The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.
So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.
Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.
Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.
We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.
Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..
Andrianandraina Ralaivaomisa, Eliane Razafimandimby, Jean Pierre Rakotovao, Lalanirina Ravony Harintsoa, Sedera Aurélien Mioramalala, Rachel Favero, Katherine Wolf, Patricia Gomez, Jocelyn Razafindrakoto, and Laurent Kapesa of MCSP/Jhpiego (Johns Hopkins University Affiliate), the Madagascar Ministry of Public Health and USAID presented their findings about febrile illness care seeking in Madagascar at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Details follow below.
Malaria Care and Treatment in Madagascar is hampered by low perception of malaria risk among caregivers. There is use of self-medication and a lack of health provider knowledge about malaria prevention and treatment in pregnant women. Low-quality care in primary health facilities is another concern (Source: WHO. 2015. Guidelines for the treatment of malaria, 3rd ed.).
As seen in the attached, Study Objectives focus on Caregivers and Pregnant Women as well as Health Providers to determine barriers to effective care seeking of febrile illnesses.
Both Qualitative and Quantitative Approaches were used. Among care seekers we conducted 16 focus group discussion sessions with 128 caregivers and pregnant women. There were also in-depth interviews with 32 pregnant women and 16 caregivers of children under 15. For Health Providers we conducted in-depth interview with 32 public and private health providers and administered 16 knowledge tests and case studies to health providers. We also reviewed logistic management information system records with 16 health
Health Provider Practices were also studied. They had low adherence to national guidelines for fever and malaria case management. Health workers reported high stock-outs rates of critical commodities (artemisinin-based combination therapy, artesunate). There was also lack of respectful care. Fortunately health provider diagnostic practices included 100% compliance with rapid diagnostic testing in cases of fever. They took temperatures and did physical exams appropriate to client’s symptoms and used microscopy at centers with local laboratory
General Bottlenecks to Timely Care Seeking still existed. There was insecurity due to political situation in some regions. Inability to pay for care or medications was common. Alternative health behaviors included seeking care with traditional healers, and self-medication. There was fear by clients of going to health facilities and inaccurate perceptions of care provided by formal health care system
Recommendations start with the need to train providers and CHWs on national treatment guidelines for managing fever in all age groups and in pregnant women. Efforts are needed to strengthen onsite provider mentoring and supportive supervision and improve respectful care of clients, especially in public sector. Since care seeking still based on cultural norms, there is need to strengthen community/family education about febrile illness dangers and advantages of timely care seeking. Communities can also consider forming “mutuelle” community insurance schemes to relieve cost of care burden.
This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.
Kate Klein as part of her Master of Science in Public Health program in Social and Behavioral Interventions at the Johns Hopkins Bloomberg School of Public Health undertook a study of the potential for private sector involvement in malaria prevention in Ghana. She shares a summary of her work here. During her practicum in Ghana she was hosted by JHU’s Center for Communications Programs and its USAID supported VectorWorks Program. Her practicum she was also supported by the JHU Center for Global Health, and she presented her findings in a poster at the CGH’s Global Health Day on 30th March 2017. Her essay readers/advisers were Dr. Elli Leontsini (Department of International Health) and Kathryn Bertram (Center for Communication Programs).
Malaria is endemic in all parts of Ghana and significantly burdens families, communities, and economies. Malaria remains a leading cause of morbidity and mortality in Ghana; it accounts for eight percent of deaths in the country (The Global Fund, Ghana). It was also responsible for about 38% of outpatient visits, 27.3% of admissions in health facilities, and 48.5% of under-five deaths in 2015 (Nonvignon et al., 2016). In Ghana, the estimated cost of malaria to businesses in 2014 alone was estimated to be US$6.58 million, and 90% of these were direct costs (Nonvignon et al., 2016). Malaria leads to reduced productivity due to increased worker absenteeism and increased health care spending, which negatively impact business returns and tax revenue to the state (Nabyonga et al., 2011).
Although long-lasting insecticidal treated nets (LLINs) are a well-documented strategy to prevent disease in developing countries, most governments, including Ghana, lack the resources needed to comprehensively control malaria. The Global Fund (GF), USAID/President’s Malaria Initiative (PMI Ghana), and the United Kingdom Department for International Development (DfID Ghana) are the main donors for the national malaria control strategy and have worked primarily with the public sector (World Malaria Report, 2015). As government funding remains unable to close the funding gap for malaria, there is an increasing need to revitalize the private sector in sales and distribution of this life-saving technology.
Ghana is looking to the private sector to encourage a departure from previous dependence on donor-funded free bed nets. The Private Sector Malaria Prevention (PSMP at JHU) project is being implemented in Southern Ghana to increase commercial sector distribution of LLINs. Three case studies served as a situation analysis and exemplified the potential for the PSMP: a rubber producing company, a mining company and a brewery.
All three had experience in malaria control and prevention but only one had specific experience with LLINs (which dovetailed well with its own corporate strengths in logistics management as exemplified by other bottling companies in Africa). Another supported the idea of adding LLINs to its existing indoor residual spraying and community health education efforts, but needed to consider how to develop the flexibility to engage in multiple malaria interventions.
The third had had the right climate and leadership to be able to partner with PSMP, but recently underwent a takeover by a large multinational brewing company and the resulting period of transition could potentially complicate their participation in LLIN distribution efforts from a budgetary standpoint. Generally these companies had the understanding of the potential benefits to the company of situating malaria control within their structure, and thus being early candidates for adoption of the PSMP.
While the three case study companies recognized the business case for malaria, this was not a unanimous opinion among other five companies interviewed. Their concerns ranged from a preference toward treatment interventions to concerns expressed by employees about the difficulty of achieving high levels of net usage due to an array of complaints surrounding sleeping under LLINs. Some of these others had financial constraints.
Through case studies and interviews PSMP was able to identify various challenges moving forward as well as areas where further clarity must be sought. PSMP learned that several companies are pouring their resources into strong treatment and case management programs, and one challenge will be determining how to push for preventative action, such as LLIN distribution, when treatment mechanisms are so established and bias exists.
For those companies who are making tremendous strides in malaria prevention, bringing recognition to these successes through advocacy will be necessary for encouraging future participation and convincing other similar employers of the benefits of starting their own LLIN distribution programs. Finally, PSMP needs to prioritize clarifying viewpoints on LLIN efficacy and use, with a focus on understanding why employers may hold unfavorable views and what it would take to overturn them.
In the future it will be necessary to move beyond the occupational considerations specific to mining and agro-industrial operations and consider how the work has changed the environment into a malaria habitat and the non-traditional work hours that may create more significant Anopheles mosquito exposures. PSMP should gather specific information on lifestyle, housing, and work environments during future visits with employers so that companies that have the most to gain through LLIN distribution are identified and targeted.
The technology of insecticide treated nets (ITNs) to prevent malaria has been around for over three decades. ITNs have evolved from a process of semi-annual soaking and impregnating nets with a safe insecticide at the household or community level to long lasting insecticide-treated nets (LLINs) where the insecticide is integrated into the nets during the manufacturing process. The challenge has always been guaranteeing enough currently treated nets to cover the population and impede malaria transmission.
Recently Rwanda announced its intentions to establish LLIN manufacturing in-country. The Ministry of Trade and Industry has begun screening of bidders. The government’s main rationale for this move is projected the need for a large and continuous supply of LLINs in the country through 2020, “making it a prudent to set up a production plant in the country.” When this information was shared with our malaria/tropical health update mailing list a number of readers expressed interest and hope that their own governments would follow suit. This post provides some background for readers to consider.
The idea of locally made mosquito nets is not new. MacCormack and Snow documented that, “95% of people were already sleeping under locally-made nets,” in The Gambia in the 1980s. Likewise in Burkina Faso it was common to find nets made from imported materials or local cotton that were sewn by local tailors.
The idea of drawing on the combination of local or regional textile and chemical industries to produce an ITN kit containing both net and approved insecticide for home/community soaking was tested in several countries by the USAID sponsored NetMark project between 1999–2009. Although the project made ITNs available at reduced prices and resulted in gains in awareness, ownership, and use of nets, “none of the countries reached the ambitious Abuja targets.”
Even at reduced prices the ITNs made available through this commercial sector approach were still more expensive than most families could afford. In addition partway through the project the emphasis shifted from local products to imported LLiNs leaving a leaving a very bitter taste, particularly in Nigeria with its large industrial sector, in mouths of the textile and chemical partners who during malaria partners meetings at the time expressed a sense of betrayal.
Talk arose in Nigeria about the potential for starting LLIN production in the country, but no one stepped forward with funding or technical assistance. In the meantime, on the other side of the continent, A to Z Textiles of Tanzania entered into a partnership and by 2003 LLINs were being produced in Arusha. Sumitomo Chemical provided a royalty-free technology license to the company for its Olyset LLINs. “By 2010, Olyset Net production capacity (at A to Z) reached 30 million LLINs per year, creating 8,000 jobs; more than half of the global Olyset Net output and an outstanding contribution to the local economy.”
Over the years A to Z Textiles were hard pressed, just like the few other LLIN manufacturers, to meet global demand. Over the period, the focus changed from protecting young children and pregnant women to universal coverage of the population. Also research and actual use found that the lifespan of an LLIN was not the 5 years as initially projected, but more like two. These factors meant that supply could rarely meet demand for regular replacement nets. No wonder Rwanda wants its own LLIN factory!
In addition to supply issues, does local availability of LLINs make a difference in fighting malaria? Regular studies by the Demographic and Health Survey group of USAID in Tanzania found that ITN use increased over time by children below five years of age. The most recent survey still shows that the 2010 Abuja target of 80% was not met (let alone a target of universal coverage), but the findings hint at the importance of having locally available LLINs.
Let’s wish Rwanda success in establishing its LLIN manufacturing capacity. For colleagues in Nigeria and elsewhere who have expressed interest in this issue, your advocacy work is just beginning.
On their website Sproxil says that, “Sproxil actively supports Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) in the fight against counterfeiting by pioneering Nigeria’s first Mobile Authentication Service.” They note further that …
“On February 2, 2010, NAFDAC launched the NAFDAC MAS, putting the power of product verification right in the hands of the consumer. MAS is powered by Sproxil’s award-winning cloud-based Mobile Product Authentication™ technology, and remains the world’s largest nation-wide implementation of consumer-facing SMS anti-counterfeiting technology in the world.”
Below are two malaria medicine packets recently purchased. After scratching the small label (see it circled, we got the SMS messages as posted. The NAFDAC registration number alone is not enough to ascertain the validity. This is a smart procedure, even without a smart phone. Of course one still needs to read the expiry dates!
Our team had planned supervisory visit last week to patent medicine vendors (PMVs) where shop owners have been taught the correct management of childhood illnesses. Our experience one particular shop pulled together so many lessons about training and supervision, and we are sharing this here. In the first shop we visited that day we found a boy aged 12 behind the counter. I took on the role of a mystery client, and mentioned some symptoms to the boy. “My 5-year old son is at home with catarrh. His nose is really running and his breathing is fast. What do you recommend I give him?”
The boy mentioned a local brand of antihistamine. I asked if there was anything else we should do, and the boy said that should work fine.
Next I said my two-year old daughter was also unwell. She was having fever, shivers with aches and pains. Did he have any suggestions for her? His prompt answer was “Ampiclox.”
I then asked him where the owner of the shop was. He said, “Oh my father has traveled.” I asked what class the boy was in school, to which he said the first class of junior secondary school.
Word of our visit must have spread in the area, because then a woman rushed in who it turned out to be the boy’s mother and asked how she could help us.
We explained that we were from the Ministry and were going around to help medicine shop owners improve the quality of their services. The mother happily reported that she had received training “in malaria and those other small small diseases of pickin,” from the Minsirty fo health and again from a NGO.
I went back to case of the child with a respiratory infection and pointed out the breath counting beads on the table. She said it was her husband who had done the training where the beads were explained but never taught her how to use them. We then spent some time explaining to the mother and her son about the beads and demonstrated how to use them, and also explained about management of fever.
Finally I asked the mother why she was not in the shop since her husband had traveled. She said she was in the kitchen preparing lunch for the children, and as the oldest, the 12-year old was assumed capable of running the shop. We encouraged her to discuss as a family how they could share what they have learned about managing child illness and always ensure that a competent person is available in the shop.
Training of PMVs is not a simple matter. The person trained may not always be in the shop nor share what he/she learned with other salespeople. Supervision is necessary in order to reinforce what was learned during training and provides an opportunity to teach others on-the-job. PMVs provide a large portion of the services in many African communities, and we must ensure that they can focus on quality.
Jhpiego staff will again present a poster at the Tuesday noon (Nov 4) session of the American Society of Tropical Medicine and Hygiene Annual Meeting. Augustine M. Ngindu, Muthoni M. Kariuki, Sanyu Kigondu, Johnstone Akatu, Isaac M. Malonza, with support from USAID’s Maternal and Child Health Integrated Project (MCHIP) will share experiences with a poster titled, “Improving maternal and neonatal health: Complementary role of the private sector increasing uptake of intermittent preventive treatment for malaria in pregnancy in Kenya.” The abstract is provided below.
Malaria in pregnancy (MIP) is associated with poor pregnancy outcomes including maternal anaemia, intrauterine growth retardation and low birth weight. Kenya changed its policy on intermittent preventive treatment using Sulfadoxine Pyrimethamine (IPTp-SP) in 1998. However, IPTp coverage rates have remained low: 4% in 2003, 14% in 2007, 15% in 2008 and 25 % in 2010.
To increase the coverage rate, MCHIP supported malaria control and reproductive health divisions of the ministry of health, first to harmonize knowledge among service providers on provision of IPTp-SP in 2011, and second to train community health workers (CHWs) on sensitization of pregnant women to start early antenatal care (ANC) attendance in 2012.
A community survey conducted in 2013 showed a significant increase in the proportion of pregnant women receiving two or more IPTp doses from 25% to 63%, the highest increase in IPTp uptake since 1998. Following the successful scale up of IPTp, one sub-county conducted an assessment of its health facilities to determine quality of data on ANC clients accessing IPTp-SP.
A total of 15 (58%) out all 26 health facilities in the sub-county (public – 6 out of 8, faith-based – 2 out 3 and private – 7 out of 15) were selected. Data on new ANC clients, revisits and IPTp doses given was collected from the ANC registers.
Among the assessed health facilities 13 (87%) out of the 15 were registering new ANC cases, revisits and provided IPTp-SP (public 6, faith based 2, private 5. One private clinic provided ANC services to revisits and IPTp2 doses only after the clients had been registered in public facilities, the second did not offer ANC services.
In 2013 the government declared provision of free maternity services in public facilities but ANC clients have continued to utilize services from the private sector. This is an indication of the untapped potential in the private sector in increasing access to high impact interventions and importance of supporting the sector by all partners to provide these interventions.
Such complementary efforts if implemented will not only result in enabling the country to move towards achievement of set targets but also improve pregnancy outcomes through reduction in effects of
malaria in pregnancy.
The first Poster Session of the American Society of Tropical Medicine and Hygiene (Monday noon) will feature a study on availability of malaria medicines in rural Ghana. “Mapping out of antimalarial drugs on stock at the market in a rural districts of Ghana” was developed by Alexander A. Nartey, Evelyn K. Ansah, Patricia Akweongo, Gloria A. Nartey, Mary A. Pomaa, Doris Sarpong, Clement Narh, and Margaret Gyapong of the Dodowa Health Research Centre.
Antimalarial drugs are a very important component of any policy for effective reduction of morbidity and mortality related to the malaria disease. The availability of efficacious and high quality antimalarials and their correct use can mitigate the risk of morbidity and mortality among the people of sub-Saharan Africa who have the highest risk of contracting and dying
Chemical (medicine) shops are major source of care for most developing countries where anti-malarial drugs can be purchase at the counter. The paper seeks to identify the different kinds of anti-malarial drugs on the market for malaria treatment in a rural district in Ghana.
A structured questionnaire was used during two seasons (peak and low malaria transmission seasons) to collect information on anti-malarial drugs from all 58 chemical shops within the Dangme West district now (Shai Osudoku and Ningo Prampram districts). Pictures of the anti-malarial drugs were taken,
The active ingredients, and also the source of the drugs documented. GIS locations of the shops were also recorded to ascertain the proximity of the shops to households in the communities. Majority (72.0%) of the chemical and pharmacy shop owners are males. Only 7.0% of the shops are pharmacy while the remainder is licensed chemical shops.
The total numbers of antimalarial drugs counted were forty nine (49). Among the stock, 4.2% were quinine, 31.9% of them were monotherapies such as artemether, Amodiaquine, Artesunate etc. Altogether, 59.4% of the artemisinin combination therapies (ACTs) were artemether + Lumefantrine, 25.0% were Artesunate + Amodiaquine.
Other antimalarials observed were 9.4% Sulfadoxine + Pyrimethamine and 3.1% of of Artesunate + Sulfamethoxypyrazine + Pyrimethamine. About 47% of the anti-malarial drugs were pediatric formulations.
The national antimalarial drug policy recommends the use of ACTs for malaria treatment however; all sorts of anti-malarial drugs which are not ACTs are in stock at the chemical shops in Ghana. Chemical shops are closer to households and play a very important role in the treatment of malaria hence there is the need to train chemical sellers to stock and administer the recommended antimalarials.
The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.
Below is an abstract by Freddy Kitutu, Chrispus Mayora, Phyllis Awor, Forsberg Birger, Stefan Peterson, and Henry Wamani of Makerere University and the Karolinska Institute on use of medicine shops in Uganda.
“Under-five child mortality in Uganda is still high and majority is caused by easily treatable pneumonia, malaria and diarrhoeal diseases among the poorest people. One of the reasons for these deaths is the lack of timely access to proven life saving medicines. This hinders progress towards attainment of MDG 4 target by 2015.
“To increase access to quality medicines and diagnostics for child febrile illnesses, Makerere University School of Public Health (MakSPH) in collaboration with WHO Alliance for Health Policy and Systems Research, is doing a project to assess the potential to deliver quality integrated care for malaria, pneumonia and diarrhoea using integrated community case management (iCCM) strategies and tools. Hence, an assessment was conducted to determine baseline care seeking preferences.
“A baseline household survey interviewed caregivers of children under-five years. The study protocol and data collection tools had been reviewed and approved by Research and Ethics Committees at WHO, MakSPH and Uganda National Council of Science and Technology.
“A total of 2606 households were surveyed. The main childhood diseases reported included fever (70%), cough (77%), and diarrhoea (40%) convulsions (16%) Most households use private drug shops to purchase medicines to manage these illnesses. Use of drug shops was attributed to long distances to public health facilities, availability and reliability of drug stocks at drug shops, perceived high quality of services, and options for credit.
“Interventions that target public health facilities are likely to miss many healthcare seekers especially the poor in rural distant areas. Conclusion: Drug shops are the convenient and preferred outlets for rural poor communities, and therefore need to be included in interventions such as iCCM strategy.
“Significance for the selected field-building dimension: This abstract presents findings from the baseline assessment prior to introducing a health system intervention in drug shops to improve access to and quality of care for under-five children.”