Pharmaceutical Management for the Control of Malaria in

Pregnancy

Rima ShrettaMay 2, 2012

CORE meeting, Wilmington, Delaware

Background: IPTp

• By 2010, 37 countries had adopted IPTp (WMR, 2011)• SP for IPTp is free for pregnant women and available at health

facilities during ANC• Household survey data from 13 African countries 2008–2010

indicated that women who received two doses of IPTp during pregnancy in ranged from 4% in Namibia to 68% in Zambia (average: 24%)

• Data on IPTp coverage from national surveys remains limited

Background: Insecticide Treated Nets

• A total of 82 countries, of which 38 are in the African Region, distribute ITNs free of charge to for all persons at risk for malaria in accordance with WHO recommendations

• Mass distribution was the primary channel of distribution in followed by distribution through antenatal clinics

• Proportion of households owning at least one ITN in sub-Saharan Africa has risen from 3% in 2000 to 50% in 2011

• Despite the investment in LLIN distribution, global coverage still below the 80% target set by RBM and 85% by PMI

Background: Treatment

• 11 of 13 countries surveyed in 2007-8, fewer than 15% of children received an ACT. WMR (2011) estimates that about 65% of treatment needs are fulfilled for patients attending public health facilities (children)

• Limited data available for pregnant women for ACTs and quinine

• Coverage still below the 80% target set by RBM and 85% by PMI

• Anectdotal data: high percentage of quinine use for uncomplicated malaria in children and non-pregnant adults

Challenges

• Availability of SP: 0-100% (PMI)• Frequent and long stock-outs of SP. Data from PMI:

• Stock outs greater than 3 days: SP: 0-37.5% facilities

ITNs: upto 47% RDTs: upto 46%

• Number of days of stock outs of SP vary from a 16 days (data from PMI countries) to four months (MCHIP, 2011)

• Availability of LLINs: inadequate distribution of LLINs particularly at ANC level

• Use of SP for treatment: 1-25% health facilities (PMI)

Challenges

• PMI (2009-2011)• ACT stock outs: Up to 90% in some countries• Quinine stock outs: > 60% (tabs); Up to 63% (inj)

• Poor inventory management• Facilities with up to date stock cards: 27-78%

• Training• Providers with in-service training in IPTp: 36-96%• Providers with in-service training in SM: 36-100%

• Poor distribution• Difference between products ordered vs. received: 64%

Countries Reporting Stock Outs of SP at Central Level

Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 2010 2011

0

5

10

15

20

25

67

6

10

5

8

13

17

14

1920

19

SP Stockout

Total Countries Re-porting SP ProductsN

umbe

r of

Cou

ntri

es

Source: USAID|DELIVER Project. 2012. Procurement Planning & Monitoring Report – Malaria. Note: Quarters 2, 3, and 4 of 2011 include 6, 8, and 7 Nigerian states, respectively, reporting independently.

Countries Reporting Stockouts of Artemether/Lumefantrine Products at Central Level

0

2

4

6

8

10

12

14

16

18

Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2

2008 2009 2010 2011

Num

ber o

f Cou

ntrie

s

A/L 6x1 Stockout

A/L 6X2 Stockout

A/L 6x3 Stockout

A/L 6x4 Stockout

Total Countries Reporting A/L Products

Source: USAID|DELIVER Project. 2011. Procurement Planning & Monitoring Report – Malaria.

Percent of Facilities Stocked Out of SP on Day of Visit: One Country Example

Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 12009 2010 2011 2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Source: USAID|DELIVER Project. 2012. PMI End Use Verification Activity. Data provide a snapshot of commodity availability and are not nationally representative.

Zambia: Case Study

• In 2008, 50.3% of pregnant women reported sleeping under a mosquito net the previous night and 43.2% reported sleeping under a treated net

• SP is stocked out much of the time in health facilities and at the central level and ITNs are available in health facilities only periodically

• Misuse of SP for case management• Procurement and distribution not efficient• Responsibilities of the NMCC and Pharmacy Unit in

addressing stockouts not clearly definedSource: MCHIP, 2010

Zambia: Case Study

• A 2008 assessment by HSSP in Central and Eastern provinces found that of 54 facilities surveyed, 95% had experienced a stock-out of SP in the period of July 2007 to July 2008

• No procurement plan in place-procurement according to funding level available

• Lack of accurate consumption data from health facilities challenging quantification

• Delays in the receipt of donor funds

Source: MCHIP, 2010

Improving access to Malaria in Pregnancy Strategies by Pharmaceutical Management and Health Systems

Strengthening

• Diagnosis and treatment with ACTs/quinine

• Intermittent preventive treatment of pregnant women (IPTp)

• Safe motherhood and f-ANC strategies including detection and treatment of anemia

• Long lasting insecticide-treated nets (LLINs)

Selection and Policy Quantification and

ProcurementStorage,

Distribution and Inventory Management

Prescribing, Dispensing and Patient Adherence

Governance

InformationFinancing

Service Delivery

Human Resources

Access

Selection and Policy

• Lack of clarity in policy guidelines causing uncertainty among health workers including timing of doses

• Suspicion in promoting SP for IPTp, but using ACTs for treatment

• Free vs. payment for products

Selection and Policy

Quantification and Procurement

• Poor quantification• Lack of procurement plan – uncoordinated

procurement• Lack of consumption and burden data• Problems with management of stocks at all levels

Quantification and

Procurement

Storage and Distribution

• Poor storage capacity: LLINs• Poor distribution to peripheral areas• Transport• Poor reporting systems and inventory management

Storage, Distribution and Inventory Management

Prescribing, Dispensing and Use

• Use of SP for treatment – stock outs and resistance development

• Lack of water and cups for administering DOT• Concerns about administering SP late in pregnancy• In-service training and supervision

Prescribing, Dispensing and Patient Adherence

Recommended Pharmaceutical Management Intereventions• Clear guidelines emphasizing efficacy (even in areas with 25%

SP treatment failures, IPTp with SP provides benefits to pregnant women)

• Financing• Procurement planning• Forecasting• Distribution plans/microplanning• IEC/BCC• Training in case and supply chain management and IPTp• Strengthen routine distribution of nets through ANC• Strengthen monitoring and data reporting on IPTp as well as

treatments given during pregnancy