NIATA MALARIA EPAI BA MAMA YA ZEMI

CRUSH MALARIA IN PREGNANCY IN DEMOCRATIC REPUBLIC OF CONGO

NIATA

MALARIA

This Presentation will discuss:

Background Information on DR CongoBackground on prevalence of Malaria, international strategiesObjectives and Intervention of NIATA MALARIAEvaluation and Structure

THE DEMOCRATIC REPUBLIC OF THE CONGO

DR Congo in ContextCentral African country of 55 million peopleAverage annual per capita income of $110 USOnly 1% of government budget is allocated to public health

Over 9 Years of war and political instability have affected the population’s healthNo socialized healthcare Patients must pay or provide all materials, such as gloves

Health in DR Congo

MMR: 940/100,000 with about 25% from MalariaCMR: 210/1000IMR: 130/1000< age 5 MR: 115/1000LBW: 15%

68% of Women have antenatal visits Malaria is the leading cause of morbidity and mortality in the country

Structure of Health System

National level: Public Health Minister Provincial Level: Provincial Health Inspector District Level: 3 divisions: General, Medicine, & HygieneZone Level: Local Directors for ~150,000 people, includes 1 hospital and 15 health clinics (Barumbu)

KINSHASA

BARUMBU

Barumbu, KinshasaBarumbu is a health zone of 100,000 people Home to numerous social groups including: women’s groups, religious organizations, a hospital, and a community center

In Kinshasa, population 5 millionKinshasa’s population has increased by 500,000 in 2 years because of people displaced by war in the east High population density, poor sanitation

Malaria is the principal cause of morbidity and mortality in the city

Malaria in DR Congo

80% of pregnant women test positive for trophozoitesOnly 5% receive preventive care1.5% of pregnant women use bednets (ITN) 45% of children under 5 receive anti-malarial drugs

95% of malaria is from p. falciparumMost patients with fever self-medicate at home with anti-malarial drugsIncreased ResistanceBeliefs that fevers are treatable with traditional remedies, or will run their course

National Malaria Control Program (NMCP)

The control of malaria was deemed a priority health action and the following strategic plan was created:Train: - 39 physicians and 680 health workers in management of severe malaria- 70 laboratory technicians in diagnosis- Conduct operational research on chloroquine sensitivity and ITN utilizationImplement Roll Back Malaria campaign (1999)

MALARIA AS A MATERNAL & CHILD HEALTH PROBLEM

(WHO, 2003)

Agreement with 2000 Abuja Declaration

African heads of state agreed that by 2005 the following could be achieved:

At least 60% coverage of pregnant women at risk of malaria with the most suitable combination of personal and community protective measures

At least 60% of all pregnant women at risk of malaria, especially those in their first pregnancies, should have access to intermittent preventive treatment

Strategic Framework for Malaria Control during Pregnancy

Insecticide-Treated Nets (ITN)Intermittent Preventive Treatment (IPT)Effective case management of malarial illness

Intermittent Preventive Treatment (IPT)

2000 WHO Expert Committee on Malaria agreedAll pregnant women should receive at least 2 doses of Sulphadoxine-pyrimethamine (SP or Fansidar) after “quickening,” during routinely scheduled antenatal clinic visitsReduces anemia and placental malaria infection at delivery

We Propose a Health Intervention for DR Congo that Will:

Institute the Recommendations of the Abuja Conference and the World Health OrganizationEngage in the Global Roll Back Malaria Campaign Build upon the DR Congo’s own recognition of the gravity of malaria as a public health concernRecognize the efforts of the National Malaria Control Program (NMCP)Partner with existing anti-malarial campaigns, such as PSI and social marketing/distribution of ITN

NIATA MALARIA: CRUSH MALARIA IN

DR CONGOObjective #1: By the end of the project, the percentage of antenatal health workers in 15 clinics in the district of Barumbu trained in the WHO’s recommended treatment regimen for IPT (intermittent preventive treatment) and in BCC strategies for promotion of ITNs (insecticide treated nets), will increase ~20% to at least 90%

INTERVENTION

Training of Health Workers in Zone of Barumbu, Kinshasa, DR Congo

Inputs: Project staff (see organizational chart); PSI personnel; teaching materials

PROCESS

 Initial training will be held at the zone hospital (10-15 minutes from farthest clinic)Training will occur in 5 waves, 1 worker from each clinic (total 15) per 2-day session, in order to respect the staffing requirements of each clinic Ultimately, 5 workers from each clinic (total 75) will receive training over a ten-day period.

PROCESS

Training will consist of: review of BCC in prevention of malaria, particularly as it applies to pregnant women,instruction in IPT protocol and promotion of use of ITNs.

Methodologies will include role-play with anticipated questions from both fellow health workers and patients. A pretest will be administered to assess baseline knowledge; a post-test will assess progress and competency. Should post-test performance be substandard, a decision by the Project Coordinators (Trainer of Trainers) will determine whether to pursue additional training or to seek a replacement.

OUTCOMES

Increased number of health workers with knowledge in two areas, as measured by post-test performance, and observed competency :

1)      Current recommendations for use of the IPT regimen

2)      Counseling skills in promotion of ITN 

OBJECTIVE #2

By the end of the project, the percentage of pregnant women seen for routine antenatal visits in Barumbu’s 15 antenatal clinics who receive at least one dose of intermittent preventive medication (IPT), sulphadoxine-pyrimethamine (SP) will increase from 5% to at least 80%.

 

INTERVENTION

Delivery of IPT to Clinic Attendees in Zone of Barumbu

Inputs: Program staff; Medication [Public/private partnership: Roche Pharmaceuticals, manufacturer of SP, is donating all medication for this pilot project in cooperation with the Ministry of Health of the Democratic Republic of Congo.]

PROCESS

Training clinic health workers (30-50) at each of Barumbu’s 15 clinics: special training of 5 workers from each participating clinic in the use of ITP and ITN. They, in turn, will be responsible for training the health workers in their respective clinics, using techniques acquired during TOT sessions.

PROCESSMedication stock maintenanceAdequate supplies of SP will be stocked in 15 clinics in Barumbu, DR Congo. Quantity stocked for each clinic will be calculated based on two doses per number of women who attend prenatal clinics, based on the previous year’s clinic records.Medication administration All pregnant women will be advised to take at least 1 dose of SP/ IPT after "quickening," 2 doses if possible, during routinely scheduled antenatal clinic visits, no matter how late in pregnancy they present to the clinic.

EVALUATION

Baseline data Data gathered from TOT regardingPre-test and Post-test of knowledge of trainees Number of clinic facilitators who attended trainingNumber of trainees successfully trained Number of health workers receiving clinic trainingPercentage of women who visited the 15 antenatal clinics who received one dose of IPTPercentage of women who visited the 15 clinics who received 2nd dose of IPTPercentage of women who used ITN to help evaluate PSI’s efforts

TIME FRAME

Duration: 1 year2 weeks : Training of Trainers, 2 work days per training, 5 waves1 month: Trained workers train colleagues10 months: application of intervention2 weeks: evaluation

OUTCOMES

Increased number of pregnant women in Barumbu receiving at least one dose of IPT during pregnancyIncreased knowledge of medical prevention of malaria during pregnancy in Barumbu’s health workers and pregnant women

IMPACT Decrease incidence of malarial disease in pregnant women in Barumbu:

Decrease incidence of anemia in pregnant women in BarumbuDecrease LBW and infant mortality rates in Barumbu

Decrease the economic impact of malaria on families, health resources, and the community as a whole

CRUSH MALARIA IN PREGNANCY IN DR CONGO

                                                  

NIATA MALARIA

MONITORINGProject Coordinators/Trainer of Trainers will make weekly site visits to observe implementation and adequacy of training at the individual clinic level and to troubleshoot.

1-day refresher course for clinic trainers will be held every 3 months, to incorporate feedback from the Multidisciplinary Advisory Board, including community input.

The Multidisciplinary Advisory Board will meet bimonthly for progress reports, feedback, and troubleshooting. It will issue recommendations as indicated. Project manager will act as liaison between the District Director of Health, PSI and Project Coordinators/TOT as interim needs arise.

MONITORING

• Records will be kept of # of antenatal visits during which IPT was advised and taken.

• Project Leads will make weekly site visits to individual clinics to assess implementation, record keeping, medication supply and to troubleshoot.

• Records will be kept of # of antenatal visits when ITN was used the night prior to the visit, to Provide data for collaborative project with PSI.

 

PROGRAM STRUCTURE

Multidisciplinary Advisory Board

Project Manager

Project AdministrativeAssistant

Financial Administrator

Director, “Zone De Sante”

PSIPSI Partnership

Research Analyst(Contract Consultant)

Public Relations Coordinator

Project Coordinators(TOT)

Project Coordinators(TOT)

Project Coordinators(TOT)

25 Clinic Facilitators(5 from each clinic)

25 Clinic Facilitators(5 from each clinic)

25 Clinic Facilitators(5 from each clinic)

Sustainability Advantages of NIATA MALARIA

 Improves possibility of expanding scope of implementation of ITP and ITN through:

Training of Trainers, antenatal clinic health workers and community workers (PSI)Utilization of established antenatal care delivery systemCollaboration with established social marketing organization (PSI) with expertise in health promotion through community activities and mediaInvolves community representatives on Advisory BoardWorks in conjunction with objectives of National Malaria Control Program

NIATA MALARIA is Cost-EffectiveIs a cost-effective intervention, as shown by studies in Kenya, Malawi, Tanzania (decision re: budgetary commitment must be decided by MOH after review of project evaluation report)

Cost-Effectiveness of ITP: 2 Doses SP/ area with HIV seroprevalence < 10% (HIV/AIDS prevalence = 5.07%)Potential costs of malaria during pregnancy: Infant mortality, maternal mortality, anemia, hospital care of LBW, and ongoing health needs of LBW, including medication, special medical needs, home care, and lost productivity within family and communityDose of SP 0.10 -0.15 $US per dose in DRC, Analysis indicates cost savings if <0.40 $US per doseCalculated cost per DALY of IPT in area of no resistance is $12 (highly attractive if < $ 25)