Category Archives: Essential Medicines

Zero Malaria Starts with Universal Coverage: Part 2 Preventive and Curative Treatments

April hosts several important global health days or observances. On World Health Day 2019 WHO stressed that, “Universal health coverage (UHC) is WHO’s number one goal. Key to achieving it is ensuring that everyone can obtain the care they need, when they need it, right in the heart of the community.” Nationwide monitoring through the Demographic and Health Surveys (DHS), the Malaria Indicator Surveys (MIS) and the Multi-Indicator Cluster Surveys (MICS) can document the status of appropriate malaria treatment and intermittent preventive treatment in pregnant women (IPTp).

Definitions of indicators have evolved for treatment-related malaria interventions. When Intermittent Preventive Treatment for pregnant women (IPTp) began in the early 2000s, the recommended dosing was twice during pregnancy after the first trimester one month apart in high and/or stable transmission areas. Due to lessening efficacy of sulfadoxine-pyrimethamine (SP), the dosage recommendation has changed to at least three times, still a month apart from the beginning of the second trimester.

This updated policy was broadcast widely between 2012 and 2013, but it took countries some time to build capacity and scale up for the expanded coverage goals. UNICEF Data5 again show that between 2014 and 2017 coverage was far below either 80% of pregnant women, let alone reaching them universally (Figure 2). Most countries achieved 30% or less coverage. Zambia at 50% was the highest. Low coverage leaves both pregnant women and the unborn child at risk for anemia and death in the former and low birth weight, still birth or miscarriage for the latter. The World Malaria Report of 2018 estimates that three doses of IPTp were received by only 22% of pregnant women in the target countries in 2017.

The concept of IPT was investigated for infants and children during by a consortium of researchers in several African Countries. It was found that IPTi with SP could have a positive effect on preventing malaria. To operationalize this concept, the World Health Organization developed what is known as Seasonal Malaria Chemoprevention (SMC) that would be delivered in the Sahel region of West Africa where malaria transmission itself is seasonal and where there are some countries with very low transmission with implications for malaria elimination.

The SMC delivery process was not linked to immunization but provided by community health workers and volunteers. SP and Amodiaquine (SP-AQ) were used in combination and provided monthly, three or four times during the rainy/high transmission season. Coverage was targeted at children below school age. It is only recently that SMC has been scaled up to reach all eligible countries or states and regions within designated countries.

WHO states that SMC focuses on, “children aged 3–59 months (and) reduces the incidence of clinical attacks and severe malaria by about 75%.” In some countries the coverage is extended to primary school aged children, making comparisons and calculations of coverage (universal por otherwise) challenging.

The World Malaria Report of 2018 notes that, “In 2017, 15.7 million children in 12 countries in Africa’s Sahel subregion were protected through seasonal malaria chemoprevention (SMC) programs. However, about 13.6 million children who could have benefited from this intervention were not covered, mainly due to a lack of funding.” This implies that 54% of eligible children were reached.  Coverage of SMC can refer to receiving any of the doses or as having received all the monthly doses offered by a nation’s malaria control program. Specifically, the World Malaria Report 2018 drew on surveys in 7 countries that provided 4 monthly doses to determine that 53% of children received all doses.

Determining coverage for malaria treatment for sick people is not as straightforward as finding out the numbers who slept under an ITN or swallowed IPTp doses, and even those are not simple. As defined, correct treatment first consists of parasitological diagnosis, which at the primary care level could be by microscopy or rapid diagnostic test (RDT). The next issue is treating only those with positive tests. Finally, the treatment must consist of age- or weight-specific doses of an approved artemisinin-based combination therapy (ACT) drug. Very few clinic records or surveys document whether the treatment given is ‘correct’ by these standards.

WHO addresses the need for achieving universal access to malaria diagnostic testing and notes this will not be easy. They provide a successful example of Senegal, where following the introduction of malaria RDTs in 2007, malaria diagnostic testing rates rose rapidly from 4% to 86% (by 2009). Logistics, funding, training and supportive supervision complicate implementation.

UNICEF Data report that performance of malaria diagnostics in febrile children in surveys between 2014-17 was approximately 30% on average for countries with national surveys within that time frame (Figure 3). Only 4 countries achieved 50% or better. Most surveys then go on to report the number of febrile children who received ACTs, but do not necessary indicate how many who were correctly diagnoses were given ACTs vs those who received ACT but did not receive a test or tested negative.

The Nigeria 2015 Malaria Indicator Survey Illustrates this dilemma. Among 2600 children who reported having a fever in the two weeks preceding the survey, 66.1% sought advice (or care). Overall, 12.6% of febrile children received a diagnostic test as defined in the question as to whether the child was stuck on the finger or heel to obtain blood. Among the febrile children 37.6% reportedly were given some type of antimalarial drug. Overall 15.5% of febrile children were given an ACT. Even if ACTs were given only to tested children, not all tests would have been positive.

The overall implication of measuring treatment without a link to testing is that if more children receive any, let alone the correct drugs, is that evidence for actual presence of disease. We have a long way to go to measure malaria treatment coverage correctly, not to mention achieving universal coverage with appropriate treatment. Different malaria treatment-related interventions with different steps and different target groups in different regions of Africa and the World make defining, no less achieving UHC, a huge challenge.

The Essential Health Service Package in Nigeria

When examining the service delivery building block of a health system we much ask what, how and where?  “What” addresses the package of services, “How” describes the mechanisms and personnel who do the delivery, and “Where” considers making services accessible in or very near the community. These are the issues explored in this case study on Nigeria. As USAID notes, “An Essential Package of Health Services (EPHS) can be defined as the package of services that the government is providing or is aspiring to provide to its citizens in an equitable manner. Essential packages are often expected to achieve multiple goals: improved efficiency, equity, political empowerment, accountability, and altogether more effective care.”[i]

Although Nigeria has held Primary Health Care as the official foundation of its national health policy since 1986, it took nearly 30 years to give legal backing to a standard service package with the legislative passage and presidential signing of the National Health Bill in 2014. The law says that “all citizens shall be entitled to a basic minimum package of health services…” defined as “the set of health services as may be prescribed from time to time by the Minister after consultation with the National Council on Health” (National Health Bill, 2014 (SB. 215)).1

Up until that time one could infer the existence of an essential medicines list for primary care through the “Standing Orders” service provision algorithms.[ii] These algorithms guide front line health staff known as community health extension workers (CHEWs) in providing quality and accurate treatment and prevention for common illnesses. The Standing Orders also form the basis for training for CHEWs. For each area, “there is a set of actions including health education, further investigation, treatment, and follow-up necessary for good client’s care.”

As an example of essential medicines, the section of an algorithm for fever management below indicates that Artemisinin-Based Combination Treatment (ACT) malaria medicines and Long-Lasting Insecticide-Treated Nets (LLINS) for malaria prevention should be part of the basic package found at the front line.

USAID describes the official service delivery system in Nigeria as organized in three tiers. Tertiary facilities operated by the Federal Ministry of Health are the highest level of health care and serve as referral centers for patients. State Ministries of Health manage secondary facilities, which provide some specialized health services. Local Government Area (LGA) PHC Departments manage primary facilities, which provide the most basic entry point to the health care system-health centers, clinics, and dispensaries. It is at the LGA level in frontline PHC clinics where the CHEWs mentioned above function and deliver the basic package. Volunteer CHW programs exist and are often run by NGOs and are poorly coordinated, although efforts in recent years have aimed at standardizing their training and activities.

In reality, Nigerians at the community level face a mosaic of health service delivery mechanisms ranging from LGA clinics and dispensaries, patent medicine shops, private clinics often run by nurses and licensed to physicians living in the city, and a range of indigenous practitioners (herbalists, bone setters) and faith healers (based in all major religious groups).[iii]

CHEW providing Essential Services

The USAID report on Nigeria’s essential services shows major challenges in health equity.1

  • Coverage is low for reproductive health, maternal health, and immunization varies widely and is strongly associated with wealth, education level, and rural versus urban place of residence.
  • On some measures, health services coverage among populations with urban residence is more than double the coverage among populations with rural residence.
  • Only about 30% of women in the poorest households receive at least one antenatal care visit, compared to over 90 percent of woman in the wealthiest households, with service coverage steeply increasing along with wealth.
  • Coverage of most key preventive and curative health services is relatively low with large disparities in geopolitical zones, between rural and urban zones, and with regard to socioeconomic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20 percent of the population.

USAID’s Health Financing and Governance Project,1 helped group the Essential Package of Care into three “service delivery modes”:

  • family-oriented, community-based services that can be delivered on a daily basis by trained community health, nutrition or sanitation promoters with periodic supervision from skilled health staff;
  • population- oriented, schedulable services that require health workers with basic skills (e.g. auxiliary nurses/midwives and other paramedical staff) and that can be delivered either by outreach or in health facilities in a scheduled way; and
  • individually oriented clinical services that require health workers with advanced skills (such as registered nurses, midwives or physicians) available on a permanent basis.

These modes come along with recommended actions which could be interventions like safe water for the family or drugs like antibiotics for child pneumonia. Therefore, at present the package focuses more on essential interventions (than essential medicines) for groups such as adolescents, pregnant women, women in childbirth, and infants and children among other populations to be reached with of RMNCH services (reproductive, maternal, neonatal, and child health). In conclusion, Nigeria has articulated its PHC service delivery in terms of what, how and where, but has some ways to go in articulating a clear essential package across the life span and ensuring equitable access to and provision of these services across the country and among all income groups.


[i] Wright, Jenna (2016), ESSENTIAL PACKAGE OF HEALTH SERVICES COUNTRY SNAPSHOT: NIGERIA. United States Agency for International Development (USAID), Health Finance and Governance Project (Abt Associates). https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-nigeria/

[ii] National Primary Health Care Development Agency (2015) NATIONAL STANDING ORDERS FOR COMMUNITY HEALTH OFFICERS/COMMUNITY HEALTH EXTENSION WORKERS, Revised By CHPRBN IN COLLABORATION WITH NPHCDA. Nigeria Federal Ministry of Health, Abuja.

[iii] Brieger WR. PHC: in search of a system that works. Africa Health 1987; 10: 30 31,26.

Burkina Faso Ensures Essential Medicines Reach the Front Line

Meike Schleiff of the Department of International Health, The JHU Bloomberg School of Public Health has explored how Burkina Faso manages to get essential medicines, including those for malaria, to the front line health services. She explains that the World Health Organization (WHO) has determined essential medicines to be, “those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.”(WHO, 2018) These medicines should be available as part of health systems functioning to all persons at appropriate amounts, affordable costs, quality standards and sufficient information assured to consumers. Every country develops an essential drug list,

In Burkina Faso, approval of modern medicines (specialty and generic), traditional pharmacopoeial drugs, medical consumables and medical biology reagents is assigned to the Drug Regulatory Directorate (DRP).

Essential Medicines in Burkina Faso are purchased and distributed primarily through the Centrale d’Achats des Médicaments Essentiels (CAMEG), or Central Purchasing of Essential Drugs system.(CAMEG, 2018) This CAMEG system operates with two agencies in Ouagadougou, and then has seven additional agencies in other zones of the country (see map). From the zonal agencies, the CAMEG supplies 67 District Dispatching Depots (DRDs), and also supplies University Hospital Centers, regional hospitals, and additional services provided by the Ministry of Health. For the private sector, the CAMEG manages supplies for NGOs, faith-based organizations, medical laboratories, pharmaceutical companies, and the Global Fund for HIV, tuberculosis, and malaria.(CAMEG, 2018)

Before the CAMEG was created, access to essential medicines and supplies was very difficult, particularly for rural and other hard to reach populations. This was due to geographical access as well as high prices for specialty drugs, limited availability of generic drugs, and prohibitive regulations against the introduction of generic medicines. In response to this situation, the CAMEG was created under a presidential decree in 1992 and commenced activities in 1994. In 1997, an evaluation was carried out to determine the impact of the CAMEG and decide whether to continue the activities through a long-term structure; the results of this evaluation proposed establishing a legally and financially autonomous non-profit entity to carry forward the work of the CAMEG.(CAMEG, 2018) Today, the CAMEG manages the selection of drug suppliers for the country, ensures compliance with WHO and national regulations on price and quality, and facilitates distribution and storage of drugs across the country. A full product list of the drugs managed by the CAMEG can be found on their website (www.cameg.com).

Medicines Reach Front-Line Health Facility

Community Level

The availability of essential generic medicines at health and social welfare centres in Burkina Faso is 74.5%, compared with an average of 40% across the African region and less than 60% globally.(World Health, 2016, Ministry of Health, 2010) For hospitals, rates are slightly lower with 61% of generics available and regional hospital centers and 39% at university hospital centers (Saouadogo and Compaore, 2010), but only 1.2% of branded medicines; this situation results in patients who are referred to hospitals from lower level facilities often being forced to purchase medicines from more expensive private pharmacies in order to receive the necessary care at higher levels of the health system.(Vervoort, 2012)

While immense progress has been made in ensuring affordability and accessibility of essential medicines in Burkina Faso, mark-ups at different points along the supply chain still result in prohibitively high prices at final points of sale; patients still pay for 37% of the cost of essential medicines and remain the single greatest healthcare cost for households in Burkina and a burden for the majority of the population who still live on less than $1.25 per day.(Vervoort, 2012)

References

CAMEG 2018. Centrale d’Achats des Médicaments Essentiels. Ouagadougou, Burkina Faso.

Ministry of Health 2010. Measuring the Price, Availability, Financial Accessibility, and Price Composition of Medicines in Burkina Faso. Ouagadougou, Burkina Faso: Ministry of Health of Burkina Faso.

Saouadogo, H. and Compaore, M. (2010) ‘Essential Medicines Access Survey in Public Hospitals in Burkina Faso’, 4(6), pp. 373-380.

Vervoort, K. 2012. Ensuring the Availability of Essential Medicines in Burkina Faso: A Shared Responsibility.

WHO 2018. Essential Medicines. Geneva, Switzerland.

World Health, O. (2016) Burkina Faso: Country Cooperation Strategy. Available at: http://apps.who.int/iris/bitstream/handle/10665/136973/ccsbrief_bfa_en.pdf (Accessed: May).