Meeting the Abuja Targets in Ghana: experiences with interventions for Malaria and other Childhood Diseases

Meeting the Abuja Targets in Ghana: experiences with interventions for Malaria and other Childhood Diseases * Dr Constance Bart-Plange Introduction Malaria is hyperendemic in Ghana with minimal seasonal variations and remains the major cause of morbidity and mortality among children under five years and pregnant women. The disease contributes to 44% of all outpatient visits to health facilities (2004 Annual Report, NMCP). The most recent Ghana Demographic and Health Survey, conducted in 2003, showed that the national average of underfive mortality is 111 per 1000 live births. Integrating services Ghana adopted the Roll Back Malaria initiative in 1998 and, subsequently, the Abuja targets set in 2000. Interventions were thus put in place, some of which were integrated into existing approaches at the community level. Accelerated Child Survival Development Project in Upper East Region The Accelerated Child Survival Development (ACSD) project was initiated by UNICEF in 2002 in the Upper East region and later in four districts in the northern region to scale up the delivery of cost effective child-survival interventions. That region was selected because of the high under-five mortality and the widespread poverty in the area. The majority of the interventions had been introduced in the districts before ACSD was initiated. However, the project harnessed the collective experiences in the region and elsewhere with a view to rapidly reducing underfive mortality and malnutrition by 15% in three years or by 25% in five years with the involvement of all stakeholders. Key components of the strategy were to define a package of costeffective interventions, train community-based volunteers and social support groups, provide logistics, and introduce new interventions. The interventions were re-packaged and dubbed: EPI plus, ANC plus IMCI plus. They were implemented systematically depending on the capacity of the district. These packages became vehicles for introducing new interventions: EPI plus added vitamin A supplementation, de-worming and defaulter tracing to routine EPI interventions; ANC plus added ITN and intermittent preventive treatment (IPT) to routine antenatal care; ** Dr Felicia Owusu-Antwi IMCI plus added homebased care for fevers as well as ITNs use. To improve uptake of these interventions three complementary delivery strategies were used based on a community s proximity to a heath facility. Health facility based delivery targeted communities located close to health facilities; outreach delivery targeted at communities located far from a health centre but accessible by motorcycles; and community-based delivery targeted at remote communities. The community-based strategy is modeled on community IMCI and uses trained and equipped community-based volunteers (mostly women) to manage fevers, treat diarrhea, and give health talks at homes. A review of ACSD in 2004 revealed the following: 50 AFRICAN HEALTH MONITOR JANUARY JUNE 2006

The proportion of children sleeping under ITNs increased from 4.6% in 2002 to 21% in 2003 in Upper East region compared with 0.8% and 1.9% in the Upper West region over the same period. The proportion of children correctly managed with oral rehydration salt increased from 35% to 65% in Upper East region. The proportion of fully immunized children aged 12-23 months increased from 44% to 77% during the same period, at an estimated cost of US$ 5 per capita of the targeted population. Even though other factors may have contributed to the programme s effectiveness, these findings reveal the potential benefits of a focused and integrated approach. Integrating ITN distribution in existing programmes Ghana has made significant strides in the integration of ITN promotion in child survival programmes. Notable among these are the Expanded Programme on Immunization (EPI) promotion and the child health promotion week. Child health promotion and ITN distribution Ghana has set aside one week in May every year to promote child health. This involves providing a package which includes insecticides-treated nets (ITNs) distribution and re-treatment using community-based agents and organizations, growth promotion, immunization, ORT administration as well as birth registration. This approach has Figure 1: NID-ITN integration: Immunization coverage in four districts in Central Region, Ghana led to an increase in ITN use among children and pregnant women. Integration of ITN distribution into EPI in the Central Region, 2004 Ghana integrated the distribution of ITNs into the National Immunization Programmes. National Immunization Day (NID) volunteers distributed special coupons to caretakers and mothers of all children under five years of age. The coupons were then exchanged for highly subsidized nets from nearby health facilities. A total of 70 000 ITNs were thus distributed within a period of four months. EPI subsequently conducted an integrated immunization and ITN coverage survey in four of the districts. The findings revealed an increase in ITN use from 7% to 34.8% four months after the exercise was completed. Immunization coverage was also high during NIDs with ITN distribution (2004B) as compared with NIDs done without ITN distribution (2004A) and 2005 (see Table 1). It can be concluded that integrating ITN distribution with NID has synergistic effect: ITN distribution enhanced immunization coverage while NIDs enhanced ITN uptake and use. Note: 2004(B) is the only time ITNs were integrated with NIDs in Central Region. The graph clearly shows a high immunization coverage compared with the other periods (2003, 2004 A and 2005) when NID was done without ITN distribution. The impact of integrated interventions has been great. The use of ITNs in children and pregnant women increased from 3.3% in 2003 to 15.1% in 2004. Malaria cases per thousand population decreased from 173/1000 in 2003 to 160/1000 in 2004 (Figure 2). Mothers and child caretakers knowledge of malaria recognition and management has improved to about 52% (NMCP Rapid Assessment, 2005). Lessons learnt and the way forward Lessons can be summarized as follows: The coverage of existing interventions can be increased if activities are integrated. AFRICAN HEALTH MONITOR JANUARY JUNE 2006 51

Table 1: ITN coverage in children under five years, 2003-2004. REGION % ITN USE 2004 (EPI SURVEY) % ITN USE 2003 DHS SURVEY WESTERN 4.8 1.0 CENTRAL 6.6 0.7 GAR 5.4 3.1 B/A 7.7 2.1 EASTERN 6.9 0.3 VOLTA 6.0 2.2 ASHANTI 7.9 1.2 UPPER WEST 19 1.9 UPPER EAST 41 20.7 NORTHERN 25 7.2 NATIONAL 15.1 3.5 Figure 2: Prevalence of malaria in Ghana, 2001 2004 (per thousand population) Figure 3: Status of malaria control interventions in Ghana in the context of Abuja targets Community-based agents, if trained and equipped, can facilitate the dissemination of innovations in the community. A carefully considered combination of delivery strategies can increase the uptake of health services. Active tracing of each defaulter improves coverage. Non-government actors can facilitate community action to improve health. Integrated interventions can be scaled up to the whole country to maximize coverage. * Dr Bart-Plange is the Manager, National Malaria Control Programme, Ghana ** Dr Owusu-Antwi is the National Professional Officer for Malaria, WHO, Ghana 52 AFRICAN HEALTH MONITOR JANUARY JUNE 2006

Malaria Control in Burundi By Dr Akadiri Inoussa Malaria burden in Burundi Malaria is the leading public health problem in Burundi by virtue of its morbidity and mortality. It is endemic and occurs in three epidemiological strata: - lowlands where malaria is hyper-endemic ( and where lives 23% of the total population); - central highland plateaux (1400-1800m) which are potentially epidemic areas, especially around marshlands where more and more rice farms and fish ponds are being opened (56% of the population); - and Congo-Nile ridge (>1800m), which is a non-endemic area where there are only imported cases In 1987, the overall economic loss due to malaria in Burundi was estimated at US$ 730 million, or US$ 117 per capita. It includes direct losses related to the cost of managing diseases and indirect costs related to the absenteeism of working adults. In 2002, malaria accounted for 46% of consultations in health facilities and 47% of deaths among children under five years of age (source: National Epidemiology and Statistics Service). For more than a decade now, prevalence of malaria in Burundi has been increasing, for example from 548 201 cases in 1991 to 3 047 319 cases in 2000 (cf 2000-2004 incidence table in annex). This malaria situation has been aggravated by the increasing appearance of resistance of P. falciparum to first-line (Chloroquine) and second-line (Sulfadoxine Pyrimethamine) drugs and by a particularly severe malaria epidemic at the end of 2000 and in early 2001. This led the Burundian health authorities to opt for a change of malaria treatment policy during a national consensus workshop held in July 2002. Following the results of Therapeutic Efficacy Tests conducted with two combinations drugs artesunate/amodiaquine and artemether/lumefantrine (efficacy test table), the artesunate/amodiaquine (AS/AQ) combination was chosen as first-line treatment and as treatment during malaria epidemics. The new protocol was officially launched on 10 November 2003 at Gatumba under the effective chairmanship of His Excellency the Minister of Public Health. The ceremony was attended by top officials from the Ministry of Health, local political and administrative authorities, representatives of UN organizations and donors who supported to the change process (cf launch photo in annex) Implementation of the new ACT-based malaria treatment protocol WHO has been promoted and supported implementation of the new malaria treatment protocol since November 2003 through: Partnership building - Formation by the Ministry of Health of a technical group responsible for the implementation of the new protocol. The group comprises officials of the Ministry of Public Health, NGOs, UNICEF and WHO. - Support for local mobilization of resources (DFID, GFATM, etc) for the implementation of the new protocol. Supply of ACTs The first supply comprising separated blisters (903 645 AS and 947 959 AQ) covered the first ten months of implementation of the new protocol. With the second order of 305 000 co-blisters of 12 + 12 tablets and 305 000 co-blisters of 6 + 6 tablets, the country s requirements were covered up to February 2005 as projected. A third order of 479 280 co-blisters of 12 + 12 tablets, 166 880 coblisters of 6 + 6 tablets and 147 180 co-blisters of 3 + 3 tablets provided a stock of drugs up to June 2005 in the entire country. Supply of ACTs to health facilities was done Through Provincial Health Offices from the central stock ordered and deposited at the UNICEF office. Replenishment of supplies is subject to presentation of documents on the use of the previous stock at both the Provincial Health Offices and health facilities levels (number of pa- AFRICAN HEALTH MONITOR JANUARY JUNE 2006 53

tients treated, quantity of drugs used, statement of income from the sale of anti-malarial drugs, etc.). Through the normal channel of the Ministry of Public Health to approved public health facilities exclusively from the stock financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM): from CAMEBU to Provincial Health Offices and from the latter to health facilities. Payment is on a service basis: consultation, laboratory tests and drugs are billed separately. Concerning the sale of antimalarial drugs, under-five children pay a fixed sum of 100 Burundian francs (US$ 0.1) and people belonging to other age brackets pay 200 Burundian francs (US$ 0.2). Provision of tools - Preparation of modules for health personnel training in the management of malaria, including the integrated management of childhood illness (IMCI) approach, by WHO, UNICEF and the Médecins sans Frontières (MSF) group. - Preparation and validation of the malaria epidemic control plan with the support of WHO experts (Regional Office and country office), national experts and health partners. Implementation of the plan activities has started with various training sessions in integrated disease surveillance and response (IDSR). - Preparation of pharmacovigilance tools for detection of the adverse effects of drugs (AED) and establishment of six pharmacovigilance sentinel sites. - Preparation of an operational plan for promotion of the use of impregnated mosquito nets. - Preparation of supervision protocols. Enhancement of health personnel skills - A series of cascade training courses for implementation of the new protocol: 15 national trainers and 85 provincial trainers: 1845 health workers have been trained (400 with financing from the Global Fund and 1 445 with financing from WHO, UNICEF and the European Development Fund (EDF); all heads and deputy heads of approved public CDS of the country s 17 provinces were trained. - Training of 64 health workers in pharmacovigilance. - Supervision activities were jointly carried out by P/LMTC, WHO and the technical committee responsible for monitoring implementation of the new protocol. Monitoring and evaluation WHO continued to play a supervisory role by addressing all technical issues and intervening actively in monitoring and evaluation. - Holding of information meetings on the implementation of the new protocol through health exchange meetings organized by WHO and bringing together all health partners. - To render the sentinel sites functional, each site was provided with a microscope, reagents, slides and sundry accessories for preparing thick and thin films. - Support for the periodic monitoring of the sensitivity of parasites to antimalarial drugs (AS + AQ) and that of vectors to routine insecticides. - A periodic review of morbidity data is carried out in health centres and hospitals. Monitoring and evaluation results Monitoring It is early to measure the impact of the new protocol as implementation started only in November 2003. Also many other factors which may influence morbidity and mortality must be taken into account. However, a review of morbidity data for 2000 to 2004 in the country s health centres and hospitals was conducted. Malaria incidence among patients dropped from 46% in 2000 to 23% in 2004. - A rapid analysis of data in the provinces hosting the sentinel sites (Kayanza, Gitega, Cankuzo, Bubanza, Karusi and Bujumbura Mairie) shows that monthly incidence rates dropped during 2004 compared with the previous years. This is attributable to several factors including the introduction of the new malaria treatment protocol. The case of Karuzi deserves special mention. In this province, 54 AFRICAN HEALTH MONITOR JANUARY JUNE 2006

the monthly malaria incidence curve during the first quarter of 2004 is lower than all the other years and is almost horizontal, which can be explained by the fact that: - Most CDS in this province are supported by the Belgian MSF; these centres conduct a clinical diagnosis using the paracheck quick screening test before the patient undergoes treatment. The patients treated were therefore more likely to be suffering more from malaria. - There is a parallel multiple environmental interventions programme in this province, including indoor residual spraying and treatment of waste water pipes, which could have a positive impact on malaria morbidity as well. In one health exchange meeting, partners reported about an ACTs stock shortage since June 2005 in some provinces : the order placed by GFATM which was expected since June 2005 was received at CAMEBU in August 2005. Evaluation A WHO Regional Office for Africa and ICP/MAL team supported the Ministry of Public Health in the conduct of the evaluation of malaria management in health centres from 24 January to 23 February 2005. The following were the conclusions of the evaluation: - AS+AQ was available in 77.5%, 91.3%, 40% of public health services, licensed health centres and private sector respectively. - 45% of workers involved in the management of malaria cases were trained but the training did not take into consideration the Integrated Management of Childhood Illness (IMCI) approach; - 89% of health workers were trained and supervised at least once during the last six months preceding the survey; - the clinical examination inadequately screened for signs of danger in underfive children with fever; - frequency of prescription of Artesunate + Amodiaquine combination in the case of uncomplicated malaria was not different in children under five years of age and those over five years, that is 71% as against 69% (X2= 2.9 ; p=0.08) and quinine was still prescribed in most cases of uncomplicated malaria, that is between 50% and 80% of cases; - the proportion of people accompanying sick children or of the patient themselves who understood the advice given by health workers during outpatients consultations was 86%; - on the day of the survey, 80% (n = 80) of health facilities reported having the Artesunate + Amodiaquine combination in stock whereas direct observation of the stock revealed that the combination was physically available in 75% (n-75 ) of health facilities; 50% of private health facilities did not have any first-line antimalarial drug on the day of the survey; Availability of the Artesunate + Amodiaquine combination was: 50% (n-8) in hospitals and 81% (n-64) in health centres. Challenges and prospects In view of the fact that the success of implementation of the new malaria treatment protocol depends largely on the availability of drugs used at all levels of the health system, the challenges to be faced are: - sustained availability of ACTs; - engaging private sector involvement (pharmacies and health centres) in putting ACTs at the disposal of patients; - provision and management of ACTs at community level in the home management of cases of uncomplicated malaria; - uncertainty in the outcome of proposal submitted to the fifth round of the Global Fund to Fight AIDS, Tuberculosis and Malaria regarding the malaria and strengthening of health systems components. The strengthening of the health system will help remedy constraints in performance observed during the first evaluation and contribute to effective Roll Back Malaria in Burundi. AFRICAN HEALTH MONITOR JANUARY JUNE 2006 55

ANNEXES Trends in malaria incidence in Burundi from 2000 to 2004 Year Population Malaria cases Indicence 2000 6 685 713 304 7319 0.46 2001 6 866 226 2 891 229 0.42 2002 6 747 420 2 326 339 0.34 2003 6 799 326 2 023 121 0.30 2004 7 003 304 1 591 655 0.23 Source: EPISTAT/MSP Artemisinin-based combination therapy efficacy test results (AQ+ASU and COARTEM) Product Included RCPA ETT ETP ETP+ETT AQ+ASU 149 95.3% 3.4% 0.7% 4.1% COARTEM 141 99.3% 0.7% 0.0% 0.7% Source: Report of National Workshop on Prospects for Malaria Treatment Therapies in Burundi, July 2002 Official launch of the new malaria treatment protocol at Gatumba on 10 November 2003: the Minister of Public Health holding an AS + AQ blister in the company of partners (WHO, UNICEF, etc.) 56 AFRICAN HEALTH MONITOR JANUARY JUNE 2006