Working Together to Maximise Health Impact of New Anti-Malarials Lessons Learned from Scale Up of Malaria Control in Zambia Dr Naawa Sipalanyambe Zambia National Malaria Control Programme Presentation for MMV 1st Access Symposium Livingstone, Zambia 6th May 2006
Problem of Malaria in Zambia Malaria: a major public health problem. 36.2% of total diagnosis 33,000 deaths /year 383.1/1000 cases Past - notifiable disease. Malaria: linked to MDGs and a key Highly Indebted Poor Countries (HIPC) trigger. A disease of poverty Minus 1% of national GDP Impact on infant and maternal mortality rates 40% - IMR (95/1000) Possibly 20% -MMR(729/100000)
Why the Changing Patterns? Economic conditions? Vector control activities? HIV/AIDS? Quality of care? Chloroquine and SP resistance?
Ministry of Health A 5-year Strategic Plan A Road Map for Impact on Malaria in Zambia 2006-2011 Rapid Scale up of Malaria Control Interventions for Impact in Zambia
Targets and Goals National Strategic Plan 2006-2011 Reduction of malaria incidence by 75% and deaths due to malaria will be significantly reduced by the end of 2011 Reduction of all cause mortality by 20% in children under five Abuja Targets 60% 80% At least 80% of those suffering from malaria should be able to access and use correct, affordable and appropriate treatment within 24 hours of onset of symptoms. At least 80% of those at risk of malaria, particularly pregnant women and children under 5 years of age, should benefit from suitable personal and community protective measures such as ITNs. At least 80% of all pregnant women who are at risk of malaria, especially those in their first pregnancies should receive IPT
Integrated Package of Core Interventions 1. Reduction of disease burden Insecticide Treated Nets Indoor Residual Spraying Intermittent Preventative Treatment 2. Care of the sick Case Management Laboratory Diagnosis 3. Management programme and system support functions.
Strategic Decision 1 Scale up for impact Impact assessment Achieve a coverage of at least 3 ITNs per household for 80% of all eligible households. With the above coverage, achieve the following utilization rates: Children under five sleeping under ITNs 80% Pregnant women sleeping under ITNs 80% Specific economically vulnerable groups particularly in rural hard to reach areas-80%.
Strategic Decision 2 Scale up for impact Impact assessment Achieve a coverage of at 85% of the target population sleeping in sprayed structures by 2008. Adherence to strict eligibility criteria. Weaning off the use of DDT for IRS in accordance with the Stockholm Convention. Multisectorial involvement for IRS
Strategic Decision 3 Scale up for impact Impact assessment At least 80% of women have access to the package of interventions (3-doses of IPT, ITN, and anaemia reduction) to reduce the burden of malaria in pregnancy by 2008 Partnership and reliance on Reproductive Health to provide an integrated package.
Strategic Decision 4 Scale up for impact Impact assessment At least 80% of suspected malaria patients are correctly diagnosed by 2008. Reduction in the misdiagnosis of malaria. Improvement in monitoring of true cases» Challenge of IMCI strategy and HIV/AIDs
Strategic Decision 5 Scale up for impact Impact assessment At least 80% of malaria patients in all districts are receiving prompt & effective case management according to the current drug policy within 24hrs of onset of symptoms by 2008. Strengthen community IMCI and private sector involvement in case management
Supportive systems Strong emphasis on the development and strengthening of systems: Programme planning and management support Human resources Financial management systems Procurement and supply chain management
Information to inform decisions Studies during 2000-2005 inform decisions Disease patterns Drug efficacy and use patterns ITN coverage and use IRS coverage IPT coverage Implementation of new drug policy
Reported HMIS malaria Reported cases malaria per 1000 cases population 180 160 140 reported malaria cases per 1000 120 100 80 60 40 Central Copperbelt Eastern Luapula Lusaka North Western Northern Southern Western National 20 0 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 2000 2001 2002 2003 2004 by quarter
Parasite prevalence From baseline (season?) and follow up (Aug-Sept) surveys in 10 sentinel districts Children 2-9 years Using RDTs 100 80 % positive 60 40 20 0 Chibombo Chingola Chipata Chongwe Isoka Kalomo Kaputa Mwinilunga Samfya Senanga baseline - 2001 follow up - 2004
6000 U-5 Malaria Deaths Under-5 Malaria Deaths 5000 No. of Deaths 4000 3000 2000 U-5 Malaria Deaths 1000 0 1999 2000 2001 2002 2003 2004 Year Source : HMIS -Zambia
SP Treatment Failures by Site and Study Year TTF (%) 35 30 25 20 15 10 5 0 1996 1997 1999 2000 2002 2003 2004 Study Year Chipata Chongw e Isoka Mansa Lundazi Choma Mpongw e Mw inilunga Sesheke
ITN distributed per planned distribution expressed as a percentage (through 2004, 6 persons per HH * 3 nets per HH) Source: ITN Database, NMCC ITNs distributed per planned distribution (%) 1-5 6-17 18-23 24-35 36-74
100 80 60 40 20 0 ITN: HH Net possession 2004 2000 Chadiza Chama Chipata Kitwe Lundazi Petauke Choma Kaoma Kitwe Lusaka Mansa Chibombo Chingola Chipata Chongwe Isoka Kalomo Kaputa Mwinilunga Samfya Senanga 100 Ndola 80 60 40 20 0 From studies done by Society for Family Health, Net Mark, RBM baseline and follow-up surveys, and DHS Central Copperbelt Eastern Luapula Lusaka Northern North-Western Southern Western Urban Rural TOTAL DHS (2001/02) TOTAL SFH (2005) %
Chilubi Lufwanyama Kaputa Kawambwa Mporokoso Chinsali Mwense Luwingu Chama Samfya Mwinilunga Mpika Solwezi Lundazi Serenje 1 3 2 Kabompo 5 7 Lukulu Katete Chadiza Kaoma Kalabo Mumbwa Mongu Luangwa Mazabuka Sesheke Choma Sinazongwe Livingstone Shangombo Senanga Zambezi Chavuma Kazungula Kalomo Kafue Chongwe Lusaka Chibombo Mkushi Kapiri Mposhi Mpongwe Nyimba Petauke Mambwe Chipata Isoka Nakonde Kasama Mungwi Mbala Mpulungu Nchelenge Mansa Milenge Gwembe Siavonga Namwala Itezi-Tezhi Monze Kasempa Mufumbwe 4 Chienge Kabwe 6 Masaiti 4 Mukinge Minga Macha N Kasaba Ndola Phase I Phase II Coartem Distribution
Baseline Coverage of Key Malaria Indicators 100 90 80 70 60 50 40 30 20 10 0 2001 2002 2003 2004 2005 % U5s with fever promptly treated %urban HH sprayed %HH with >=1 ITN % U5s sleeping under ITN %PW sleeping under ITN %PW receiving IPT-1 %PW receiving IPT-2
Malaria Trends, Choma District, Zambia 1200 1000 800 Deaths Cases Deaths/Cases 600 400 200 0 2000 2001 2002 2003 2004 2005 Years Source : Thuma et al
Basis for confidence Political commitment Technically sound package of core interventions. Strong Implementing Partners High ANC participation; Child Health Ability to fit into the MTEF Framework and district readiness to implement. Global commitment and substantial financial resources Impact being tracked
Critical Challenges Procurement and supply chain management and logistics Donor and partner harmonization-- multiple processes, multiple models, potential duplicative efforts huge transaction costs Health Systems vs. Scale up for Impact Ambitious programme in a weak system
As you think about ACCESS Everything about a new drug will be interesting, but,.. Not everything will have the same importance for us in our programmes Case management is the hardest part of our strategy It is best done in the context of high coverage with preventive interventions (ITNs, IRS, IPT, etc) It is not just about the name of the drug We welcome MMV and your considerations via ACCESS.
Moving towards a Malaria Free Future!!