Learning from experience Seasonal chemoprevention as an effective preventive strategy for children in the

Produced by Malaria Consortium as part of the Unitaid-funded ACCESS-SMC project Contents

2 Introduction

5 The project

6 Project design SMC medication

8 Achievements

11 The cost of seasonal malaria chemoprevention

12 Approaches used to scale up seasonal malaria chemoprevention

Health workers administer SMC medication, 20 Continuity of seasonal malaria chemoprevention post ACCESS-SMC

22 Key learning

24 Recommendations Acknowledgements Moving the seasonal malaria chemoprevention This learning paper was prepared by Malaria Consortium and made possible 25 through funding by Unitaid under the Achieving catalytic expansion of seasonal coverage agenda forward malaria chemoprevention in the Sahel (ACCESS-SMC) project. The views expressed do not necessarily reflect those of Unitaid.

ACCESS-SMC is a Unitaid-funded project, led by Malaria Consortium in partnership with Catholic Relief Services, which is supporting National Malaria Control Programmes to scale up access to seasonal malaria chemoprevention to save children’s lives across seven countries in the Sahel. http://access-smc.org • http://www.unitaid.eu/en

1 What is seasonal malaria chemoprevention? Introduction SMC is a relatively new and effective intervention to prevent malaria in children Malaria in the Sahel as long lasting insecticidal nets and operational support can under five — those most vulnerable to the disease’s effects. It involves In sub-Saharan , malaria remains improved case management tools, such be safely administered the intermittent administration of full the leading cause of morbidity and as rapid diagnostic tests for malaria, by community health treatment courses of an antimalarial mortality, especially in young children. and -based combination workers in resource- medicine to children in areas of high An estimated 285,000 children died from therapy drugs. Despite their proven constrained countries. transmission of malaria during the malaria before their fifth birthday in effectiveness, access to and acceptance This paper highlights rainy season. WHO recommends SMC 2016 despite the notable achievements of these tools varies. As a result, there the positive experience with sulfadoxine-pyrimethamine plus made in reducing malaria cases and is unacceptably high morbidity and of ACCESS-SMC, the key amodiaquine (SP+AQ), which prevents deaths since 2000.[1] Out of the 15 mortality attributable to malaria among successes, the main constraints malarial illness by maintaining therapeutic countries carrying 80 percent of the the biologically most vulnerable groups: and the remaining gaps for antimalarial drug concentrations in the global malaria burden, all but one are under-fives and pregnant women. universal access by eligible blood throughout the period of greatest located in sub-Saharan Africa,[2] with Emerging resistance of malaria parasites children to this life-saving malarial risk. many in the Sahel region. Targeting to artemisinin and of mosquitoes to intervention. commonly used insecticides threatens malaria prevention and treatment efforts This intervention is recommended: in this region is, therefore, of paramount to reverse progress that has been importance if global elimination goals made, and there is not likely to be a • where malaria transmission and more are to be met. highly effective for than 60 percent of clinical malaria cases many years to come. It is, therefore, occur during a period of four months imperative that the interventions coinciding with the rainy season Malaria and the Sustainable currently at our disposal are used more Development Goals effectively and in ways that achieve a • where the clinical attack rate for malaria is greater than 0.1 attacks With the introduction of the Sustainable rapid and sustainable impact. There per child per transmission season in Development Goals (SDGs), governments is also increasing recognition that the target age group (children 3–59 and development stakeholders made effective malaria control will require months) a bold commitment to end malaria by different strategies contextualised 2030. Earlier global initiatives, including to specific geographic areas and • where SP+AQ is efficacious (>90 the Millennium Development Goals populations, particularly as countries percent efficacy). and the ongoing Roll Back Malaria aspire to achieve pre-elimination. It Partnership, have strengthened malaria is in this context that, in 2012, the This confines the intervention to the Sahel control strategies and helped stabilise WHO approved seasonal malaria and sub-Sahel areas of central and western funding, but a lack of sustained local chemoprevention (SMC) as an effective Africa. government commitment and financing, tool in the prevention of malaria. as well as international funding, continue to be the main barrier to eliminating the Across the Sahel subregion, most disease. Indeed, in 2016 only US$2.7 childhood malarial and billion (£2.1 billion GBP) was spent on deaths occur during the rainy season, malaria control and elimination — a which is generally short, lasting three figure far below the annual $6.5 billion to four months. Giving effective (£5.1 billion) investment recommended antimalarial SMC treatments at monthly by the World Health Organization (WHO) intervals during this period has been if the 2030 target is to be achieved.[3] shown to be 75 percent protective against uncomplicated and severe There has been some progress in the malaria in children under five.[4] SMC past decade with the introduction of is cost-effective and, as shown in this more effective preventive tools, such paper, with adequate supervision and

1 World Health Organization. Malaria in children under five. [2018 Jan 26; cited 2019 Jan 9]. Available from: http://www.who.int/malaria/areas/high_risk_groups/children/en/. 2 World Health Organization. World Malaria Report. Geneva: World Health Organization; 2017. 3 Ibid. A child is given water to help swallow the 4 World Health Organization. Seasonal malaria chemoprevention (SMC). [2017 May 01; cited 2019 Jan 25]. Available from: medication, Burkina Faso https://www.who.int/malaria/areas/preventive_therapies/children/en/.

2 3 The project

Aims ACCESS-SMC was launched in 2015 to overcome barriers to SMC scale-up, supporting national malaria control/ elimination programmes (NMCPs) in Burkina Faso, , Guinea, Mali, Niger, and The Gambia. Funded by Unitaid, the project was led by Malaria Consortium in partnership with Catholic Relief Services and supported by the London School of Hygiene & Tropical Medicine (LSHTM), Centre de Support de Santé International, Management Sciences for Health, Medicines for Malaria Venture, and Speak Up Africa.

The project aimed to provide up to 30 million SMC treatments to 7.5 million children under five per year for two years, preventing millions of cases of malaria and helping to avert many thousands of deaths. This would require rapidly expanding the global supply of quality-assured and child-friendly SMC treatments, which would be achieved by significantly increasing predictable demand through feasible, acceptable and affordable implementation of SMC owned by national governments.

An SMC elegible child

4 5 Project design

ACCESS-SMC project’s Reduction in all cause under five theory of change child mortality Before the project began, key partnerships were formed with each of the seven countries’ NMCPs and indicators of success were agreed. The partnerships, which included cost-sharing arrangements and concessions on tax waivers for SMC supplies, were designed to strengthen NMCP Reduction in under five child morbidity ownership, ensure their continued engagement and commitment to the due to malaria scale-up of SMC, address bottlenecks and leverage resources.

Increased number of children NMCPs committed to using only the new quality-assured, co-blistered protected through SMC, which is integrated into the national SP+AQ drugs, instead of previously used loose tablets. This, in turn, malaria control response influenced other implementing partners to commit to using only quality- assured commodities. It was also agreed that the purchasing price Supply of SMC fits into Demand for of SMC products would remain at an acceptable level near budgeted SMC products Supply quality- an integrated Demand for Supply of SMC assured SMC price, and that country-level pharmacovigilance systems would be malaria control is high, SMC products meets products reliable and demand products Maintained safety of package is high and strengthened to meet the needs of the mass drug administration (MDA) SMC medicine predictable reliable campaigns.

SMC One of the objectives of the project was to identify the key cost Maintained efficacy implementation and effectiveness of is affordable SMC drivers of SMC administration and use this information to improve the SMC medicine and scalable products are affordable affordability of equitable SMC implementation. The activities associated with this objective would then help to promote its wider adoption by: Development partners have increased Country governments have commitment and contributions to increased commitment support country governments and and contribution to SMC • influencing changes in the global supply of acceptable, quality- their implementation partners to implementation, covering all SMC assured SP+AQ treatments implement SMC and cover all eligible eligible children according products children according to national policy to national policy and WHO are readily and WHO recommendations recommendations available • demonstrating feasibility and impact of SMC at scale • strengthening national pharmacovigilance systems and generating Reduced evidence of the safety of SMC cost of SMC implementation Increased demonstrated timeliness of Increased production Development • assessing the efficacy of SMC drugs and monitoring parasite SMC product capacity for SMC of new and resistance deliveries to products that are userfriendly country SMC quality assured SMC products programmes • mobilising additional resources to sustain demand for SMC and reach more children. Increased efficiency Increased and effectiveness acceptance of SMC Increased in safe and feasibility of SMC The requirements for achieving this objective were adapted to reflect as an effective tool quality SMC to prevent malaria implementation implementation demonstrated the individual country context once the project had begun to operate at amongst children delivery demonstrated demonstrated scale.

SMC product Market SMC product sellers buyers comprising transactions comprising product governments, within a manufacturers and development regulated distributors partners and NGOs framework

6 7 Since 2015 Malaria Consortium Achievements has helped prevent In 2012, SMC was recommended by WHO as a preventive A consortium of leading organisations working in malaria intervention in areas with high seasonal malaria prevention formed a partnership to deliver SMC in seven transmission in the Sahel region of sub-Saharan Africa. countries and ACCESS-SMC’s first campaign in 2015 provided However, by 2014, less than five percent of all eligible preventive SMC treatment to over 3.1 million children. The 10 million children (an estimated 25 million) were benefiting from this following year saw over 6.3 million children reached. During cases of malaria relatively new approach. 2017 and supported by new funding mechanisms, Guinea, Mali, Niger and The Gambia continued implementing SMC By improving demand forecasting and ensuring centralised programmes through different funding mechanisms, whilst and procurement, ACCESS-SMC helped catalyse the supply ACCESS-SMC continued to support a further SMC season in market volume from 9.9 million treatments delivered Burkina Faso, Chad and Nigeria, reaching an estimated 3.9 to target countries in 2014 to over 70 million by 2017. million children. over ACCESS-SMC was the first buyer for newly introduced, quality-assured dispersible tablets, with over 80 percent of ACCESS-SMC orders in 2016 being for these more palatable and easier to administer tablets. By 2017, all buyers were 60,000 purchasing dispersible tablets. Over three years of implementation (2015–2017), according deaths to project data, it is estimated that ACCESS-SMC may have averted over 60,000 deaths and prevented over 10 million cases of malaria.

We ensured an increase in production of SMC medicines

We reach children in Burkina Faso, Chad, Guinea, 2017 Mali, Niger, Nigeria and The Gambia with SMC 2014

9.9 million over 70 million

8 9 The cost of seasonal malaria chemoprevention

Before ACCESS-SMC, there was limited across a larger target population. In information on the key cost drivers of 2015, ACCESS-SMC supported the Estimated average SMC and competing funding priorities distribution of 12.4 million treatments annual recurrent cost of led to significant barriers for scaling up to approximately 3.1 million children, the intervention in the Sahel. In 2015 while in 2016 it more than doubled SMC per child and 2016, surveys were conducted to its coverage to an average 6.3 million determine the cost of implementing children (6.6 million at its peak), SMC in all seven countries, including: distributing over 25 million treatments. equipment, drugs, travel and transportation, salaries and incentives, Preliminary analysis of potential health social mobilisation, and meeting and systems savings and cost-effectiveness 2015 training costs. shows that SMC is comparable to other cost-effective malaria interventions, with Findings indicated that, at an average a median incremental cost-effectiveness cost of less than $5 (£4) per child treated ratio of $21.10 (£16.54) per disability- $4.30 each year, SMC was a cost-effective adjusted life year averted. On potential intervention for preventing millions of savings for health systems concerning Evolution of seasonal malaria cases of childhood malaria. The survey the cost of diagnostics and treatment, chemoprevention medication results also highlighted a reduction in project data suggest that ACCESS-SMC the average cost of administering the may have saved over $120 million (£94 Between 2014 and 2015, SMC medication equivalent of four monthly cycles to million). evolved from non-dissolving loose pills one child, falling from $4.30 (£3.37) in to co-blistered SP+AQ tablets that were 2015 to $3.3 (£2.65) in 2016. Across the These results suggest that large-scale crushed and mixed with water and sugar 2016 seven project countries, the majority of implementation of SMC is a worthwhile to mask the bitter taste of amodiaquine. costs were attributed to the purchase investment, which can result in a greater The process took at least five minutes to of SMC drugs and supplies, training and reduction in the overall burden of administer per child and often children spat $3.38 distribution and supervision/monitoring. malaria in the Sahel as well as a lower the mixture out, requiring the treatment to average cost per child reached by SMC. be administered a second time. The reduction in costs was primarily Understanding the cost of delivering due to the increased geographical SMC has allowed countries to advocate The move to sweetened, dispersible tablets and demographic coverage of SMC more effectively for sufficient financial in 2016 reduced delays and logistical and the spread of fixed costs (e.g. for resources to introduce and scale up the costs, eliminated the need for sugar, management, supervision and training) intervention. increased acceptability among children and simplified administration practices. With the introduction of these child-friendly SP+AQ tablets, drugs now take less than one minute to administer. Only a small amount of water is required and the taste is much more palatable. $120 million

saved through ACCESS-SMC

10 11 Approach used for scaling up seasonal malaria chemoprevention

Increasing global production outperformed those where in-country In 2013, at the time of the launch ownership was weaker and planning less of SMC, funding exceeded available effective. commodities, with no WHO prequalified manufacturers of SP+AQ. While the For example, Burkina Faso, Guinea and procurement target for 2015 at the Mali’s respective Ministries of Health start of ACCESS-SMC was 30 million were all heavily involved in planning treatments, only about half of that and launching SMC cycles — even amount could be procured and delivered embedding these processes in official to countries in time for distribution. ministerial calendars and setting up coordination groups in some cases — By 2016, all 30 million treatments and had high SMC coverage. Meanwhile, were available for purchase but, due Niger’s planning was less timely and did to the limited capacity of the only not fully address serious social barriers manufacturer of Expert Review Panel to SMC roll-out, which resulted in lower approved SP+AQ formulations (Guilin coverage. Pharmaceuticals), a number of countries had to delay the start of SMC campaigns In the case of Niger, conservative gender as they waited for product delivery. norms that limit women’s access to healthcare contributed to the very low ACCESS-SMC initiated the push to coverage achieved with a fixed point increase production of quality-assured approach (7–11 percent) and it took SP+AQ treatments by providing stable three cycles to recognise and remedy demand for a few years, enabling Guilin this issue. It was solved by switching Pharmaceuticals to invest in productivity to the door-to-door approach, which improvements, as well as encouraging enabled women and children to be other drug manufacturers to enter reached at home. Had there been production of SP+AQ as its feasibility was better planning and consideration of being demonstrated. Global production the context and relevant cultural factors of SMC treatments reached 60 million by in the choice of approach before the the end of 2016, and stabilised at nearly start of the campaign, the initial poor 70 million in 2017. coverage may have been prevented. This demonstrates the importance Setting agendas and planning of timely planning and identification ACCESS-SMC provided partners with of possible barriers and risks well in an opportunity to strengthen their advance of the start of any SMC cycle. capacity for in-country coordination Doing so enabled any potential problems and accurate planning, by supporting to be addressed expediently, e.g. via each country with needs assessments, increased advocacy or local engagement, planning workshops before each SMC identification of the right distribution round, and operational review meetings methods, and/or improved, locally- at the end of each season. Countries adapted social and behaviour change where the SMC agenda was clearly set communication (SBCC) tools. (including roles and responsibilities for coordination, and defined planning ACCESS-SMC also facilitated cross- A mother waits for her child to receive SMC and implementation) consistently country learning between the seven treatment, Burkina Faso

12 13 project countries. Via jointly attended building in-country capacity: Distribution methods annual planning and review meetings, ACCESS-SMC enabled countries’ NMCPs • Skills: to ensure high-quality used by project countries and implementing/research partners to implementation and reporting, critically assess SMC implementation, local trainers, supervisors and revise planning timelines, review volunteers were recruited based on project data, and identify successes specified criteria, and recruitment and failures. As a result of these processes were carefully monitored. lessons-sharing events, all ACCESS-SMC Nonetheless, in some countries, countries’ planning and implementation financial incentives (such as per performance improved incrementally diems) occasionally led to biased over time. recruitment (e.g. nepotism), which threatened the quality of delivery With the clear purpose of demonstrating and coverage. As such, Malaria that SMC is a successful and cost- Consortium increasingly oversaw the effective intervention and promoting project’s human resource-related the uptake of best practice beyond the processes (including recruitment, focus countries, Malaria Consortium retention and dismissal) wherever organised a joint consultation on SMC in such problems risked compromising collaboration with WHO and the West the quality or reach of the African Health Organization (WAHO), intervention. held in Burkina Faso in February 2017, • Training: building on WHO’s SMC which was open to all eligible countries. Field Guide, ACCESS-SMC developed The success of this coordinated SMC SMC training materials, field forum encouraged stakeholders to guides, and job aids in English and continue organising similar events post French. These were adapted by ACCESS-SMC; the latest took place in implementing countries based on Niger in February 2018, and hosted their past experience with SMC and all eligible countries’ NMCPs and on available national standards. At implementing/research partners. the end of the 2015 SMC campaign, they were reviewed and updated Building in-country capacity based on identified implementation ACCESS-SMC, like any MDA campaign, needs and CHWs’ capabilities. For required a large network of human instance, the original training guides resources, including trained health and materials were quite content- volunteers and distributors, Ministry of heavy, and the training sessions they Health staff, health workers, supervisors, facilitated were found to be less and monitoring and evaluation and practical than they needed to be. logistics personnel. As such, project Thus, revisions simplified content, partners developed training materials used less text and more images, and protocols in collaboration with and encouraged training sessions to national health authorities and in line concentrate more on practical skills with WHO guidelines, and trained (e.g. drug safety and administration). approximately 29,000 people in 2015, Overall, training topics included: SMC 60,000 in 2016, and 50,000 in 2017. eligibility criteria, SMC administration methods, monitoring severe adverse Shaped by continuous learning over reactions to SMC and effective the three years, ACCESS-SMC took communication with caregivers. into consideration the following when

14 15 Distribution methods • Door-to-door: two CHWs travelled to • Tasks: the roles and each house and used WHO’s eligibility responsibilities of all criteria to identify which children should implementers and supervisors receive SMC. One CHW administered were clearly defined and were the medicine, while the other entered based on local contexts and information into a tally sheet, beneficiary skills. For example, in some card and, if the child was sick, a referral settings frontline volunteers form. As per the project’s administration were unable to complete key protocol, children with a fever or with any tasks (e.g. stock reconciliation) signs of adverse reactions were referred due to low literacy levels. In to the nearest health facility for medical others, community health attention. workers (CHWs) sometimes • Fixed point: a team of three to six CHWs, overlooked sharing information sometimes headed by a qualified health with caregivers about the worker, administered SMC to children importance to adhere to at-home brought to a predetermined location doses. by caregivers. Health facilities were • Gender: during the first few converted to fixed points so children were cycles of SMC, male health able to receive referrals and be tested workers and volunteers were and treated for malaria immediately if generally refused access to any symptoms were present. households in northwestern • Mixed/semi-mobile approaches: these Nigeria due to gender-related included a range of mixed methods social norms, which resulted which, while used sparingly, enabled in children not receiving SMC CHWs to serve hard-to-reach populations, and in incomplete monitoring such as children in nomadic communities of SMC administration and or in areas with significant seasonal communication practices. migration, mostly linked to agricultural As such, in 2016 the project work. primarily recruited female distributors and supervisors in Sokoto and Zamfara. • Supervision: having found that weak supervision was responsible for SMC campaigns underperforming in some areas in 2015, the project prioritised delivering effective supervision — i.e. supervision that was efficient, high-quality and accountable. It implemented creative solutions (such as using teachers, social workers or retired health workers to distribute/supervise SMC where skilled volunteers were in short supply) to ensure efficiency and to improve service quality. Likewise, it instigated a full performance management system, complete with clear processes for managing underperforming employees/volunteers (starting with constructive feedback, moving to a formal warning, and concluding with Mother and baby, Burkina Faso dismissal), to strengthen accountability.

16 17 Using multiple distribution very conservative urban society resulted further built via the project’s training In focus: responsive programming in Nigeria methods in extremely low coverage (7.2 to and multimedia activities; using project 13.6 percent in the first three cycles) toolkits, trained facilitators convened The project used various approaches to despite increasing communication and social mobilisation events/community During the 2015 door-to-door SMC campaign in the predominantly deliver SMC across the seven countries. sensitisation efforts. When the decision fora at which videos on SMC were Of these, door-to-door distribution was Muslim Sokoto and Zamfara states of northern Nigeria, many male health to test using the door-to-door approach shared, while community radio stations favoured in most countries and became in the fourth cycle of 2015 was made, broadcast public service announcements workers and volunteers were refused access to households due to gender- widespread by 2017, primarily because administrative coverage shot up to and interactive shows to encourage related sociocultural norms that preclude men from entering other men’s it enabled the project to maximise 87.8 percent and the number of teams adherence. its coverage without increasing costs households (especially when women are present) and women from increased with limited impact on overall significantly. The method was also cost. Maradi and other urban areas in ACCESS-SMC conducted mixed leaving their homes without the patriarch’s permission. As the majority preferred because it helped improve Niger have been served mostly through methods studies in all project countries adherence to the full four month long of frontline health workers were male, this resulted in many children door-to-door delivery since 2016. to examine social acceptability — treatment schedule (including delivery specifically looking at ability (knowledge not being able to receive SMC and in incomplete monitoring of SMC of the second and third doses at home). Delivering social behaviour and skills), motivation (beliefs, values administration and communication practices. During household visits, CHWs explained and incentives) and possibility (access to the benefits of SMC, built trust among change communication activities services, products and social norms) — communities and opened further To ensure local support, malaria and to identify the information sources To avoid such eventualities in the 2016 SMC campaign, the project dialogue with caregivers about malaria control interventions, like many that influenced families’ decision-making primarily recruited women into the frontline roles in Sokoto and Zamfara and its prevention, all of which fostered health interventions, require a strong processes. It found high acceptance states. Additionally, since men are the core decision makers in these a positive environment for SMC uptake. community engagement component of SMC in all countries; caregivers This was especially the case in locations and investment in a coherent, perceived that SMC would provide a communities, the project also enlisted male community and religious where CHW networks were already well- evidence-based SBCC strategy that very tangible protective impact against a leaders — alongside traditional public announcers — as community established and where volunteers were takes into account local social norms known deadly disease. Coverage surveys well-trained and skilled. and communities’ understanding of conducted across all countries at the end mobilisers to help improve the campaign’s access to eligible children the needs, risks and benefits of an of the first round (between November through dialogue and sensitisation events. Project learning revealed that The door-to-door approach also intervention. and December 2015) also revealed overcame some of the challenges that interaction with these mobilisers had been key to men allowing female that intention to take up SMC was high had limited the success of the fixed ACCESS-SMC’s SBCC strategy was multi- — 96 percent of respondents reported distributors to enter their households and, subsequently, to women point approach during the 2015 cycle. By pronged, comprising training of CHWs planning to use the preventive measure tasking and incentivising CHWs to reach accepting and adhering to the full course of SMC treatment for their and town announcers (local volunteers in the future. The studies additionally eligible children regardless of distance specialised in social mobilisation), found that, in all countries, caregivers child(ren). and/or weather, door-to-door delivery multimedia activities and engagement preferred to hear about information obviated the need for caregivers to with trusted local leaders. The latter was before the campaign through radio This case study highlights the importance of adapting programming to make four, often long and challenging, particularly integral as, when caregivers shows, town announcers or CHWs, with journeys over a period of four months sociocultural realities, particularly in settings where SMC campaigns have were first introduced to SMC, their the latter being the preferred channels for their children to receive SMC – a hard motivation to travel to fixed points for interpersonal communication been less successful in the past. By identifying and addressing previously sell given SMC’s preventive rather than and to give their children subsequent together with health workers. Despite curative nature. encountered bottlenecks and norms, context-specific communication doses of SMC at home was limited. By strong communication with beneficiaries seeking the support of trusted local in countries like Mali that predominantly strategies and delivery models can be developed that should increase SMC Likewise, by having CHWs visit leaders and community members in used fixed point distribution, door-to- households, door-to-door delivery of coverage among target communities. delivering its sensitisation activities, door distribution was almost universally SMC was able to overcome cultural the project was able to improve valued as the most appropriate strategy or social norms that may limit female caregivers’ understanding of malaria by caregivers due to geographical and caregivers’ movement outside of the and the benefits of prevention, as well economic barriers to access. This is household and, therefore, their ability as to manage their expectations around why, over the years, most countries to bring their children to fixed points SMC’s purpose (as a complementary shifted to a door-to-door strategy and for SMC. For example, in the city of malaria control strategy), availability progressively achieved higher coverage. Maradi, Niger, the decision in 2015 to and potential side effects. Caregivers’ use fixed point distribution within a knowledge and trust in SMC was

18 19 Continuity of seasonal malaria chemoprevention post ACCESS-SMC

The transition of SMC support from continuity in all former ACCESS-SMC Tropical Medicine and International Most significantly, in February 2017 90 participants from 12 NMCPs and in the coming years, with a focus on Unitaid-funded ACCESS-SMC towards districts in these four countries, keeping Health (October 2017) featuring a poster Malaria Consortium, in collaboration 24 implementing partners attended, increased government ownership. other donors was completed by late over 3.2 million children covered by presentation on ACCESS-SMC, and the with the WHO Global Malaria including NMCPs from the seven project 2017, with the Global Fund, USAID’s SMC. American Society of Tropical Medicine Programme, WAHO and ACCESS-SMC countries and ACCESS-SMC partners Despite the project’s success in these President’s Malaria Initiative (PMI), the and Hygiene’s annual conference partner organisations, organised a invested in funding SMC (such as efforts to promote SMC, the supply and World Bank and philanthropic funding The engagement of the Global Fund did (November 2017) featuring, for the third three-day seminar to share key lessons Unitaid, the Global Fund, Unicef and funding constraints still limit SMC to only covering all previous ACCESS-SMC not materialise at the expected scale year running, a symposium dedicated to learnt and recommendations for PMI). The recommendations generated just half of the eligible children in the districts in all seven countries. This (in Chad), time (Burkina Faso) or at SMC co-chaired by Malaria Consortium future implementation of SMC beyond highlighted the importance of improving Sahel and sub-Sahel regions of Africa, support is expected to remain consistent all (Nigeria) by the end of the project. and LSHTM. the ACCESS-SMC project. More than coordination, delivery and monitoring with over 12 million still left out of this throughout 2019, while geographical However, Malaria Consortium managed life-saving intervention. coverage from 2020 onwards is to secure transition funding from sever- uncertain due to concomitant end of al philanthropic organisations, and in Core programme funding for each country World Bank project, end of Global Fund particular from , as a round 2017–2019, and likely exhaustion result of achieving GiveWell top charity of the current designated funding status in 2017 (and since) for its SMC phase. However, both Global Fund activities. With these funds, Malaria and philanthropic support are likely to Consortium was able to support former continue in 2020 and beyond. ACCESS-SMC areas in Chad and Nigeria in 2018, and will continue to do so in Throughout the project, ACCESS-SMC 2019. members have engaged at country, regional and global levels to secure In Burkina Faso, ACCESS-SMC and the buy-in for SMC during and beyond the NMCP have regularly liaised both with project. In general, this engagement the Global Fund and the two other since 2015 has translated to a successful major funders, the World Bank and transition of all ACCESS-SMC target PMI, to discuss potential transition districts to alternative funding streams options, thanks to their commitment after the end of the project in 2017. In to large-scale SMC support in the an effort to secure successful transition country. As a result, PMI replaced of SMC in the seven ACCESS-SMC ACCESS-SMC support in six districts countries, ACCESS-SMC members began from 2018, while the Global Fund and discussions in 2015 with the Global the World Bank started supporting five Fund and other donors (such as PMI, and four former ACCESS-SMC districts the UK Department for International respectively, ensuring a transition for 15 Development and the World Bank) to out of 31 districts supported by ACCESS- ensure SMC would be included in their SMC. Malaria Consortium continued plans for 2017 and onwards. supporting the remaining districts thanks to philanthropic funding mentioned In four of the seven countries — Mali, above. Guinea, Niger and The Gambia – SMC activities in ACCESS-SMC areas, includ- Besides direct fundraising efforts, and ing commodities and implementation as part of the advocacy endeavors to costs, were included in the Global Fund’s reach a broader audience and promote New Funding Model from 2017, and the sustainability of the intervention, a all have prospects to continue for at number of visibility activities boosted least up to 2019 and possibly beyond. awareness on the impact of SMC. These The project thus managed to ensure included the European Congress on

20 21 • Smart, effective and focused most critical physical, economic, supervision is crucial. It enables geographical, climactic and cultural accurate monitoring of SMC barriers to access and, therefore, Key learning performance, rapid identification to adherence to the full treatment of potential coverage issues, and schedule. Its impact on cumulative strong quality assurance. Lessons costs is marginal, while its unit cost The ACCESS-SMC project has shown treatments per month and orders from the first two years showed per child treated is lower than the that high coverage and a major scale- are required at least nine months in that supervision was often carried fixed point method — making it up of SMC in the Sahel is feasible and advance. Even if yearly production CHWs out as a tick-box exercise (mostly to an effective means of maximising effective. Key lessons from implementing capacity (approximately 75 million is relatively check operational aspects of SMC coverage. SMC activities in seven countries include: treatments) was used in full, with administration), without a focus weak. In addition, • Targeting both male and female orders being given a year in advance, on quality improvement, and by different task assignments caregivers when designing SBCC • Efficient and timely supply chain it would still be insufficient to reach personnel who did not have the skills should be considered for interventions to foster acceptance management, from quantification, all eligible children in the region. and/or were not sufficiently engaged different countries, and of SMC is vital. Although it is usually to procurement and distribution, Additionally, decisions to fund SMC to generate meaningful the focus should be on a women, as primary caregivers, who is essential due to the seasonal are often made annually by donors change among frontline few key elements: identify signs of illness and know nature of SMC campaigns. Orders and confirmed later in the calendar distributors or caregivers. By when advice from a health worker should be made at least nine months year, reducing the capacity of • age-based eligibility enhancing its supervision should be sought, the ultimate in advance of the SMC season, suppliers to produce and ship SMC framework through • correct drug dosage choice to seek care often lies with but ideally up to one year before. commodities in time for the start of improved supervision tools • directly observed men, as primary decision makers. Failure to address the complexities the rainy season. and in-process monitoring, treatment of first Importantly, coverage surveys that of a monopolistic and undersized ACCESS-SMC witnessed a • User competencies and learning combined dose of assessed knowledge of SMC by drug market or appropriately general improvement in skills need to be critically assessed SP+AQ (mostly) female caregivers showed mitigating against supply-related the ways supervision was prior to heavy investment in training • complete and precise that there was still a lot of confusion risks (e.g. incorrect quantification of carried out and drugs were and development of comprehensive documentation of the drug on what SMC does (prevention medication required, shipment and/ administered, and, above training materials (field guides administration process versus treatment, and malaria or importation delays, and localised all, in coverage. and job aids). These assessments versus other diseases) and how stock-outs) will result in lower SMC • effective communication on need to be based on best practices • Door-to-door distribution often it should be given to children. coverage, reduced effectiveness, and the importance of treatment and implementation needs most of SMC is cost-effective. SMC is more likely to reach its full an increase in the average cost of adherence (for both home appropriate to the context. For While administration protective potential if mothers and SMC per child. doses and across four cycles) instance, it has been more effective methods should always other caregivers are both thoroughly • basic awareness of adverse • Barriers to increasing production to use training options and materials be selected based on informed and empowered to reactions and severe adverse still remain, with market constraints with less theory and more practice, local, cultural specificities eventually become advocates within events having an impact on planning. and less text and more images in and accessibility, the their families so that key positive The global production capacity is countries where the skills base of • basic referral protocols. door-to-door approach is behaviours can be fully adopted. SMC health worker, Burkina Faso currently approximately 6.3 million generally able to overcome the

22 23 Recommendations

Ministries of Health should lead Ministries of Health should guide in coordinating SMC planning and stakeholders in using standardised implementation from the outset, indicators and tools in their SMC aligning and integrating these with programming that will enable national-level malaria control and comparison across geographical Moving the elimination initiatives, plans and areas within each country and across seasonal malaria policies. By embedding SMC into existing 6interventions, while also allowing for 3technical coordination/planning working the use of context-specific supervision chemoprevention Governments/donors should commit to groups and mechanisms, it will be and monitoring tools. Implementing coverage agenda increasing funding for SMC by $48–56 possible to improve future ownership partners should provide the technical million (£37–44 million) per year. SMC and sustainable financing of SMC among assistance required to continually forward is a safe and cost-effective intervention countries’ core packages of malaria review/strengthen these tools to that can easily be implemented at scale. interventions. improve operational results monitoring In the five years since being However, half of all eligible children and programme accountability and recommended as a promising in the Sahel are still not receiving this to ensure that a sustained standard Ministries of Health should pilot the malaria control intervention, vital preventive measure due, largely, of activities is delivered. In addition, integration of other preventive and SMC distribution has expanded 1 research initiatives (that are overseen curative services (e.g. screening and to funding shortages. SMC requires dramatically and now covers more predictable and steady future funding Ministries of Health and other relevant by and conducted in collaboration with referral for severe acute , than half of all eligible children so that market inefficiencies can be stakeholders should work together to Ministries of Health) should continue deworming and other integrated in the Sahel. ACCESS-SMC has minimised by timely orders and planned enhance the quality of malaria-related to be prioritised to ensure appropriate8 community case management been catalytic in this expansion, production of the right quantities of data captured by health management assessment of interventions’ continued priority interventions) within the reaching millions of children in quality-assured drugs. information systems (HMIS). This effectiveness and impact. SMC implementation framework. This three years with a life-saving should include identifying a proxy will require effective coordination of intervention and encouraging measure for SMC impact. By routinely various vertical health programmes other players in to 4 and stakeholders that are likely to have collecting (in a timely manner and to support SMC. While this scale-up an acceptable level of completeness) different priorities. By taking advantage was successful and relatively swift, of SMC’s extensive, mass community Stakeholders should plan SMC and disaggregating such data, impact Ministries of Health, through their there is still a large gap to fill. health platform, such a pilot could campaigns in a timely and accurate analyses of and decision making on NMCPs and with the support of have a significant impact on child manner. This will necessitate improved malaria interventions will be facilitated. donors, implementing partners and The challenges in increasing health. However, integration should population estimates, reliable academia, should establish evaluation access to and coverage of SMC not compromise SMC coverage and quantification and timely procurement frameworks for SMC interventions that are many (whether related effectiveness, but rather help improve of drugs, and coherent, decentralised include continuous measurement of to the supply side, to local coverage, impact and efficacy, as well as SMC’s cost-effectiveness. implementation choices, planning and programme resourcing. Stakeholders should adopt a 7monitor the potential development of inadequate planning, insufficient 2Given the supply capacity constraints, collaborative approach to strengthening parasite resistance to SMC. A regional quality assurance processes or Ministries of Health should start pharmacovigilance systems in line with collaboration framework should also limited resources) and some procuring medication at least 10 months WHO’s guidelines. However, while be established to support standardised evidence gaps remain. However, before the first cycle of SMC is due to ACCESS-SMC provided a window of evaluation methods, in coordination the knowledge base around commence. opportunity for targeted improvements, with key regional bodies such as WHO’s best practice is ever-expanding this should be achieved by a transversal Inter-country Support Teams for West and the benefits of SMC as a approach to continuous adverse events and Central Africa, Roll Back Malaria’s complementary preventive 5monitoring, carried out throughout the West Africa Network and WAHO. approach to malaria control are year beyond just SMC and under the evident. As such, SMC merits aegis of WHO. greater investment so that the remaining 15 million children who currently are not receiving SMC can be reached.

24 25 ACCESS-SMC partnership

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