NIATA MALARIA EPAI BA MAMA YA ZEMI

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NIATA MALARIA EPAI BA MAMA YA ZEMI
CRUSH MALARIA IN PREGNANCY IN DEMOCRATIC REPUBLIC
OF CONGO
NIATA MALARIA
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This Presentation will discuss

• Background Information on DR Congo
• Background on prevalence of Malaria,
  international strategies
  
• Objectives and Intervention of
• NIATA MALARIA
• Evaluation and Structure

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THE DEMOCRATIC REPUBLIC OF THE CONGO
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DR Congo in Context

• Central African country of 55 million people
• Average annual per capita income of 110 US
• Only 1 of government budget is allocated to
  public health

• Over 9 Years of war and political instability
  have affected the populations health
  
• No socialized healthcare
• Patients must pay or provide all materials, such
  as gloves
  

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Health in DR Congo

• MMR 940/100,000 with about 25 from Malaria
• CMR 210/1000
• IMR 130/1000
• LBW 15

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

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Structure of Health System

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

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KINSHASA
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BARUMBU
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Barumbu, Kinshasa

• Barumbu is a health zone of 100,000 people
• Home to numerous social groups including womens
  groups, religious organizations, a hospital, and
  a community center
  

• In Kinshasa, population 5 million
• Kinshasas 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

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Malaria in DR Congo

• 80 of pregnant women test positive for
  trophozoites
  
• Only 5 receive preventive care
• 1.5 of pregnant women use bednets (ITN)
• 45 of children under 5 receive anti-malarial
  drugs
  

• 95 of malaria is from p. falciparum
• Most patients with fever self-medicate at home
  with anti-malarial drugs
  
• Increased Resistance
• Beliefs that fevers are treatable with
  traditional remedies, or will run their course

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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 utilization
  
• Implement Roll Back Malaria campaign (1999)

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MALARIA AS A MATERNAL CHILD HEALTH PROBLEM
(WHO, 2003)
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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

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Strategic Framework for Malaria Control during
Pregnancy

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

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Intermittent Preventive Treatment (IPT)

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

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We Propose a Health Intervention for DR Congo
that Will

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

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NIATA MALARIA CRUSH MALARIA IN DR CONGO

• Objective 1 By the end of the project, the
  percentage of antenatal health workers in 15
  clinics in the district of Barumbu trained in the
  WHOs 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

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INTERVENTION

• Training of Health Workers in Zone of Barumbu,
  Kinshasa, DR Congo
  
• Inputs Project staff (see organizational
  chart) PSI personnel teaching materials
  

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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.
  

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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.

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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
•  

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OBJECTIVE 2

• By the end of the project, the percentage of
  pregnant women seen for routine antenatal visits
  in Barumbus 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.
•  

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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.

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PROCESS

• Training clinic health workers (30-50) at each of
  Barumbus 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.

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PROCESS

• Medication stock maintenance
• Adequate 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 years 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.

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EVALUATION

• Baseline data
• Data gathered from TOT regarding
• Pre-test and Post-test of knowledge of trainees
• Number of clinic facilitators who attended
  training
  
• Number of trainees successfully trained
• Number of health workers receiving clinic
  training
  
• Percentage of women who visited the 15 antenatal
  clinics who received one dose of IPT
  
• Percentage of women who visited the 15 clinics
  who received 2nd dose of IPT
  
• Percentage of women who used ITN to help evaluate
  PSIs efforts

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TIME FRAME

• Duration 1 year
• 2 weeks Training of Trainers, 2 work days per
  training, 5 waves
  
• 1 month Trained workers train colleagues
• 10 months application of intervention
• 2 weeks evaluation

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OUTCOMES

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

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IMPACT

• Decrease incidence of malarial disease in
  pregnant women in Barumbu
  
• Decrease incidence of anemia in pregnant women in
  Barumbu
  
• Decrease LBW and infant mortality rates in
  Barumbu
  
• Decrease the economic impact of malaria on
  families, health resources, and the community as
  a whole

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CRUSH MALARIA IN PREGNANCY IN DR CONGO
NIATA MALARIA
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MONITORING

• Project 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.

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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.
•  

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PROGRAM STRUCTURE
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Multidisciplinary Advisory Board
PSI PSI Partnership
Director, Zone De Sante
Project Manager
Project Administrative Assistant
Financial Administrator
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)
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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 system
  
• Collaboration with established social marketing
  organization (PSI) with expertise in health
  promotion through community activities and media
  
• Involves community representatives on Advisory
  Board
  
• Works in conjunction with objectives of National
  Malaria Control Program
  

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NIATA MALARIA is Cost-Effective

• Is 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
  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 community
• Dose of SP 0.10 -0.15 US per dose in DRC,
  Analysis indicates cost savings if
  dose
  
• Calculated cost per DALY of IPT in area of no
  resistance is 12 (highly attractive if