Improving access to effective malaria treatment:
The ACCESS project in Tanzania
Access to healthcare and medicines remains a challenge for the majority of people in developing countries. Availability and affordability of safe and efficacious medicines are crucial factors impacting access, which in turn affects the ability to combat diseases, as well as child and maternal mortality. The complexity of the access issue, however, extends far beyond the availability of affordable medicines and even the healthcare system. Many different factors and causes must be taken into account and targeted.
The Novartis Foundation for Sustainable Development (NFSD) and its partners have developed an access to healthcare framework, defined as the degree to which a patient’s resources, needs and expectations (demand) are aligned with a healthcare system’s services and providers (supply). Access to healthcare and medicines can only be sustainable if the local healthcare system and services meet demand. Drawing on this framework, the ACCESS project aims to analyze and improve access to effective malaria treatment and care in four rural districts in Tanzania, in particular for pregnant women and children under five years of age. Supported by the foundation in collaboration with the Ifakara Health Institute (IHI) and the Swiss Tropical and Public Health Institute (Swiss TPH), the ACCESS project intervenes on both the supply and the demand side of access.
Analyzing the access obstacles to
effective malaria treatment
During the first project phase from 2003 to 2007, ACCESS generated empirical evidence on obstacles to access and developed a generic analysis and planning framework (see figure 1 on page 2) for the issue of access to medicines and healthcare, which can be applied to other diseases and contexts. Looking at both the supply and the demand side, the framework defined five access dimensions (the 5 As): Availability, Accessibility, Affordability, Adequacy and Acceptability. The project’s interventions are designed based on this framework.
Source: Obrist B. et al. (2007)
ACCESS I informed people in the project districts on the causes, symptoms and treatment of malaria through social-marketing campaigns in order to spur demand of treatment in case of need. Previously, many Tanzanians tended to seek treatment with a traditional healer, often believing that convulsions due to severe malaria were caused by evil spirits. The results of an evaluation towards the end of 2007 indicated that the local population’s illness perceptions with regard to malaria symptoms coincided better with evidence-based disease concepts.
At the end of the first phase, ACCESS collected data showing that 96% of investigated fever cases were treated with a malaria drug (see number 3 in figure 2). Though the overall number of fever cases in the communities and delays in treatment seeking could be reduced (see number 5), patients do not always receive the recommended anti-malarial in the correct dosage (see numbers 4 and 6). Only 22% of the investigated fever patients received a recommended malaria drug in time and in the correct dosage.
Source: Alba S. et al. (2010)
The low number of correct dosages can be explained by the quality of care in health facilities. Only 54% of health workers observed in the 2010 assessment, for instance, have been trained in Integrated Management of Childhood Illnesses which includes malaria case management.
Assessing quality of health services and bringing medicines closer to people
Effective malaria treatment largely depends on quality health services, e. g. appropriate diagnosis, medicines and treatment. To improve quality, ACCESS I introduced a tool to assess the performance of health services with regard to physical environment and equipment, job expectations and staff skills, facility management and administration, as well as staff motivation and client satisfaction. The assessment result is a total score across all of these areas. According to how significantly the score has improved from one assessment to the next, staff members of each facility receive an annual reward between 25,000 and 100,000 TSH (16-66 USD). The assessments are conducted by the Council Health Management Team of the district with support of the ACCESS project team. Better quality of health services results in higher utilization rates and ultimately in better treatment outcomes and reduced mortality.
Treatment delays were addressed by convincing the Tanzania Food and Drugs Authority (TFDA) and the US Management Sciences for Health (MSH) to extend their Accredited Drug Dispensing Outlet (ADDO) program to the project districts. ADDOs are licensed to sell a limited number of prescription medicines, which include the first-line malaria treatment Coartem©. The proportion of patients who received the right drug and medical advice according to their symptoms in such private for-profit drug shops improved to 80% in 2008, compared to 35% in preexisting outlets. Today, there are 2,215 ADDOs in 8 out of 22 Tanzanian regions. In the Morogoro region alone (in which the project districts are situated), 551 ADDOs have been set up. Once roll-out is completed in the remaining 13 regions, more than 7,000 ADDOs will cover the entire country.
Improving access to healthcare through supply and demand side interventions
The second phase of the project started in 2008, building on the previous results and learnings. ACCESS II looks at both the demand and the supply side, combining five intervention components.
1) Quality of health service assessments
To address the issue of quality, ACCESS II continues with the assessments of health services and training of healthcare personnel. As mentioned above, not only infrastructure and equipment, but also job expectations, motivation and clinical skills of healthcare staff, as well as facility management and patient satisfaction are continuously measured. Improvements in quality of services are rewarded through a performance-based incentive system.
Results show that in 2010, the Ulanga district achieved a total score of 78% and an overall improvement of 15% across all quality indicators compared to 2009 figures. The score in the Kilombero district, however, increased by only 2% (from 63 to 65%). This trend in Kilombero can be attributed to unsatisfactory performance of private for profit health facilities. While staff motivation and health service administration and management improved from 2009 to 2010, professional clinical skills and knowledge are still unsatisfactory. Hence, in the 30 lowest performing facilities, the ACCESS project will facilitate on-the-job training.
The foundation is currently working together with Vodafone on the development of a mobile phone-based version of this performance assessment tool. The current paper-based tool comprises a rather detailed list of indicators, and questionnaires and checklists require a large number of copies. Data handling and analysis is complex as in each round 162 healthcare facilities are assessed. Moreover, the data entry, cleaning and analysis are lengthy processes. The m-health-based tool will allow for a more viable and time-efficient performance assessment approach, which requires less financial and human resources to be scalable for the rest of Tanzania.
2) Rapid Diagnostic Test for malaria
To strengthen the supply side, ACCESS also introduced the Rapid Diagnostic Test (RDT) for malaria as a pilot in six health facilities and the hospital of Ifakara. The RDT has been made available by the Tanzanian Ministry of Health and Social Welfare with financing from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. The test is easy to administer and diagnoses malaria efficaciously: The proportion of malaria-positive fever cases decreased from 58% to 42%. Healthcare personnel also acts upon the results: only 0.5% of patients with a negative result are wrongly treated with an anti-malarial as opposed to 22% when testing with a microscope. The RDT therefore improves malaria diagnosis and facilitates detection of non-malaria fever-cases where other treatments should be given.
Currently, the ACCESS project is part of a national group to facilitate the country-wide roll-out of RDT, still aiming to include the Ulanga, Kilombero, Kilosa and Gairo districts in the early roll-out phase.
3) Social-marketing campaigns to create demand for effective malaria treatment
On the demand side, ACCESS II continues with sensitization programs, focusing more on participatory community-based campaigns. Emphasis is placed on social-marketing campaigns in school curricula; children are not only the future generation, but also often care-takers of their younger siblings especially during cultivation time when their parents move to temporary shelters. ACCESS has reached 67 % of all primary schools (156 schools) in Kilombero and Ulanga districts. In total, 5,000 persons have been trained.
Thanks to various information campaigns, the proportion of convulsion and fever cases (common symptoms of malaria) treated in health facilities has increased. Studies also show that the knowledge about causes, symptoms and treatment of malaria has increased among school children.
4) Women saving groups to raise income for accessing healthcare
To address the affordability of healthcare, ACCESS supports ten women saving groups with grants, which they can loan to their members for investment in profitable income generation. With the micro-credits, women can start small businesses such as piggery, beer brewing, food kiosks and bee keeping. The project also trains women in entrepreneurship and cooperative formation.
68% of the group members have experienced an average monthly gain of more than 30’000 TSH (USD 20) from these activities. This income can be reinvested in education and the health of the family.
In return for the project’s grant, women also commit to sleeping under bed nets, using ante- and post-natal care and to conducting community sensitization with regard to malaria and other health issues.
5) Community Health Funds for better access and financial protection of the population
The Community Health Fund (CHF) is a Tanzanian prepayment mechanism at district level whereby members pay an annual fee that allows them to use the health services of their nearest facility for free during a whole year. The ACCESS project has supported district authorities in Ulanga to develop an action plan, as its CHF was not functional. The project has also trained the Fund’s representatives on management and administration as well as roles and responsibilities of each institution.
By the end of 2010, over 4,600 households with approximately 20,000 beneficiaries in the Ulanga district were registered as members of the CHF. Given the target that 60% of the district population should be covered by the CHF, the current coverage rate reaches an encouraging 14.5% after only two years of intervention. Moreover, the flow of collected funds from the fund at 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 performance assessments.
Ensuring sustainability and scaling up
Results to date are promising. From 2004 to 2008, data show that the proportion of investigated fever cases treated with an anti-malarial within 24 hours increased from 66% to 89%, indicating improved and prompter treatment-seeking behavior (see number 5 in figure 2). The overall mortality for children under five years of age has decreased from 28.4 to 18.9 cases per 1,000 person-years as part of a longer trend dating back to 1997. This is partly due to the ACCESS interventions and the national program on insecticide treated nets, as malaria is a major cause of overall child mortality.
A final evaluation of ACCESS will show to what extent the quality of health services has been improved, in particular providers’ compliance with malaria treatment guidelines, and shed more light on the impact of the interventions with regard to malaria cases (morbidity) and ultimately the reduction of child and maternal mortality.
To ensure sustainability beyond ACCESS II, the team is working on integrating project components into district health plans, e.g. funds for conducting regular assessments of health services and for rewarding performance of health workers. Furthermore, the m-health-based performance assessment tool will facilitate effective supportive supervision managed by the district authorities. Though the second phase of ACCESS will come to an end by December of 2011, the partners are currently analyzing whether and which project components will be scaled up to the whole region of Morogoro or even beyond.