FORMATIVE WORK TO INFORM THE CONCEPTUAL FRAMEWORK & OBJECTIVES Assessment of drivers and barriers for achieving target IPTp coverage in and districts, , Presentation outline

• The IPTp program in Zimbabwe • Study rationale • Formative work • The Conceptual Framework • Main study objectives Control of MIP in Zimbabwe

• Control of MIP, including IPTp, was adopted as a policy in Zimbabwe in 2004 to be implemented in the moderate to high-burden malaria transmission areas, with 30 districts designated for MIP interventions

• In 2014 NMCP adopted the WHO 2012 guidelines for IPTp-SP

3 Study rationale

• MiP remains a problem of public health concern, globally, nationally and in Manicaland province where it was the highest cause of MM contributing to 20%, 21% and 14% of maternal deaths in 2013, 2014 and 2015 respectively. (Provincial Maternal death audit data, MOHCC , Manicaland) • Zimbabwe IPTp coverage target: 85% of pregnant women receive two or more doses of IPTp during that pregnancy. (National Malaria Strategic Plan, 2008-2015, Extended) • However, indications are that this target has not been met: The 2016 Malaria Indicator Survey (MIS) preliminary results show that 37% received two or more doses of SP (2% ‘increase’ from the MIS 2012).

4 Objectives of the Formative work

• To identify all relevant national documents for desk review and carry out mapping of MOHCC partners who are actively engaged in IPTp program in order to inform selection of key informants for main study protocol. • To document the facility based IPTp 1,2 and 3 coverage rates in health facilities in Mutasa district. • To document various data elements possibly affecting reported IPTp coverage rates in health facilities in Mutasa district ,i.e. the ANC coverage, frequency of missed IPTp opportunities and rates of clients ineligible for IPTp in Mutasa district. • To describe the data capturing processes and data quality for the IPTp program in HFs in Mutasa district. • To create a process map for the IPTp program that outlines the key steps and elements that need to be in place for an eligible pregnant woman to ultimately access SP for IPTp.

5 Methodology of the Formative work

• Descriptive cross sectional design • Random selection of half (21) of the 42 health facilities in Mutasa district for data collection, including interviews with nurses at the health facility, observation of work flows and extraction of ANC registers and T5 summary forms. • The nurses interviewed at the facility were a convenience sample of Family Child Health unit Sisters In Charge on duty on the day of the visit. • Key informants from the NMCP, the provincial MOHCC office in Manicaland province and the Mutasa district MOHCC office were purposively selected for interviews. • Double data entry was carried out and quantitative data analysis was done using Excel. • Qualitative data was reviewed and analyzed manually.

6 Formative work FINDINGS...HIGHLIGHTS

7 Trends in Early ANC booking, IPTp2 and IPTp3 in 22 HFs in Mutasa district, 2012-2015 (3,904 records)

ANC <16 weeks IPTp2 IPTp3

68% 68% 66% 59%

46% 44% 41% 45% 32% 31%

20% 14%

2012 2013 2014 2015 8 Missed opportunities

Missed opportunities: 207 out of 3904 eligible records(5%)

Reason for missed Missed opportunities by type of opportunities Health facility

Not Private HF SP docume 107 cases stock- Public HF nted (52%) out (111 48% 46% cases) 54% %age of women ineligible for IPTp due to CTZ prophylaxis in 2015

20%

18%

16%

14%

12%

10%

8% % of women ineligible 6%

4%

2%

0% Verification Factors calculated for IPTp2 indicator in 22 HFs in Mutasa distict Jan-Jun 2016

Facility V Facility U Facility T Facility S Facility R Facility Q Facility P Facility O Facility N Optimum Facility M Facility L Facility K Facility J Facility I Facility H Facility G Facility F Facility E Facility D Facility C Over reporting Facility B Facility A

0% 20% 40% 60% 80% 100% 120% 140% 160%11 Emerging themes: Perceived community level barriers to IPTp uptake as suggested by health workers Lack of knowledge about IPTp by the community 16

Religious beliefs/Objectors 11

Lack of provider knowledge of IPTp 6

Long distance from the facility 5

Non provision of IPTp at private facilities 5

Myths and misconceptions 4

Lack of policy on IPTp 4

Allergic reactions 3

SP not on site 3

Longer waiting times to access ANC services 3

Lack of proper documentation 3

Late booking 3

Lack of husband’s support for accessing routine ANC 2

12 Leadership, Policy & Coordination Financing

Medicines & Health Workforce Service Delivery HMIS

National Commodities

L Medicines & Commodities Health Workforce Service Delivery HMIS e Provincial a d Medicines & Health Workforce Service Delivery HMIS e Commodities District r s IPTp Data ANC QoC: Consultation h Pharmacy: Health Facility Staff: room Management: SP stock management IPTp knowledge, Capturing, reporting, i perceptions & practices verification & use p Other Facility readiness Waiting area: Quality & Health Facility components: Patient content of health flow, availability of education; Waiting times water, etc Pregnant woman eligible for IPTp

Availability: Health education & Affordability: Acceptability: Personal Role of Private sector promotion services; Transport systems perceptions; religious distance Direct & Indirect beliefs; Male partner &

household costs family involvement Community & Community HMIS=Health Management Information System;13 QoC=Quality of Care Main Study Aim

• To assess the drivers and barriers to achieving target IPTp coverage in Chipinge and Mutare districts, Manicaland province Main Study Objectives

• To explore the health system/supply-side national, provincial, district and facility level drivers and barriers to IPTp coverage in Chipinge and Mutare districts of Manicaland province. • To determine the client-related/demand side drivers and barriers to IPTp coverage among pregnant women in Chipinge and Mutare districts, Manicaland province. • To make recommendations to relevant stakeholders based on the study findings.

15 References

1. World malaria report 2014. Geneva: World Health Organization; 2014 (http://www.who.int/malaria/ publications/world_malaria_report_2014/en/, accessed 10 March 2015). 2. Resolution WHA58.2 on malaria control. Fifty-eighth World Health Assembly, Geneva: World Health Organization; 2005 (see document WHA58/2005/REC/1, http://apps.who.int/gb/ebwha/pdf_files/WHA58REC1/english/A58_2005_REC1-en.pdf, accessed 10 March 2015). 3. WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control, September 2013 (revised March 2014). Geneva: World Health Organization 4. WHO. Updated WHO policy recommendation: intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP), Geneva: World Health Organization; 2012 5. World Health Organization. World malaria report. Geneva: World Health Organization; 2012 6. Cibulskis RE, Aregawi M, Williams R, Otten M, Dye C. Worldwide incidence of malaria in 2009: estimates, time trends, and a critique of methods. PLoS Med. 2011 Dec;8(12):e1001142. 7. Bhatt S, et al. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature 2015; 526: 207–211. 8. Roll Back Malaria Partnership. Refined/updated global malaria action plan objectives, targets, milestones and priorities beyond 2011. 2011; Available from: http://wwwrbmwhoint/gmap/gmap2011updatepdf 9. Steketee R.W, Natlen B. L, Parise M.E and Menedez C. (2001), The burden of Malaria in Pregnancy in malaria endemic areas. American Journal of Tropical Medicine and Hygiene, 2001; Jan-Feb;64 (1- 2 sup):28-35 Thank you!

Acknowledgments: MoHCC Zimbabwe USAID, PMI Communities in Manicaland All partners working in Malaria programming in Zimbabwe

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