without the benefit of more orthodox health training or recent updated in-service training. Such training could also reinforce other supportive interventions such as consumer education and adherence to recommended pricing levels.

AMFm was designed as a two-year ‘pilot’ to determine subsidized antimalarials could get into the market – both private and public – in such a was as not only to increase overall supply of quality medicines, but also drive out more expensive and inappropriate drugs. As the project comes to a close at the end of this year, many people are looking to see if it would make a difference.

Earlier this year Yamey, Schäferhoff and Montagu [2] raised the question – what would AMFm’s success look like.  Would the subsidized quality drugs really ‘crowd out’ the costlier share of the market?  In the process they too addressed the importance of supportive interventions, noting that, “In addition to the price subsidy, the AMFm involves supportive interventions aimed at boosting ACT use, including in-country branding and associated awareness campaigns for sellers and patients, training for ACT providers and greater access to rapid diagnostic tests for malaria.”

Now a preliminary report has come out looking at the outcome issues of Artemisinin-based Combination Therapy (ACT) availability, affordability, use and market share. [3]  A key finding so far has been that, “It is notable that the major benchmarks for success for the upstream indicators of availability, price and market share of quality-assured ACTs have been met or exceeded in 6 of 8 pilot countries, particularly in light of the short implementation period.”

The Advisory group was concerned that, “the evaluated implementation period in each pilot was less than 12 months for assessing the full combined effect of the three components of the model: (i) manufacturer negotiations; (ii) buyer co-payment; and (iii) supporting interventions,” but were excited that even with such drawbacks, progress was evident.

They focused their definition of the ‘supporting interventions’ on consumer education and awareness (IEC/BCC) and provider training and observed that these were, “integral to assuring success of the program objectives of increasing availability and market share and decreasing price” of quality ACTs. They found that “Pilots with higher achievement had the following characteristics: longer period of co-paid ACTs in-country with simultaneous implementation of key supporting interventions (i.e., IEC/BCC and provider training) …”

The initial model for AMFm envisioned that almost 20% of the grant should be devoted to these supportive interventions, and the pay-off seems to be confirmed. The training component will become even more crucial as malaria rapid diagnostic tests (RDTs) become a more common part of provider skill sets, especially those in the private sector.

Not every health management problem can be solved by training and education, but the AMFm experience seems to show that these are crucial components in a comprehensive program to increase access to affordable quality medicines.  Whether the actual structure of AMFm continues past this year or not, we need to take the lessons and apply them in guaranteeing that those in need receive appropriate and affordable malaria medicines at the closest point of care.
[1] Technical Design for the Affordable Medicines Facility-malaria. November 2007. Prepared with guidance from the AMFm Task Force of the Roll Back Malaria Partnership. http://rbm.who.int

[2] Yamey G, Schäferhoff M & Montagu D. Piloting the Affordable Medicines Facility-malaria: what will success look like? Bull World Health Organ 2012;90:452–460.

[3] Expert Advisory Group on the Affordable Medicines Facility-malaria (AMFm) Review of the AMFm Phase 1 Independent Evaluation Preliminary Report Friday 22 June 2012, Geneva

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations. Report by James Kisia, Kenya Red Cross.

Jayne Webster of the London School of Hygiene and Tropical Medicine as the Malaria in Pregnancy Consortium shared a tool that helps identify and address barriers to the delivery of malaria in pregnancy services.  She referred to the tool as “An innovative ‘soft’ technology, a decision-making tool to improve the effectiveness of the delivery of IPTp and ITNs.” The tool is still under development, but key components were presented.

Jayne noted that there are still research questions to answer on how to effectively implement interventions, but while we are waiting for these questions to be answered there are improvements in data collection, collation and use to be made and used for decision making.

Jayne said that we must use the wealth of knowledge we already have to start to take action and make improvements! She took us through the work in progress of a decision tool for use by health managers to assess country and/or sub-national barriers and priority actions required for effective scale-up of the IPTp and ITNs. The tool will eventually be available on the Malaria in Pregnancy Consortium website.

Nancy Nachbar of Abt Associates presented her experiences on Malaria in Pregnancy: The role of the private sector. She said we must talk about the complete health system. If we fail to consider the private sector, we are not considering the whole system!

Half of care for fever or Diarrhea is happening in the private sector- and much of this is happening in the informal sector. Those who are poorer are utilizing the informal sector for treatment seeking. Unfortunately we lack similar utilization data for antenatal care.

Nancy discussed challenges to private sector participation from the public sector perspective as well as from the private sector perspective. She also discussed opportunities for improving private sector participation in MiP prevention. Nancy incited and excited us to think about way out ideas. One creative idea: Could tithing be used as a funding source for malaria in pregnancy?

A key factor to tie these presentations together is the need to develop tools to assess and guide not only the public sector, but also private health care providers on malaria services to pregnant women.

During its final day the Malaria in Pregnancy meeting in Istanbul addressed barriers to achieving malaria in pregnancy (MIP) goals at four levels: community, district/facility, national and global.

The Global Level Group  looked at global issues.  At the Global Level there is need to stress and strengthen multiple intervention package for antenatal care including malaria in pregnancy services. The group stressed that we can learn from the HIV community who promote PMTCT in ANC to and thus better promote MIP interventions in ANC.

The group also emphasized the need revise global guidance on essential drugs so Sulphadoxine-Pyrimethamine (SP) is used only for IPTp in MIP, not for malaria treatment. The group noted that there are many manufacturers of SP, but are not part of WHO pre-qualification (drug quality) process – improve quality of MIP drugs.

The Global Group observed that it takes long time for policies and evidence to filter to local level – need speed up dissemination of MIP information. The group  also pushed for harmonization of MIP guidance needed even within global organizations like WHO. We must also identify and address inconsistencies in MIP policies and messages from global level to health facility level.

They recommended MIP champions to help prioritize high burden malaria and maternal mortality areas and promote scale-up MIP services. This champion or advocacy process should take advantage of global fora and initiatives such as ‘Every Woman, Every Child’, Woman Deliver, ALMA and GMHC to share the latest evidence based information on MIP. Global advocacy should also include  publications in international journals like The Lancet on MIP and ANC packages.

The National level working group pointed out confusing guidelines as a major barrier to IPTp uptake. We cannot always wait for clarification from international partners, they noted – What to do while we wait? We we do update guidelines we need to ensure representation of all programs when updating guidelines (malaria, RH, MCH) for malaria in pregnancy. Also, countries need to simplify MIP guidelines based on learning about their own implementation barriers that can be easily overcome locally.

At national level we must focus on more than guidelines. We also need harmonized training and Monitoring and Evaluation across programs (malaria, RH, MCH) on malaria in pregnancy service delivery. At present there is often ack of coordination and harmonization across programs for that deliver MIP services. We must sit together but also harmonization implementation.

The group addressing district and facility level barriers to MIP service uptake called for user friendly services. They noted that health services must also be ‘friendly’ to the provider. In order to retain providers we must also address quality of life for staff.

Standards based management/performance improvement processes at district and facility level based on incentives including recognition may not only enhance MIP performance but give staff at these levels the tools needed to identify and solve their own problems using locally available resources and ideas.

Better tracking of commodities is needed to ensure that clients are not disappointed. We can redistribute commodities like SP within or among districts to ensure services succeed. We must prioritize SP provision as part of an essential ANC supply package.

The group stated emphatically that traditional cascade training out, that we need innovative and facility based approaches like champions at facility and text based training for malaria in pregnancy instead. Clinical mentoring and checklists can help promote malaria in pregnancy service skills, which can lead to greater consumer satisfaction and utilization.

Even when there has been traditional workshop based training the problem is that staff are often not trained on national guidelines. There is need for supervision that is also based on guidelines, not the personal beliefs and references of the supervisors. Also, without the commodities, staff can not practice what they learned.

The community focused working group started with a recognition that the ‘knowledge’ problem is a two-way street. It is not only that community members may not understand our scientific approach to defining, treating and preventing malaria. We too may fail to communicate with the community and create demand for services because we do not understand their perspectives.

The community group suggested that we combine community resource people and media and private sector actions for comprehensive malaria communication.  Mass medial can reinforce information that is shared by trusted community leaders and health volunteers.

The group debated the cost problems communities face in in accessing MIP servivces. This may include direct costs of services in some countries as well as indirect costs to the family. Women’s access to funds and income need to be considered, hence collaboration withy other sectors of the development community such as micro-finance.

The problem of linear communication from health workers to community without learning community knowledge and dialogue can be overcome if health workers are encouraged to engage in deeper dialogue with mothers, fathers, grandmothers and community leaders and become learners first, before they hope to teach about MIP.

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations. Report by James Kisia, Kenya Red Cross.

Innovative approaches to identify and apply context-specific interventions were discussed by Marcia Castro of the Harvard School of Public Health. She looked at the prevention of malaria in pregnancy with a multi-level modeling approach. She also addressed barriers to IPTp uptake spatially (geographic mapping), and considered three levels:

• Woman:
• Considered education,
• bednet ownership and income
• Facility:
• Considered access, quality and characteristics
• Cost is largely not an issue but distance and waiting time are
• Fewer women per health facility means more uptake
• She discussed the fact that measurement of quality remains poor—as we don’t understand various perceptions of quality
• District:
• Considered the proportion of district area covered by roads, and
• ANC facilities per 1000 women of childbearing age in district

Marcia pointed out that there is more to the story than access; roads do not equal access but lack of roads could serve as a proxy for isolation. She discussed the process of tracking pregnant women that can be used for planning and supply chain management.

Intermittent Screening Treatment (IST) offers a promising intervention in low transmission countries as well as high burden countries as they move closer to elimination (Consider the vivax context). In areas where IPTp may be abandoned due to low/decreasing risk and replaced with active case management, screening with RDT is likely to identify most infections in pregnant women

Ultimately we need to give greater importance of bridging the gap between ANC attendance and actually receiving IPTp.

Ib Christian Bygbjerg of the University of Copenhagen presented “Malaria in Pregnancy: Threats, opportunities, and new technologies.” He addressed both eHealth and mHealth.

ehealth is many things including electronic health records, telemedicine, consumer health informatics, knowledge management, and mhealth. WHO Bulletin had a whole issue on eHealth in May 2012, showing the growing importance of technology.

There is an obvious opportunity for mHealth because phone connections have more than tripled in past 10 years globally. An example of a program is ‘wired mothers’ —good results for maternal health generally, but can it work for malaria in pregnancy?

Cell phones raise Ethical questions. They were designed for communication, not health. Who picks up the phone? Who reads the text message? Who owns your data?

mhealth is an under-used and under-researched tool. Ib said his group found no results from pubmed for “malaria” and “mhealth”. More operations research needed!

Ib Shared an smartphone app on emergency management of post partum hemorrhage—and asked what would an app for management of MIP look like? Would it be useful?

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations. Report by James Kisia, Kenya Red Cross (with Bill Brieger)

Assessing the effectiveness of delivery of IPT and ITNs: Lessons from Mali and Kenya was the topic presented by Jayne Webster of the London School of Hygiene and Tropical Medicine as the Malaria in Pregnancy Consortium.

Jayne explained the process by which a woman goes to ANC to get IPT and ITNs. Her presentation looked at the effectiveness of intermediate processes as well as indicators for maternal health programming. Her analysis revealed that delivery for both IPTp and ITN interventions are ineffective in both countries.

Stock outs are not the only issue; even where in-stock, delivery was still ineffective. Providers lack of knowledge; misinformation was a major barrier. Content of IPTp guidelines must be reviewed for inconsistencies and clarity. Supervisors may even contradict national guidelines.

Guidelines themselves may be restrictive. In Mali they confine IPT to 4-8 months of pregnancy only, and health workers are even reluctant to give IPT in the 8th month.

Delivery of ITNs during ANC is better than IPTp. Many missed opportunities – even if women attend, they may not get the SP tablets. Giving IPTp as directly observed treatment rarely practiced.

An analysis of achievements and limitations to meeting women’s comprehensive needs during pregnancy was presented by Rifat Atun of the Imperial College using a systems approach.  He said we need complex systems approach to heath innovation that addresses perceptions, scalability, opportunity, and whether the innovation is desirable or threatening.

Unfortunately health systems tend to suppress innovation. We often ignore consumer perspectives and demand which can drive innovations.

He pointed out the Inequities in funding for malaria control—often not in line with burden of disease. Much of our funding goes into delivery systems, so we need to focus innovation on these systems.

He explained that innovation takes a long time to diffuse into the system using example lemon juice for scurvy which took 200 years for the Royal Navy to adopt. IPTp has been an innovation that has been also slow in adoption – not necessarily in terms of policy, but in terms of actual implementation. Malaria in pregnancy receives only 2% of Global Fund malaria funding.

Some of the key barriers to diffusion of an innovation include a linear view of innovation, limited evidence, imbalance in health and financing policies (not enough emphasis on demand, inadequate incentives, etc.), and institutional logic He explained that integration is a complex process; not binary.

We must consider what is being integrated and why? The communities need to feel that they are part of the solution and then they will join in the delivery of the innovation.

This panel helped us focus on the systems and processes that inhibit MIP service delivery even if women do attend ANC.

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations by James Kisia, Kenya Red Cross.

The first roundtable of the second day was moderated by Koki Agrawal of MCHIP. Key lessons were the need to strengthen ANC as a platform for IPTp and ITN delivery. We need to address how to get the ANC systems funded—not just the interventions. Dr Agarwal challenged the panel to examine how to better measure processes that facilitate the delivery of care and to consider taking service beyond the walls of the health facility… and building stronger linkages between the facility and the community. We must develop indicators for quality of care and integration of programs

Viviana Mangiaterra of WHO explained that there are systematic issues in MIP; little investment has been realized (Global Fund has been doing most of the funding and is currently getting reorganized to increase technical guidance on MIP interventions as well as delivery mechanisms). There are different entry points – each provides opportunities for improvement in continuum of care. We must strengthen at different levels (for ex: CCM) to influence process

Mary Hamel of CDC demonstrated variations and contradictions in WHO guidelines on IPTp which can translate to country-level and implementation level confusion. She explained that, in the face of confusion, health workers are likely not to want to do harm—and, hence, do nothing. A simple clarifying memo from the Ministry of Heakth to health staff can help reach the desired level of IPT uptake.

Susan Youll of PMI talked about major challenges of poor data availability, stock outs. SP is not included in “tracer” commodity; not tracked in the same way other essential drugs are tracked. She discussed the negative effects of hidden fees for ANC services and the impact of this on IPT uptake and encouraged promoting the role of community to create demand.

Elena Olivi from PSI said of Nets that —“funding, funding, funding!” – is the answer. She reminded us of the overwhelming evidence that the biggest contributor to decrease in malaria cases was nets and cited by World Bank study on Kenya. Net delivery mechanisms are established and known. Nothing fancy about it! ANC is one of many platforms to deliver nets. She cited an example of nets treated like medicine with a prescription, enabling better tracking and forecasting. Behavior not an issue; knowledge about nets not a barrier to usage. There are technical champions for nets (PSI). The Advocacy community has not recognized the severity of the funding crisis—and lack of incentive to make bednets truly longlasting!

In conclusions, international partners have found that malaria in pregnancy cannot be controlled without basic resources and commodities. Advocacy is needed.