Malaria research and interventions in the ACCESS program

The aim of the ACCESS program (2004-2011) was to improve access to prompt and effective malaria treatment with a set of integrated interventions which target both users and providers. The program was implemented in two phases. During the first phase covered in this thesis (2004-2008), the ACCESS program carried out interventions in the two districts of Kilombero and Ulanga in the south-east of Tanzania. In the second phase it extended its activities to the adjoining Kilosa District.

Research

The research on which this PhD is based was conducted in an interdisciplinary team of epidemiologists and anthropologists/sociologists. Three PhD theses and three MA thesis carried out with the ACCESS program have already been accomplished: Manuel Hetzel (2007) and Sandra Alba (2010) were my Swiss counterparts and analyzed studies of the Monitoring and Evaluation component of the ACCESS program from a public health perspective. We collaborated very closely in data collection, management and analysis as well as in writing papers. Two papers which are directly linked to my own studies and to which I contributed as a co-author are included in this thesis (Chapters 5 and 7). My understanding of treatment seeking has further been influenced by the PhD thesis of Karin Gross (in press) on Intermittent Preventive Treatment during pregnancy and antenatal care in practice, the MA thesis of June Msechu (2004) on home management of malaria, Mariette Frankhauser (2006) who conducted a cohort study of treatment seeking during the seasonal migration to the shamba (fields) and by Iddy Mayumana (2007) on malaria case management in the light of rural livelihood and vulnerability.

Interventions

Malaria research within the ACCESS program was closely linked with interventions (see Figure 7) and considered access to malaria treatment from a user and a provider perspective. The interventions of ACCESS program use a three pronged approach targeting communities, health facilities and drug stores (Hetzel et al., 2007).

At community level, the program applied a social marketing approach to improve awareness and promote prompt and effective treatment of mild and severe forms of malaria. The main focus of the health communication campaign was to

• Increase awareness and improve malaria knowledge among the community • Encourage prompt recognition of signs and symptoms of mild and severe malaria • Promote effective treatment seeking from competent sources and the need to

Figure 7 Timeline with ACCESS interventions and monitoring and evaluation activities (Source: Alba, 2010)

The ACCESS program recommended first-line drugs in accordance with the national malaria treatment guidelines, i.e. SP until the end of 2006 and ALu from 2007 onwards. As competent sources for proper treatment and advice it promoted health facilities and licensed drug stores (pharmacies, part II drug stores and ADDOs from 2006 onwards).

Target audiences included mothers, fathers and other care takers of children below five years of age, pregnant women, community leaders, school children and teachers, health workers, drug sellers and the general public. The campaigns employed a mix of communication channels ranging from small to mass media. These included road shows package, football tournaments, special promotion at Reproductive and Child Health Clinics (RCHC), posters, brochures, paper flags, folders, banners, caps, T/shirts, public address through ACCESS branded vehicle.

The road show was the main vehicle to convey ACCESS key messages to the target populations. The package comprised of public lectures, comedies and role-plays,

dancing competitions and cinemas. Under role plays for example the local ideas linking convulsions with spirits and ‘degedege bird’ were discouraged and new understanding linking degedege with severe malaria was promoted. T-shirts were produced and distributed carrying corresponding messages, such as: “Convulsion is a sign of severe malaria and can be treated at the health facility” (Degedege ni dalili ya malaria kali na

inatibika vituo vya afya). In other messages, local treatment practices were

discouraged and alternatives were recommended, for instance: “Do not urinate on a convulsed child but take her to a health facility immediately” (Usimkojolee mtoto

mwenye degedege ila mpeleke kituo cha afya mara moja).

Mothers of young children and pregnant women who are more likely not to attend social marketing campaign were targeted through Mother and Child Health (MCH) Clinics. The aim of the promotion was to increase and improve awareness of new malaria treatment regime including reasons for frequent change of malaria treatment policy, dosage instructions, importance of complying with full treatment course, use of Insecticides Treated Nets (ITNs) and the importance of Intermittent Preventive Treatment in pregnancy (IPTp).

Other communication channels like posters, brochures, stickers, banners were simultaneously distributed or placed to the prominent public places like health facilities, general shops, drug shops, market places, public transport terminals, schools and other strategic eye catching places.

Between 2004 and 2008 the ACCESS social marketing road shows were conducted in 96% (78/81) of the villages in the Kilombero District and 95% (62/65) in the Ulanga District.

At the health facility level, the main emphasis is on the improvement of quality of care. As a result of the social marketing activities, the demand for quality services can be expected to increase. In order to meet this demand, health facility staff must be in a position to deliver good quality of care. Key activities of the ACCESS program in this component included refresher training for health facility staff. This training was developed and carried out in close collaboration with the Council Health management Teams (CHMT) of both district. From 2004-2005, 93% (39/42) of clinical officers in

Kilombero District and 91% (94/97) of all health workers in the Ulanga District were trained.

Similarly, since 2007, the ACCESS team and the CHMT have worked out and implemented the Quality Improvement and Recognition Initiative (QIRI) in health facilities in the Kilombero and Ulanga districts. QIRI offers an integrated approach for the evaluation of quality of care combined with a strategy to establish the root causes of performance gaps and to develop strategies to address them. Six performance indicators are measured in QIRI as part of the evaluation of health care: Job expectations, skills and knowledge, provider motivation, performance feedback, physical environment and tools, and client satisfaction.

With the QIRI, the project team supports the CHMT in improving the supervision of health staff in dispensaries, health centers and hospitals in Kilombero and Ulanga districts. In the course of their visits, the supervisory teams assess, for instance, whether health providers adhere to the national malaria guidelines and the IMCI guidelines in their day-to-day case management. Health providers are also provided with refresher trainings on malaria case management and use of new diagnostics tools i.e. rapid diagnostic test for malaria.

The intervention at the drug shop level – the ADDO program (see Chapter 1.4) - is carried out by a public-private partnership led by the Ministry of Health and Social Welfare (MOHSW) through the Tanzanian Food and Drug Authority (TFDA) and Management Sciences for Health (MSH). Its aim is to improve access to affordable, quality medicines and pharmaceutical services in drug retail outlets in rural and peri- urban areas where there are few or no registered pharmacies (Rutta et al., 2009).

The main components of the ADDO program are activities to change the behavior of shop owners and dispensing staff through the provision of education, incentives and regulatory coercion (Rutta et al., 2009). The program trains drug dispensers, for instance to listen carefully to the client’s description of the signs and symptoms and to advise him/her thoroughly, recommending and providing appropriate medicines, providing advice on the use of preventive tools like treated bed nets and seeking hospital care if no improvements are observed). It also entails efforts to positively affect client demand and expectation of quality products and services. For the districts of Kilombero and

Ulanga, ACCESS could successfully negotiate an early roll out of the ADDO in January 2006 and the introduction of highly subsidized ALu in ADDOs in July 2007. Between 2006 and 2008 135 ADDO were opened in the Kilombero district and 55 in the Ulanga district - equivalent to approximately three shops per 10’000 people in both districts (Alba, 2010). The ACCESS program through its social marketing activities promotes the use of ADDOs as a source of quality and appropriate malaria treatment.

Monitoring and evaluation

The monitoring and evaluation component aims at assessing the impact of interventions on the overall health impact based on a plausibility examination of a before-after study design. Various monitoring and evaluation activities were carried out in the Kilombero and Ulanga HDSS which served as an epidemiological framework for the study;

1. Routine monitoring of health facility utilization data: In patient and out patient diagnosis from Health Management and Information System (HMIS) were collected on a monthly basis in all private and public health facilities in the HDSS area. Standard forms allowed rapid transcription of data from the health facility records. These data were used to estimate rates of fever and malaria cases in health facilities.

2. Routine monitoring of drug stock and supply in health facilities: Data on drug stock and supply were collected in all public health facilities after every other month. Validated data collection tools were used by trained field workers to collect such information from the Health Management and Information System (HMIS) ledger books.

3. Shop surveys: Cross sectional shop surveys were carried out every year to record anti-malarials stocks and shop location in the HDSS area and Ifakara town (see Figure 3). Drug outlets include all potential sources of anti-malarials like kiosks, general shops, pharmacies, ADDOs and Part II drug shops.

4. Mystery shopping studies: Parallel with the shop surveys, performance and quality of services in drug selling shops was monitored annually through mystery shoppers who visited and bought drugs from local commercial outlets. Standardized guidelines were used to obtain relevant information for different simulated case scenarios.

5. Treatment seeking surveys: EMIC interviews were used to collect qualitative and quantitative data on patterns of distress, perceived causes and help seeking for fever and convulsion cases. The surveys have been carried out in 2004, 2006 and 2008 in the HDSS area and in Ifakara town. The interviews focused on adults and children below five years of age who had recovered from a fever or convulsion episode.

6. Monitoring of morbidity and mortality rates: Through the Ifakara HDSS, ACCESS collected community reported fever and convulsion cases. Moreover the HDSS provided ACCESS with under 5 mortality trends in area.

This thesis has grown out of the monitoring and evaluation component of the ACCESS program. It specifically built on monitoring and evaluation activities 4) mystery shopping studies and 5) treatment seeking surveys.