ACCESS project in Tanzania: improving access to effective malaria treatment

Since 2003, the ACCESS project has been devoted to analyzing and improving access to effective malaria treatment and care in Tanzania. One of the initiative’s achievements, in addition to generating empirical evidence on access obstacles, has been the development of a generic analysis and planning framework for the issue of general access to medicines and healthcare, which can be applied to other diseases and contexts. The second phase of the project started in May 2008, building on the results and experiences gathered from ACCESS I. ACCESS II focuses on interventions to improve access to malaria treatment. The project is being implemented by the Ifakara Health Institute (IHI) with technical and scientific support from the Swiss Tropical Institute, as well as technical and financial support of the Novartis Foundation.

Findings to date

The results of an independent final evaluation at the end of 2007 showed that the local population’s illness perception with regard to malaria symptoms now better coincides with evidence-based disease concepts. This is thanks to information campaigns run by ACCESS I and other programs. Previously, many Tanzanians, also in Kilombero and Ulanga districts, believed that convulsions seen in severe cases of malaria were caused by evil spirits. Therefore they initially tended to go to a traditional healer for treatment.

Data collected by ACCESS I underline that 89% of investigated fever cases in children were treated with a recommended malaria drug. For adults, the figure was 81% (see no. 4 in the graph below).

Hetzel et al. BMC Public Health 2008, 8:317

Although ACCESS I has helped decrease the number of fever cases, the main remaining challenges are the delay in patients seeking care and the correct dosage of recommended anti-malarials (see numbers 5 and 6 in the graph above). For example, only 43% of children with fever investigated received a recommended malaria drug in time and in the correct dosage.

The delay in treatment can be linked to the geographical distances and financing problems. An ACCESS survey on malaria during cultivation and harvest time, when many farming families spend weeks and months in temporary shelters in their rice paddies away from home, highlighted the geographical obstacle that often delays treatment. The need to first sell animals, rice or furniture, and/or to rent a bike to reach a health facility and afford drugs was also shown to delay treatment (although 90% eventually gained access to treatment).

The second challenge – the correct dosage – is linked to malaria case management in health facilities. ACCESS data indicated that only 54% of 253 interviewed healthcare providers were trained in malaria case management, and only 35% in Integrated Management of Childhood Illnesses (IMCI).

ACCESS addresses this issue by the assessment of each healthcare facility of the two districts covered by ACCESS team members and representatives of the Council Health Management Team of the district. The health facilities are assessed with regard to physical environment and equipment, job expectations and staff skill, facility management and administration, and staff motivation and client satisfaction. Each facility is scored based on a set of weighed indicators. According to levels of improvement (in %) from one assessment to the next, the staff of each facility receive a reward (initially up to USD 75 per staff member per year).

ACCESS also improved the availability and geographical accessibility of adequate malaria services by convincing the Tanzania Food and Drugs Authority (TFDA) and the US Management Sciences for Health (MSH) to extend their Accredited Drug Dispensing Outlet program (ADDO) to the project districts. ADDOs are licensed to sell a limited number of prescription medicines, which include the first-line malaria treatment Coartem. ADDO shop owners and sales assistants must have basic medical training and additional ADDO specific training. 553 new ADDOs have been set up in both districts and the rest of the Morogoro region. ACCESS data shows that quality of advice given in ADDOs is substantially better than in former ordinary drug shops (80% of costumers in 2007 compared to 35% in 2004 have received correct advice). Nevertheless there are challenges ahead, as the geographical accessibility has not been improved for many remote villages.
 

ACCESS II – combining supply and demand interventions

To address the above-mentioned challenges, ACCESS II looks at both the demand and the supply side, combining five intervention components: the Rapid Diagnostic Test for malaria, and assessment and strengthening of health facilities on the supply side, and sensitization in schools and communities, income-generating measures for women’s groups, and health insurance schemes on the demand side.

The Rapid Diagnostic Test (RDT) has been introduced by ACCESS as a pilot in six health facilities and the hospital of Ifakara. Made available by the Ministry of Health and Social Welfare with financing from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, the easy-to-administer test diagnoses malaria very effectively (only 0.5% of patients with a negative result are falsely treated with an anti-malarial compared to 22% when testing with a microscope). The positivity rate decreased from 58% to 42%. The RDT therefore improves malaria diagnosis and detection of non-malaria fever-cases where other treatment should be given. Currently, the ACCESS project is part of a national group to prepare the country-wide roll-out of RDT, aiming to include the Ulanga and Kilombero districts in the first roll-out phase.

To address the issue of quality of care in health facilities, and to avoid people turning back to informal healthcare service providers when not satisfied with the service in health facilities, ACCESS II continues the quality of care assessments and trains healthcare personnel, e.g. in infection control and IMCI. The increased utilization rates in health facilities for cases of suspected malaria can be attributed partially to the ACCESS project’s intensive information campaigns conducted during the first phase. The campaigns inform people of the causes of malaria, its symptoms, how to treat it correctly and where to get treatment.

On the demand side, ACCESS II continues with sensitization programs, yet with more emphasis on participatory information campaigns with community involvement. This is not only more cost-effective but also more sustainable than large-scale road shows, which were the main communication channel under ACCESS I. Currently, the focus is on malaria sensitization elements in school curricula and hence on reaching children. They are not only the future generation, but often care-takers of their younger siblings, e.g. when their parents move to temporary shelters in the paddies during cultivation time.

In order to address the affordability of healthcare on the demand side, ACCESS supports women’s groups with grants, which they use for investments in productive income generation (e.g. poultry, food kiosks and vegetable gardens). In 2008, five existing groups with more than 150 women and 900 beneficiaries in their households were supported, each with a sum of up to USD 2,500. In 2009, another five groups from remote villages in the two districts will be added. Members of those groups are expected to pay a membership fee of USD 8 as well as a monthly amount of USD 0.80 into the group account. These contributions give them access to business and emergency loans for immediate social and medical problems. All women’s groups receive training on cooperative and organizational aspects as well as entrepreneurial skills. In return for the project’s grant, the women commit themselves to conducting community sensitization with regard to malaria and other health issues. At the same time, they commit themselves to sleeping under bed nets, using ante- and post-natal care in case of pregnancy and joining the Community Health Fund.

The Community Health Fund is a Tanzanian prepayment mechanism at district level whereby members pay an annual fee that allows them to use the health services of their facility for free. The Ulanga district’s Health Fund was set up in 2006, but was not functional. For that reason, the ACCESS project started supporting the district in organizing a situation analysis workshop with all responsible parties, develop an action plan based on the shortcomings, and train the Fund’s representatives on the roles and responsibilities of each organ, management and administration.

The Council Health Service Board responsible for the Fund reported an increase in membership from 1,080 to 1,955 households between April and July 2009 after the first sensitization campaign. Moreover, the flow of collected funds from the district level back to health facilities has begun to work: several health facilities have been able to upgrade their equipment and infrastructure (e.g. placenta pits, examination coaches and drugs) according to gaps identified by quality of care assessment. So far, USD 8,000 have been paid to the various facilities.

In 2009, ACCESS II is focusing on further increasing the number of Health Fund and women’s group members, on strengthening women’s groups to run additional viable income generation activities, and on improving quality of care based on assessment results.