Category Archives: Universal Coverage

Malaria Status in the 2014-15 Rwanda Demographic and Health Survey

Rwanda is experiencing low and very low levels of malaria test positivity rates, thought there are a few districts near the borders with Uganda, Tanzania and Burundi that have relatively higher transmission. Overall the country is strategizing how to move toward the pre-elimination phase on the pathway to malaria elimination. This is defined as a test positivity rate of less than 5% during the high transmission season.

DHS 2010 Malaria Prevalence in Children 6-59 MonthsIt is important to distinguish between test positivity rate and prevalence rate. The most recent survey report that gives prevalence is the DHS 2010 with a rate of 1.4% in children below 5 years of age and 0.7% among women of reproductive age. During 2010 the health management information system shows that among those tested (microscopy or RDT) for malaria, 24% were positive. The population for test positivity reports is a much smaller group that is already suspected of having malaria. That said, 24% or the 2013 rate of 29% is still far from the 5% cut-off for pre-elimination status.

Rwanda still maintains a policy of universal coverage with insecticide treated nets (ITNs). Rwanda also has a policy that every pregnant woman should receive an ITN during her first antenatal care visit. Ideally in order to reach pre-elimination status, a country needs to sustain high coverage of malaria prevention and treatment interventions at an 80% level for several years.

The newly released preliminary results of the 2014-15 DHS provide an opportunity to examine achievements. The 2014-15 DHS found that 81% of households had at least one ITN, while 43% had achieved the universal coverage target of one ITN per two household members. These numbers remain basically unchanged from the 2013 Malaria Information Survey (83% and 43%), while the 2010 DHS found 82% of households had a net, but did not report on the indicator of one net per two people. In short, it appears that coverage levels have been maintained at a certain level.

DSCN7129a pregnant women get ITNs when register for ANC RwandaDHS 2014-15 shows that 99% of pregnant women in Rwanda received antenatal care from a skilled provider. That means that basically all pregnant women should have received an ITN. 73% of pregnant women had slept under an ITN the night before they were surveyed, while 88% of all women of reproductive age slept under a net. 68% of children below the age of five years slept under an ITN the night before their household was surveyed, while 80% who lived in households that owned an ITN did so.

Indoor Residual Spraying (IRS) is focused on certain high transmission/burden districts. The preliminary 2014-15 DHS does not report on this and the 2013 MIS reports broadly by region, hence one sees coverage reports for IRS in the east (22%) and south (16%), where there is greater malaria burden, but this cannot be linked to specific districts that may have been targeted.

Rwanda also has a policy that all suspected malaria cases should be tested, whether with microscopy in health centers or rapid diagnostic tests by village health workers. It is only those persons testing positive for malaria who are supposed to be given malaria medicine.

DHS shows that 1439 children below five years of age (or 19% of the total) had fever in the two weeks prior to the survey. Of these 36% reported having a blood test performed, and 11% of those with fever received the approved artemisinin-based combination (ACT) therapy drug. The report does not indicate the actual testDSCN7282 results of those receiving ACT.

As Rwanda strategized toward reaching malaria pre-elimination status it can consider ways of enhancing ITN use, not only among vulnerable groups like small children and pregnant women, but all members of the household. As prevalence drops, so does acquired immunity, putting adults at greater risk.

The universal coverage target of at least 1 net for every two people in a household must be maintained, especially since it is nearing three years since the last universal coverage distribution campaign. Either another campaign will be needed or efforts to strengthen delivery of nets to families through routine health services.

In addition prompt and appropriate treatment based on diagnostics can be strengthened. One would have expected more children with fever to have been tested for malaria that the DHS reports.

Internal and external support is needed. Rwanda has been on the verge of reaching malaria pre-elimination status several times in the past decade. Even though malaria is no longer the top cause of death, we should not reduce our efforts to create a malaria-free Rwanda.

Malaria Care: Can We Achieve Universal Coverage?

uhc-day-badgeIn New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

  1. A strong, efficient, well-run health system
  2. Affordable care
  3. Accessible care
  4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

DSCN2885aWhile much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Slide1Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Slide2Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.

Malaria and febrile illness care seeking in Bauchi State, Nigeria

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health. Admiral Tim Ziemer, the Coordinator of the US President’s Malaria Initiative was keynote speaker. Other speakers from the NGO and faith based organization community also talked about the importance of partnership in fighting a disease that still claims 600,000 lives annually.  In addition 21 posters were presented.

Below is the abstract of one poster representing our work with USAID’s Targeted States High Impact Project in Nigeria.

Malaria and febrile illness care seeking in Bauchi State, Nigeria: context for improving case management at the primary level

Seeking of appropriate and qDSCN2939uality care for childhood illnesses is a major challenge in much of Africa including Bauchi State, Nigeria. In advance of an intervention to improve available care in the most common points of service (POS), government primary health care centers (PHCs) and patent medicine vendors (PMV), a survey was done of child caregivers in four districts concerning responses to febrile illness, suspected malaria, acute respiratory disease and diarrhea. The ethical review committee in the Bauchi State Ministry of Health approved of the study.

A total of 3077 children below the age of five were identified in the households sampled. Their mothers, fathers or other caregivers consented and were interviewed. Among the children 74% had any Illness, 57% had fever, 26% had cough, and 15% had diarrhoea. Only 8.7% of 1186 febrile children had their blood tested.

Care seeking from PMVs varied from 45% with fever, 40% with cough to 36% with diarrhoea. Care from public sector POS varied from 26-33%. Treatment that might be considered ‘appropriate’ for each also varied with 30% receiving antimalarial drugs for suspected malaria, 20% getting oral rehydration solution for diarrhoea and 50% being given an antibiotic for a suspected acute respiratory illness.

The results show that providing quality integrated case management with appropriate commodities through PHCs and PMVs can improve the illness care of a majority of children in Bauchi State, and interventions are currently being planned to do this.

Poster by … William R. Brieger, MPH, CHES, DrPH 1, Bright Orji, MPH 2, Masduk Abdulkarim 3, (1) International Health, Bloomberg School of Public Health, The John Hopkins University, 615 N Wolfe St, Baltimore, MD 21205 (and Jhpiego). (2) Jhpiego, Thames St, Baltimore, MD 21231`. (3) Targeted States High Impact Project USAID Nigeria, Bauchi, Nigeria.

Research on Universal Coverage: the malaria examples

whr-2013-sm.jpgThe World Health Report 2013 entitled Research for Universal Health Coverage has been released. Since universal coverage has been a central Roll Back Malaria target since 2009, we have included below some of the mentions of studies and activities around malaria service provision and scaling-up.

The case for investing in research is made, in part, by demonstrating that scientific investigations really do produce results that can be translated into accessible and affordable health services that provide benefits for health… In one (example) a systematic review of survey data from 22 African countries showed how the use of insecticide-treated mosquito nets was associated with fewer malaria infections and lower mortality in young children. This evidence underlines the value of scaling up and maintaining coverage of insecticide-treated nets in malaria-endemic areas. (page xiv)

(Environmental risk factors) also contribute to the transmission of vector-borne diseases: malaria is associated with policies and practices on land use, deforestation, water resource management, settlement siting and house design. (Page 41).

By killing or repelling mosquitoes, insecticide-treated bed nets protect the individuals sleeping under them from malaria. By killing mosquitoes, they should also reduce malaria transmission in the community. Randomized controlled trials conducted in sub-Saharan Africa in a range of malaria endemic settings have provided robust evidence of the efficacy of ITNs in reducing malaria parasite prevalence and incidence and all-cause child mortality. Such trials showed that ITNs can reduce Plasmodium falciparum prevalence among children younger than five years of age by 13% and malaria deaths by 18%. (page 61)

(More research is needed because) In contrast with the findings of controlled trials, ITNs may be less effective in routine use because the insecticidal effect wears off, or nets may be used inappropriately or become damaged. The impact of ITNs, as used routinely, on malaria and childhood mortality is therefore uncertain.  (page 62)

As we can see from the World Health Report, malaria research has made a major contribution to our understanding of factors and effects of scaling up programs to try to achieve universal coverage.  As WHO recommends, more funding for health service coverage is needed, and malaria countries countries themselves need to contribute their own share in supporting their own research institutions.

Appreciating Many Years of Malaria Partnerships and Investment

wmd2013logo-sm.jpgWhile today it technically the sixth World Malaria Day, one should actually trace the origins back 13 years to the first Africa Malaria Day (AMD) in 2001, held to encourage progress based on the Africa malaria Summit in Abuja just one year before.  And since the Abuja summit and its resulting declaration were backed by the Roll Back Malaria Partnership, which formed in 1998, one could say the world has 15 years to considering in judging progress in and plans for partner investments in ridding the world of malaria.

In 2001 organizers of Malaria Day events were encouraged to feature a ‘new’ medicine that WHO said could save 100,000 child healths annually in Africa. artimisinin-based combination therapy (ACT) drugs are now the front line treatment in most all endemic countries, and deaths have declined somewhat on the order of 400,000. At that time there was only one major manufacturer of ACTs. Investments by pharmaceutical companies in generic ACTs now means that there are at least nine companies that produce prequalified ACTs. What is needed is more indigenous African pharmaceutical companies approved to invest in ACT production.

logo_animated.gifThe first AMD stressed the risk of malaria to pregnant women and recommended widespread use of Intermittent Preventive Treatment in pregnancy (IPTp).  This recommendation has been adopted in countries with stable falciparum malaria transmission, but has lagged in terms of implementation, and coverage still lags below the 80% target set at the 2000 Abuja Summit.  There are missed opportunities to provide IPTp at antenatal clinics due to stock-outs, provider attitudes, and client beliefs. Weak health information systems mean that even when services are provided, reporting may not accurately reflect true coverage of IPTp.

In the meantime resistance is growing to sulphadoxine-pyrimethamine (SP), the drug used for IPTp in part due to the inability or unwillingness of country drug authorities to curb its inappropriate use for case management.  WHO now recommends more that the original two IPTp doses and suggests that pregnant women get SP at each ANC visit after quickening.  In the meantime research is underway to find substitutes for SP.

The first AMD addressed the role of insecticide treated nets (ITNs) in helping halve the world’s malaria burden by 2010.  Major progress came in 2008 when the whole United Nations community and of course companies invested in net production got behind universal coverage. In addition the advent of the long lasting insecticide-treated net with insecticide infused in the fabric from point of production pointed the way to success.

These three core interventions – ACTs, IPTp and ITNs – have been strengthened with better diagnostics and a variety of other vector control measures, Hopes for a vaccine still remain a dream, though an achievable one.  While we have high expectations for eradication, we can see that some of the health systems challenges that thwarted the first malaria eradication effort are still with us including weak procurement and supply management, inadequate human resources and gaps in health information systems.

The foregoing implies that we need at least two forms of future investment in malaria. First is investment by governments in strengthening the health system that deliver malaria services. The second investment is in continued biomedical research in order to fend off resistance by mosquitoes and parasites and of course social research to address issues of behavior, adoption of innovations and program management practices. Let’s hope that when World Malaria Day 2014 rolls around, we can measure these increases investments.

Malaria Thoughts on International Youth Day

Youth, those 15-24 years old, are usually thought to be generally healthy and often do not occupy the minds of health planners. It is the pre-school age child who dies from infectious diseases and the older adult who succumbs to non-communicable afflictions. Actually as an e-mail today from USAID points out …

Approximately 16 million girls between the ages of 15 and 19 give birth each year. The impact of pregnancy on adolescent girls can be devastating: girls who become pregnant face a higher risk of maternal mortality, often drop out of school, and are sometimes forced into early marriage. In 2009, nearly 2.5 million boys and girls under the age of 15 were living with HIV, and 370,000 were born HIV-positive. For many, HIV has become a chronic disease that requires lifelong treatment, care, and support.

Pregnant teens living in malaria endemic areas are usually at high risk because it is the first and second pregnancies especially that are more prone to the disease and the anemia, miscarriage, still birth and possible death that comes in its wake. For example, researchers in Western Region, Ghana recently found that …

… adolescent pregnant girls were more likely to have malaria and anaemia compared to their adult pregnant counterpart. Results from this study shows that proactive adolescent friendly policies and control programmes for malaria and anaemia are needed in this region in order to protect this vulnerable group of pregnant women.

dscn2401sm.jpgOf course, youth are not only victims of malaria, but agents for change. A youth group in Uganda has launched the  Make Malaria History Campaign (MHC) and plans to distribute over 100,000 treated mosquito nets. Youth often organize community drama to highlight health issues as seen in the photo from Bauchi State, Nigeria.

Elimination of malaria means protecting all segments of the population in the spirit of universal coverage. Youth are not an exception.

Universal Coverage is not Universal Use

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.

sleeping-under-an-itn-in-tanzania-from-2010-sm.jpgAnother 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.

Sustaining the Gains

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.

uganda-malaria-indicators-from-2006-11.jpgDocumentation 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?

Off-Road in Uganda

Uganda’s 2010 Roll Back Malaria Roadmap seemed reassuring.  Apparently 2.7m nets were already in place by late 2009, and supposedly a supply of another 18m long lasting nets (or at least the funding) was ready for achieving universal coverage by December 2010.

Assessment of Uganda’s Roadmap progress credited the country with achieving procurement of these nets. It seems odd therefore that the 2011 Roadmap indicates that 6.4m nets are in place and 10.4m need to be distributed in 2011. What’s going on?

staying-on-the-road.jpgA new study by Carla Proietti and colleagues provides some answers. Not only do they document continued high transmission in the northern part of Uganda (polymerase chain reaction rate of 72% in children below five year of age), a situation that threatens control efforts by neighbors, but they also identify plausible reasons for the lag.

The researchers politely suggest that, “The failure to reduce the burden of malaria could reflect sub-optimal implementation of malaria control measures.” They also explained that, “Malaria control efforts in Apac (sub-county) were not reliably monitored in the last decade and affected by political unrest in preceding years.”

Stockouts of anti-malarial ACTs was also listed as a problem. It should be recalled a few years ago that, “The Global Fund has decided to suspend its five grants to Uganda because there is evidence of serious mismanagement by the Project Management Unit (PMU) for Global Fund grants in Uganda.” Although the programs have resumed, satisfactory settlement of the problem was not achieved.

In light of this study Childsurvival.net warns us not to let successes in recent years blind us to reality. “Those who believe that Africa is within shooting distance of malaria elimination may wish to reconsider their position after reading this article (Proietti et al.). One should qualify this Ugandan article in several ways: 1) Local insurgency in the area under consideration, 2) Hiccoughs with the GF over misappropriation of resources, 3) Autocratic gerontocracy at the national level. Unfortunately, these three factors are not peculiar to Uganda.”

As mentioned yesterday, Roadmaps are a good tool to help us plan for malaria control and elimination – but we must stay on the road for them to work.

Redrawing Roadmaps – can we get there from here?

The Roll Back Malaria Partnership guided countries to develop 2010 roadmaps for major malaria commodity and support service availability and gaps. The aim was to aid planning to reach universal coverage by the end of 2010.  Forty-seven countries/locations on the African Continent and surrounding islands completed the analysis and started moving down the road to success.

In the case of 36 countries the road became a little longer than anticipated.  Part of the challenge was international – there are only a few manufacturers of long lasting insecticide-treated nets, for example. Some of the barriers were internal, inadequate estimates of the logistical costs to distribute commodities, even if they were in hand. Now we have 2011 roadmaps in an effort to meet up with the original 2010 goals of 80% coverage with essential malaria commodities.

proportion-of-countries-that-missed-2010-rbm-roadmap-sm.jpgAt least one-quarter of countries that actually targeted a specific intervention in 2010, did not meet the 80% goals.  Of particular concern is the fact that Rapid Diagnostic test use is both off target and not keeping up with ACTs.

Meeting procurement and distribution targets is one step, but getting people to use malaria control interventions is another challenge. As the director of a prominent Nigerian NGO recently said, “… ‘though about 35.6 million nets have been distributed across the country, it is highly under utilized,’ which according to him is responsible for the high death rate associated with malaria.”

Nigeria provides an instructive case. The roadmap for 2010 called for 62.9m LLINs of which 4.4m were already in place and pledges were set for 49.4m. This left a gap of 9.2m.  While the RBM 2010 roadmap analysis shows that Nigeria met its LLIN target, the implication is that the target did not include the gap.  Now the 2011 roadmap for Nigeria now shows that resources are in hand for both the 9.2m gap from the 2010 campaign plus an additional 8.2 m for routine distribution in clinics as a keep-up measure.

The gross figures do not fully reflect the fact that of the 36 states (plus one capital territory), campaign distribution of LLINs continued from 2010 into 2011 in 17 states. So far 9 or the 17 have completed distribution, but by carrying the campaign into 2011 additional delays were met in the remainder due to national elections, delayed local funding for the effort, and distribution logistics. So again while the roadmaps help identify commodity gaps, they do not always identify the challenges at the level of distribution and use.

The roadmap process is an important planning tool. It needs to be supplemented with plans for logistical support and health education to encourage use of the malaria commodities and services that are eventually distributed.  For example, Nigeria estimates that it needs close to $17m for Monitoring and Evaluation and Information. Education and Communication. We can see from the Nigerian roadmaps that this planning needs to be a continuous process – not only is annual resupply of ACTs, RDTs and SP for IPTp needed, but also continuous stocks of nets for routine, keep-up services.