Improving Access to treatment in Myanmar

Improving Access to treatment

in Myanmar

Dr. Thar Tun Kyaw

Deputy Director ( Malaria ) Programme Manager

National Malaria Control Programme Ministry of Health, Myanmar

History

• 1950 – Anti-malaria Programme

• 1951-54-Malaria Control Demonstration Project

• 1957 - Malaria Eradication Programme

• 1963- Eradication Programme Implemented

• 1972-73-Malaria Control Programme

Malaria Mortality Rate per 100,000 population in Myanmar (1950-1974)

Population living under malaria risk areas in Myanmar,2011 High Risk Modrate Risk Low Risk Free 20% 18% 23% 39%

National Races

Pregnant Women & <5 yr Children

Miners

Children

Seasonal Migrant

Workers/ Farmers Forest-related workers

313, 0.190% 6, 0.004% 2843, 1.723% Pf Pv Pm Po Mix P.falciparum73.73 % P.vivax24.349 % P.malariae 0.19 % P.ovale 0.004 % Mix 1.723 %

Malaria Species in Myanmar

Malaria Vector in Myanmar

• Main Vector

– An. minimus

– An. dirus

• Local Vector

– An. Annularis (in Rakhine)

– An. Sundaicus (in Rakhine & Taninthayi)

• Secondary vector – An. culicifacies – An. aconitus – An. philippinensis – An. hyrcanus – An. maculatus

Community based Malaria Control in

Myanmar

Fever Patient

Treatment seeking behavior among malaria patients in village level

Before intervention After intervention

Fever Patient Shop to buy medicine Yanku(Quack) Home Medicine Health Center Shop to buy medicine Yanku (Quack) Home Medicine Health Center Incomplete treatment Fake Medicine High Cost Relapse, recrudescence Drug resistance Complete treatment Low Cost

High Mortality Low Mortality

Reliability of BHS and National Malaria

Malaria Volunteers in NMCP

• Malaria control programme started Malaria Volunteer since 2005.

• In the Eastern Shan State near the border with Thailand.

• Firstly, PDP ( Primary Drug Provider ) and then CORP ( Community Owned Resource Person ).

• Now, already trained 6100 malaria volunteers and trainings for volunteer is on going.

1. Stratum 1 a – high malaria risk area

2. Village in which health staff is non-residential 3. Crash immunization area with highly endemic

malaria

4. Village in high risk area in where Developmental project is being carried out

Criteria for selection of volunteers

who participate in malaria control

1. Must be resident of village 2. Acceptability by community 3. Willingness of volunteers

4. Priorities are given to volunteers (CHW , AMW , Ten household worker, ANMW , RH promoter , local NGOs , other primary health care providers etc.)

5. No gender preference 6. 18 years to 50 yrs of age

7. Can read and write Myanmar language and can speak local dialect

8. Occupation – not specify ( family has primary source of income )

Key activities of volunteers

• Provision of health education to community

• Impregnation of bed nets owned by community • Assists the health staff during the distribution of

LLIN in the village

• Provision of early diagnosis and treatment of uncomplicated malaria cases

• Referral of severe and complicated malaria patients to nearest hospital

• To report immediately to the health centre when there is unusually high occurrence of malaria or febrile patients in the community.

Early diagnosis and treatment of

malaria cases

• Allow to use RDT

• Allow to treat the uncomplicated malaria cases according to national treatment guidelines

• Encourage to refer the cases (complicated

malaria, malaria with pregnancy and <1yr old)

• But it is too far to reach within 24 hrs allow to treat <1yr and pregnant women

Community Involvement for sustainability of Volunteer

• Community cannot support in regular basis • Sometimes in kinds

• Incentives like perdiem and travel allowance when

they came to town for submission of report or referral of patients

• Some INGOs give award (in cash or in kind)

Challenges in Sustaining the Volunteers • Long term sustainability is very hard

• Because of many reasons such as;

- economic reasons – change of work/ change of work place

- social reasons – married and move to other village

- very remote area – very low education level to be trained as new volunteer

Private Medical Practitioners

• Myanmar Medical Association

• Quality Diagnosis and Standard Treatment of Malaria (QDSTM) Project

• 120 townships through Medical practitioners • Fixed and Mobile clinics in endemic areas

• PSI

• Franchising clinics • 220 townships

Myanmar Artemisinin Resistance

Containment

• Myanmar Artemisinin Resistance Containment frame work was developed

• MARC frame work was endorsed in April 2011

• In line with the WHO Global Plan of

Goal of MARC

• To prevent or at minimum , significantly delay the spread of artemisinin resistance parasites within the country and beyond its border

• To reduce transmission, morbidity and

mortality of Plasmodium falciparum malaria, with priority to areas threatened by

Objectives

• 1. To strengthen and improve access to and use of early diagnosis and quality treatment

according to the national treatment guidelines

• 2. To decrease drug pressure for selections of artemisinin resistance malaria parasites by

stopping the use of Artesunate Mono-therapies and sub-standard/fake drugs

• 3.To limit the transmission of malaria by intense mosquito control and personal protection

• 4.To increase migrant/mobile populations access to and use of malaria diagnosis , treatment and vector control measures including personal

protection

• 5. To support containment of artemisinin

resistant through advocacy and behavioural

change communication/ information, education and communication

• 6.To conduct studies and do operational research to support the development of evidence- based policies and strategies

• 7.To provide effective management and co-ordination to enable rapid and high quality implementation of containment strategy

Expected Output

• 1. Achieve 100 % coverage of risk population priority to resistant areas, through

multi-sectoral approach

• 2. Decrease drug pressure through rapid

elimination of AMT by replacement with ACT

• 3. Maximize effectiveness of transmission reduction by IRS, ITN/LLINs and other

personal protection and aims at 100% coverage of ITN/LLINs

Expected output

• 4. Target interventions at all age groups of migrants

• 5 . Intensify malaria surveillance to detect new foci of artemisinin resistance and mapping of migrants.

Village-wise Microstratification

• Malaria is focal disease; thus, it is

essential control to identify the areas and population at risk , which must be

prioritized preventive measures

• NMCP, WHO and UNICEF developed approached to microstratification

• 150 townships were finished microstratification activities

Stratum in Microstratification

• Stratum 1a. High malaria risk area

• Stratum 1b. Moderate malaria risk area

• Stratum 1c. Low malaria risk area

• Stratum 2. Potential malarious area

National Anti-malaria Treatment

Policy

• Artemisinin based Combination Therapy (ACT) was endorsed as a first line drug for P.

falciparum malaria since 2003.

• Revised in 2008 and 2011.

• Recommended ACT

Artemether+Lumefantrine, Artesunate+Mefloquine

Treatment Policy ( cont: )

• Single dose of Primaquine is recommended as a gametocidal drug for falciparum malaria

• P. vivax malaria is treated with Chloroquine 3 days followed by Primaquine for 14 days.

• For severe and complicated malaria parentral artemisinin is choiced and this should be

replaced by oral admi the patient

administration as soon as patient is able to swallow drug without vomiting

Treatment Policy ( cont: )

• treatment guidelines for Malaria volunteers in the villages was developed

• For the referral of severe and complicated cases pre-referral treatment should be given by the health care providers including Volunteers and BHS

Key Challenges NMCP

• Availability of Timely reporting and analysis

• Logistic issues with seasonal and remote geographical settings

• Sharing Information and updates among partners

• Population mobility producing many malaria problems including outbreaks

• Emergence of drug resistance Pf malaria

Best Practices in NMCP

• Team spirit – well practiced as VBDC team

• Deeply inspired with PHC approach – most of the key interventions go through BHS staff

• Community based malaria control interventions take place

• Well cooperated with the research institutions for TES and other studies

• Good collaboration with national and international Partners