SP Stock-Outs – What’s the Problem?

dscn8010-sm.JPGIn today’s guest report, Michelle Wallon from Jhpiego’s Zambia office discusses the challenges of maintaining stocks of sulphadoxine-pyrimethamine (SP) for use in Intermittent Preventive Treatment for pregnant women (IPTp) that arose during recent Roll Back Malaria meetings in Livingstone and Lusaka:

The effects of malaria in pregnancy are many and the interventions, simple.  Intermittent Preventive Treatment (IPTp), insecticide-treated bed nets, and timely case management can reduce effects including maternal anemia, low birth weight, and maternal and fetal mortality. Yet, when speaking to clinicians and public health experts across Africa about prevention and control of malaria in pregnancy (MIP), there is a common theme – stock-outs of SP, the drug used for IPTp, commonly inhibit the effectiveness of MIP interventions.

IPTp is relatively straight-forward and SP, is an inexpensive drug.  Furthermore, at the time that the IPTp recommendations were adopted via the Abuja Declaration in 2000, many countries were still procuring SP as the first-line treatment for the general population (For example, Nigeria did not officially switch to ACTs as firstline malaria drugs until 2005).

SP supplies were abundant when it was still recommended as treatment. What then is the problem now?

Although SP stock-outs are formally documented in only a few African countries, including Zambia, Tanzania, and Malawi, the problem can be inferred by most of the recent Demographic and Health Survey and Malaria Indicator Survey reports (e.g. Liberia, Nigeria, Uganda, Senegal) showing low coverage of the recommended two doses of IPTp. MIP experts readily and repeatedly identify a handful of culprits for the SP stock-out phenomenon.

    One set of problems surrounds continued and irrational use of SP for treatment in RDT-negative cases in the general population that siphon off SP supplies from MIP services. These stem from …

    • Provider mistrust of RDTs coupled with policies that ACTs be provided only after positive diagnosis via RDT or microscopy
    • Real or perceived high incidences of malaria
    • Strong correlation in the community between fever and malaria with high expectations for malaria treatment
    • Weak clinical skills in the appropriate diagnosis and management of fever
    • Lack of skilled providers and high client loads

    Inaccurate SP quantification based on population rather than consumption data and/or quantification failing to account for irrational use also create stock problems. Weak logistics systems with bottlenecks between central-level drug stores and receiving facilities result in stock-outs of both SP and ACTs.

    These problems are not new and neither are the solutions.  MIP has a potential advantage in that it falls under both reproductive health and national malaria control programs, and yet the persistence of SP stock-outs indicates that this is often used less as an opportunity for collaboration than as an excuse to pass the buck.

    As the public health community moves towards more integrated programming, we must seize the opportunity to bridge the programmatic gap.

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