Report on the Malaria Commodity End- Use Verification Survey for Mali, August 9-31, 2016
October 2016
Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
October 2016
SIAPS Team/Mali NMCP Team
Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
This report would not have been possible without the support of the US Agency for International Development (USAID), provided under the terms of Cooperative Agreement number AID-OAA-A-11-00021. The opinions expressed in this document are Management Sciences for Health's and do not necessarily reflect those of USAID or the US government.
About SIAPS
The objective of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program is to ensure the availability of high-quality pharmaceuticals and effective services in order to achieve desired health outcomes. To this end, the SIAPS program objectives include improving governance, building management and pharmaceutical service capacities, prioritizing information needed for decision-making in the pharmaceutical sector, strengthening financial strategies and mechanisms to improve access to pharmaceuticals, and improving the quality of pharmaceutical services.
Suggested citation
This report may be reproduced, provided that SIAPS is acknowledged. Please use the following citation:
SIAPS Team/Mali and NMCP Team. 2016. Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016. Presented to the US Agency for International Development by Systems for Improved Access to Pharmaceuticals and Services (SIAPS). Arlington, VA: Management Sciences for Health.
Systems for Improved Access to Pharmaceuticals and Services Pharmaceutical and Health Technologies Group Management Sciences for Health 4301 North Fairfax Drive, Suite 400 Arlington, VA 22203, United States Telephone: (703) 524-6575 Fax: (703) 524-7898 Email: [email protected] Website: www.siapsprogram.org
ii
CONTENTS
Acronyms ...... vi Acknowledgements ...... vii Summary ...... viii Introduction ...... 1 Objectives ...... 3 General objective ...... 3 Specific objectives ...... 3 Methodology ...... 4 Survey type and framework ...... 4 Criteria for inclusion ...... 4 Sampling ...... 4 Data collection ...... 4 Data processing and analysis ...... 5 Results ...... 6 Supply chain ...... 6 Reference document availability ...... 11 Logistics Management Information System ...... 12 Malaria case management ...... 14 Challenges and Constraints Encountered in the Field ...... 16 Corrective Measures Taken in the Field ...... 17 Recommendations ...... 18 Annex A: Kayes Region Results...... 21 Annex B: Koulikoro Region Results ...... 25 Annex C: Sikasso Region Results ...... 30 Annex D: Ségou Region Results ...... 35 Annex E: Mopti Region Results ...... 40 Annex F: District of Bamako Results ...... 45 Annex G: Definition of Indicators ...... 48 Annex H: Facilities Visited ...... 50
List of Tables
Table 1. Percentage of facilities with malaria commodities on the date of the visit, by type of facility ...... 6 Table 2. Percentage of facilities having experienced stock-outs longer than three days ...... 8 Table 3. Percentage of health facilities (CSComs, CSRéfs, hospitals) with stock levels within SDADME min/max guidelines ...... 8 Table 4. Percentage of distribution facilities (DRCs) with stock levels within SDADME min/max guidelines ...... 9 Table 5. Percentage of facilities having submitted an AL stock management report ...... 14 (n = 79) ...... 14 Table 6. Number of cases of fever by type of diagnosis ...... 15 Table A1. Percentage of health facilities with commodities on the date of the visit ...... 21 Table A2. Percentage of distribution facilities with commodities on the date of the visit ...... 21 Table A3. Worker training in Kayes Region facilities ...... 23
iii Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Table A4. Rates of uncomplicated malaria among the total numbers of patients in the Kayes Region ...... 23 Table A5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Kayes Region ...... 23 Table A6. Percentage of cases of uncomplicated malaria treated with ACT in the Kayes Region ...... 24 Table A7. Cases of severe malaria in patients in the Kayes Region...... 24 Table A8. Treatment of severe malaria cases in children under five in the Kayes Region ...... 24 Table B1. Percentage of health facilities with commodities on the date of the visit ...... 25 Table B2. Percentage of distribution facilities with commodities on the date of the visit ...... 26 Table B3. Worker training in Koulikoro Region facilities ...... 27 Table B4. Rates of uncomplicated malaria among the total numbers of patients in the Koulikoro Region...... 27 Table B5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Koulikoro Region ...... 28 Table B6. Percentage of cases of uncomplicated malaria treated with ACT in the Koulikoro Region...... 28 Table B7. Cases of severe malaria in patients in the Koulikoro Region ...... 28 Table B8. Treatment of severe malaria cases in children under five in the Koulikoro Region ...... 29 Table C1. Percentage of health facilities with commodities on the date of the visit ...... 30 Table C2. Percentage of distribution facilities with commodities on the date of the visit ...... 31 Table C3. Worker training in Sikasso Region facilities ...... 32 Table C4. Rates of uncomplicated malaria among total numbers of patients in the Sikasso Region ...... 33 Table C5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Sikasso Region ...... 33 Table C6. Percentage of cases of uncomplicated malaria treated with ACT in the Sikasso Region ...... 33 Table C7. Cases of severe malaria in patients in the Sikasso Region...... 33 Table C8. Treatment of severe malaria cases in children under five in the Sikasso Region ...... 34 Table D1. Percentage of health facilities with commodities on the date of the visit ...... 35 Table D2. Percentage of distribution facilities with commodities on the date of the visit ...... 36 Table D3. Worker training in Ségou Region facilities ...... 37 Table D4. Rates of uncomplicated malaria among total numbers of patients in the Ségou Region ...... 38 Table D5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Ségou Region ...... 38 Table D6. Percentage of cases of uncomplicated malaria treated with ACT in the Ségou Region ...... 38 Table D7. Cases of severe malaria in patients in the Ségou Region...... 38 Table D8. Treatment of severe malaria cases in children under five in the Ségou Region ..... 39 Table E1. Percentage of health facilities with commodities on the date of the visit ...... 40 Table E2. Percentage of distribution facilities with commodities on the date of the visit ...... 41 Table E3. Worker training in Mopti Region facilities ...... 42 Table E4. Rates of uncomplicated malaria among total numbers of patients in the Mopti Region ...... 43
iv Contents
Table E5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Mopti Region...... 43 Table E6. Percentage of cases of uncomplicated malaria treated with ACT in the Mopti Region ...... 43 Table E7. Cases of severe malaria observed in patients in the Mopti Region ...... 43 Table E8. Treatment of severe malaria cases in children under five in the Mopti Region ...... 44 Table F1. Percentage of health facilities with commodities on the date of the visit ...... 45 Table F2. Worker training in Bamako facilities ...... 46 Table F3. Rates of uncomplicated malaria among total numbers of patients in the District of Bamako ...... 46 Table F4. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the District of Bamako ...... 47 Table F5. Percentage of cases of uncomplicated malaria treated with ACT in the District of Bamako ...... 47 Table F6. Cases of severe malaria in patients in the District of Bamako ...... 47 Table F7. Treatment of severe malaria cases in children under five in the District of Bamako ...... 47
List of Figures
Figure 1. ACT availability at health facilities ...... 7 Figure 2. ACT availability at distribution facilities ...... 7 Figure 3. Quantity of expired commodities observed during data collection ...... 9 Figure 4. Percentage of DVs meeting standard storage conditions ...... 10 Figure 5. Percentage of distribution facility sales points meeting standard storage conditions, by region ...... 10 Figure 6. Percentage of facilities with malaria case management referral guidelines, by type of health facility and region ...... 11 Figure 7. Percentage of facilities with pharmaceutical management manuals, ...... 12 by type of health facility and region ...... 12 Figure 8. Percentage of health facilities with up-to-date RDT stock records ...... 13 Figure 9. Percentage of health facilities with up-to-date AL (6×1) stock records ...... 13 Figure 10. Percentage of health facilities with up-to-date AL (6×3) stock records ...... 14 Figure A1. ACT availability at Kayes health facilities ...... 22 Figure A2. ACT availability at Kayes distribution facilities ...... 22 Figure B1. ACT availability at Koulikoro health facilities...... 26 Figure B2. ACT availability at Koulikoro distribution facilities ...... 27 Figure C1. ACT availability at Sikasso health facilities ...... 31 Figure C2. ACT availability at Sikasso distribution facilities ...... 32 Figure D1. ACT availability at Ségou health facilities ...... 36 Figure D2. ACT availability at Ségou distribution facilities ...... 37 Figure E1. ACT availability at Mopti health facilities ...... 41 Figure E2. ACT availability at Mopti distribution facilities ...... 42 Figure F1. ACT availability at Bamako health facilities ...... 45
v
ACRONYMS
AL artemether-lumefantrine ACT artemisinin-based combination therapy BP blister pack CHU Centre Hospitalier Universitaire (University Hospital Center) CMIE Centre Médical Inter-Entreprises CSCom Centre de Santé Communautaire (community health center) CSRéf Centre de Santé de Référence (Reference Health Center) DRC Dépôt Répartiteur de Cercle (District Pharmaceutical Depot) DRS Direction Régionale de la Santé (Regional Health Department) DTC Directeur Technique du Centre (Center Technical Director) DV Dépôt de vente (pharmaceutical depot) EUV end-use verification IPT intermittent preventive treatment LLIN long-lasting insecticide-treated mosquito net LMIS Logistics Management Information System MIPROMA Mutuelle Interprofessionnelle du Mali MOPHH Ministry of Public Health and Hygiene MSF Médecins Sans Frontières (Doctors Without Borders) MSH Management Sciences for Health NA not applicable ND no data NMCP National Malaria Control Program ODK Open Data Kit PMI President’s Malaria Initiative PPM Pharmacie Populaire du Mali (Central Medical Stores) RBM Roll Back Malaria RDT rapid diagnostic test SDADME Schéma Directeur d’Approvisionnement et de Distribution en Médicaments Essentiels (Essential Medicines Supply and Distribution Plan) SIAPS Systems for Improved Access to Pharmaceuticals and Services SMR Stock Management Report SP sulfadoxine-pyrimethamine SPS Strengthening Pharmaceutical Systems USAID US Agency for International Development WHO World Health Organization
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ACKNOWLEDGEMENTS
The authors would to thank the Malian Ministry of Public Health and Hygiene (MOPHH) and its various bodies (Regional Health Departments [DRS], Reference Health Centers [CSRéf], and Community Health Centers [CSCom]), and the Central Medical Stores (Pharmacie Populaire du Mali, or PPM) for their willingness to work with the survey team, and their commitment to improving the management of pharmaceuticals, in general, and malaria commodities, in particular.
We would also like to express our sincere thanks to the directors of the regional departments of the PPM for their care in completing this process and their willingness to work with surveyors and regional health teams.
We would also like to thank USAID/Mali for its technical and financial support.
vii
SUMMARY
Mali has been a beneficiary of the President’s Malaria Initiative (PMI) since 2006. It began implementing PMI activities in 2008. PMI aims to reduce malaria-related mortality by 50% and cover 85% of the most at-risk groups (children under five and pregnant women). The Initiative helps to support the objectives of the Roll Back Malaria (RBM) initiative, which, in addition to achieving universal coverage in the public sector, aimed to cover 50% of private sector needs by 2013.
As part of the PMI's support of the National Malaria Control Program (NMCP), the US Agency for International Development (USAID) tasked the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program, implemented by Management Sciences for Health (MSH), with strengthening Mali's malaria commodity logistics management system, as has been done in other PMI beneficiary countries. The malaria commodity end-use verification (EUV) survey was launched in Mali in 2010 by the Strengthening Pharmaceutical Systems (SPS) program and is being continued under the SIAPS program. The survey aims to help reduce malaria-related mortality and morbidity by improving the availability, management, and use of malaria commodities at health facilities.
This edition of the EUV survey (the seventh under the SIAPS program) was conducted from August 9-31, 2016 under the leadership of the NMCP in the regions of Southern and Central Mali. The survey aims to help improve the availability, management, and use of pharmaceuticals and other malaria commodities at public and quasi-public health facilities in Mali. The EUV was a cross-sectional, descriptive survey that focused on points of care as well as malaria commodity supply and distribution points at health facilities in the Kayes, Koulikoro, Sikasso, Ségou, and Mopti Regions and the District of Bamako. A stratified sampling method (sample size of 85) was used to ensure that every type of health facility at every level of the health system was represented. Two quasi-public facilities (Centre Médical Inter-Entreprises [CMIE] and Mutuelle Interprofessionnelle du Mali [MIPROMA]) were visited in the District of Bamako.
The survey produced the following main results:
The availability of commodities on the date of the survey visit varied depending on the type of health facility and commodity.
• Artemether-lumefantrine (AL) (6×1) and AL (6×2) were available at 98.73% and 91.14% of the health facilities, respectively. 100% of the distribution facilities had AL (6×1) on the date of the visit, while 95.83% had AL (6×2).
• 83.54% of the health facilities and 95.83% of the distribution facilities had AL (6×3).
• AL (6×4) was available at 91.14% of the health facilities and 100% of the distribution facilities.
• Rapid diagnostic tests (RDT) were available at 91.66% of the distribution facilities and 94.94% of the health facilities.
Most commodities (10 out of 11) were less widely available at the health facilities than at the distribution facilities. This was the case for all four artemisinin-based combination therapies
viii Summary
(ACT) (AL (6×1), AL (6×2) AL (6×3), and AL (6×4)), 300 mg quinine tablets, 200 mg and 400 mg quinine injectables, 60 mg injectable artesunate, long-lasting insecticide-treated mosquito nets (LLIN), and sulfadoxine-pyrimethamine (SP). All four AL treatments were available at 93% of the distribution facilities and 79% of the health facilities visited. However, 17.11% to 29.73% of health facilities and 12.50% to 20.83% of distribution facilities had experienced a stock-out of at least one AL treatment for three days or more during the three months preceding the survey visit. It should be noted that there were no stock-outs of AL (6×2) at any health or distribution facilities.
These results demonstrate that work still needs to be done to ensure the continuous availability of malaria commodities.
In terms of malaria case management, out of a total of 20,631 patients examined during the period covered by the study,1 5,952 (28.85%) were cases of uncomplicated malaria. Of those, 2,178 patients (36.59%) were children under five. Of all the cases of uncomplicated malaria, 89.90% were treated with ACT; 90% of children under five and 89.35% of patients over five with uncomplicated malaria were treated with ACT. Some cases of uncomplicated malaria (4.60%) were not treated properly.
In addition, 19.71% of patients who were examined presented as cases of severe malaria. This rate rose to 56.45% among children under five.
In terms of reporting, well over half (91.14%) of facilities submitted AL stock level reports to the next level of the health system within the required timeframes using the Stock Management Report (SMR) form.
1 Case management data pertains to the period beginning one complete calendar month before the date of the visit (30 days beginning the day before the date of the visit).
ix
INTRODUCTION
Malaria remains a major public health problem around the world. Approximately 3.2 billion people are at risk of contracting malaria. In 2015, the number of new reported cases was estimated at 214 million, resulting in 438,000 deaths. Fifteen countries, most of them in Africa, account for approximately 80% of malaria-related deaths.2
According to the Annual Statistics for the Local Health Information System, in 2015 health facilities in Mali reported a total of 3,317,001 suspected cases of malaria, which was the reason for 41.81% of all medical consultations. Of those, 2,330,847 were cases of uncomplicated malaria and 986,154 were cases of severe malaria, resulting in 1,544 deaths,
for a fatality rate of 0.47%.
The groups most affected by malaria are children under five and pregnant women. According to the results of the Demographic and Health Survey (EDSM V, 2012-2013), 8.6% of children under five had a fever during the two weeks preceding the survey.3 Other studies conducted in Mali found a malaria-related low birth rate of 18%, a placental infection rate of 30%, and a peripheral parasitemia rate of 28%.4
Since 2007, Mali's health facilities have followed a case management policy that recommends the use of ACT for cases of uncomplicated malaria. This policy is based on the recommendations of the World Health Organization (WHO), which advises that any suspected case of malaria-related fever be biologically diagnosed before administering any antimalarials. The methods used to biologically diagnose malaria are microscopy and RDT. The national malaria control policy recommends two ACTs for treating cases of uncomplicated malaria: AL and artesunate-amodiaquine. Artesunate, artemether, and injectable quinine are used to treat cases of severe malaria. Prevention is one of the main strategic areas of focus for malaria control in Mali, through the use of intermittent preventive treatment (IPT) with SP for pregnant women, chemical prevention of seasonal malaria, indoor residual spraying, and the use of LLINs. These commodities are provided free of charge to pregnant women and children under five, and are sold at subsidized prices to other groups.
In 2006, Mali was selected as a PMI beneficiary, and program activities were launched in the country in 2008. The PMI is helping to meet the objectives of RBM, which, in addition to achieving universal coverage in the public sector, aimed to cover 50% of private sector needs by 2013. As part of PMI's support for the NMCP, USAID tasked the SIAPS program with strengthening Mali's malaria commodity logistics management system.
2 World Health Organisation (WHO). The World Malaria Report 2015 Overview. Geneva, Switzerland: WHO; 2016. 3 Planning and Statistics Unit (CPS/SSDSPF), National Institute of Statistics (INSTAT/MPATP), Center for Research and Statistical Information (INFO-STAT), and ICF International. Enquête Démographique et de Santé (EDSM V) 2012-2013, Preliminary Report. Rockville, MD, USA: CPS, INSTAT, INFO-STAT and ICF International; 2013. 4 Kayentao, K., Mungai, M., Parise, M., Kodio, M., Keita, A.S., Coulibaly, D., Maiga, B., et al. Assessing Malaria Burden During Pregnancy in Mali. Acta Trop. 2007 May; 102(2): 106–12.
1 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
As in other PMI beneficiary countries, MSH began working in Mali under the SPS program in 2010 and has continued conducting the malaria commodity EUV surveys under SIAPS. The survey aims to help reduce malaria-related mortality and morbidity by improving the availability, management, and use of malaria commodities at health facilities.
This edition of the EUV survey was conducted from August 9-31, 2016 in collaboration with the NMCP in the regions of Southern and Central Mali and the District of Bamako.
2
OBJECTIVES
General objective
Contribute to improving the availability, management, and use of pharmaceuticals and other malaria commodities at public and quasi-public health facilities in Mali.
Specific objectives
• Verify the availability of pharmaceuticals and other malaria commodities at health facilities.
• Verify end users' access to pharmaceuticals and other malaria commodities.
• Identify supply chain-related challenges and constraints for pharmaceuticals and other malaria commodities.
• Take corrective measures to improve the supply chain for pharmaceuticals and other malaria commodities.
• Verify the efficient use of pharmaceuticals and other malaria commodities.
• Propose solutions for the regular provision of pharmaceutical and malaria case management information.
3
METHODOLOGY
The survey was conducted using PMI's standardized EUV survey methodology. A total of 85 health facilities were visited. (See the list of facilities visited in Annex H.)
Survey type and framework
The survey covered the Kayes, Koulikoro, Sikasso, Ségou, and Mopti Regions and the District of Bamako. It was a cross-sectional, descriptive survey that focused on points of care as well as malaria commodity supply and distribution points at health facilities at every level of the health system.
Criteria for inclusion
• Health facilities: Any public, quasi-public, or private facility registered on the MOPHH health map that offers curative or prenatal care to fight malaria.
• Any pharmaceutical supply or distribution point (PPM store, private wholesaler, district pharmaceutical depot [Dépôt Répartiteurs de Cercle, or DRC], pharmaceutical depot [Dépôt de Vente, or DV], Reference Health Center [Centre de Santé de Référence, or CSRéf], Community Health Center [Centre de Santé Communautaire, or CSCom], and hospital pharmacies).
Sampling
A stratified sampling method was used to ensure that every type of health facility at every level of the health system was represented. Private facilities (wholesalers) and quasi-public facilities (CMIE, MIPROMA) were only sampled in the District of Bamako. CSComs were selected according to their attendance rates. However, any facility that was not accessible due to poor road conditions (in the rainy season) or insecurity was replaced with an accessible facility with the same characteristics.
Eligible facilities were broken down as follows:
• Regional hospitals (hospital pharmacies, pediatric wards): 5 • PPM stores (central and regional): 6 • CSRéfs (DRCs, DVs, curative consultations): 25 • CSComs, faith-based health centers, and CMIE (DV, curative consultations): 49
Data collection
The data were collected from August 9-31, 2016. Before this, surveyors were trained in the use of the data collection tools that had been validated during the previous EUV survey.
4 Methodology
During the data collection process, data were regularly sent to the Open Data Kit (ODK) server. The data were visible only to the SIAPS and NMCP coordination team. In addition, to further control data quality, two supervision teams composed of NMCP and SIAPS officials conducted field missions during the survey.
Data processing and analysis
Once the data collection process was completed, the data sent to the server were retrieved and converted to SPSS (Statistical Package for the Social Sciences) for analysis.
5
RESULTS
The data presented in this section describe the overall situation at all facilities visited. Results by region may be found in Annexes A through F. Key indicators are defined in Annex G.
Supply chain
Commodity availability on the date of the visit
More than 80% of the health and distribution facilities had all four ACT treatments (AL [6×1], AL [6×2], AL [6×3], AL [6×4]) on the date of the visit (table 1). However, other than AL (6×1), ACT treatments were more widely available at the DRCs than at the health facilities.
Quinine therapies (tablets and 200 mg injectables) were available at more than 80% of the health facilities. 400 mg injectable quinine was only available at 53.16% of the health facilities. More than 90% of the distribution facilities had quinine (injectables and tablets). SP was available at 84.81% of the health facilities and 95.83% of the distribution facilities (table 1).
94.94% of the health facilities and 91.66% of the distribution facilities had RDTs on the date of the visit. Mosquito nets were available at 78.48% of the health facilities and 87.50% of the distribution facilities (table 1).
Table 1. Percentage of facilities with malaria commodities on the date of the visit, by type of facility Availability at health Availability at distribution Commodities facilities facilities AL (6×1), 20 mg/120 mg dispersible tablets 98.73% 100.00% AL (6×2), 20 mg/120 mg dispersible tablets 91.14% 95.83% AL (6×3), 20 mg/120 mg tablets 83.54% 95.83% AL (6×4), 20 mg/120 mg tablets 91.14% 100.00% SP, 500 mg/25 mg tablets 84.81% 95.83% Quinine, 300 mg tablets 81.01% 92.86% Quinine, 200 mg injectables 97.47% 100.00% Quinine, 400 mg injectables 53.16% 100.00% Artesunate, 60 mg injectables 68.35% 87.50% RDTs 94.94% 91.66% LLINs 78.48% 87.50%
6 Results
Figure 1 shows that 100% of the health facilities had at least one ACT treatment on the date of the visit. 79% had all four treatments.
1 treatment 2 treatments 3 treatments 4 treatments
1% 79% 9%
11%
Figure 1. ACT availability at health facilities
As shown in figure 2, more than 90% of the distribution facilities visited (93%) had all four ACT treatments.
3 presentations 4 presentations
7%
93%
Figure 2. ACT availability at distribution facilities [presentations = treatments]
7 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Both health and distribution facilities had experienced malaria commodity stock-outs longer than three days5 (table 2). The percentage varied depending on the commodity and was highest for 60 mg injectable artesunate (stock-outs in 50.70% of the health facilities and 54.17% of the distribution facilities).
Table 2. Percentage of facilities having experienced stock-outs longer than three days Stock-outs longer than Stock-outs longer than three days in three days in Commodities health facilities distribution facilities AL (6×1), 20 mg/120 mg dispersible tablets 17.11% 12.50% AL (6×2), 20 mg/120 mg dispersible tablets 00.00% 00.00% AL (6×3), 20 mg /120 mg tablets 22.54% 20.83% AL (6×4), 20 mg/120 mg tablets 29.73% 20.83% SP, 500 mg/25 mg tablets 15.00% 08.33% Quinine, 300 mg tablets 09.72% 08.33% Quinine, 200 mg injectables 01.30% 00.00% Quinine, 400 mg injectables 00.00% 00.00% Artesunate, 60 mg injectables 50.70% 54.17% RDTs 29.23% 12.50% LLINs 23.88% 20.83%
Stock levels
Table 3 shows that most health facilities had stock levels either above or below the norm. Fewer than 36% of all health facilities were within the min/max guidelines for each commodity.
Table 3. Percentage of health facilities (CSComs, CSRéfs, hospitals) with stock levels within SDADME min/max guidelines Out of stock or Appropriate Number of Commodities understocked stock levels Overstocked facilitiesa AL (6×1), 20 mg/120 mg dispersible tablets 17.11% 18.42% 64.47% 76 AL (6×2), 20 mg/120 mg dispersible tablets 26.67% 14.67% 58.67% 75 AL (6×3), 20 mg/120 mg tablets 33.80% 9.86% 56.34% 71 AL (6×4), 20 mg/120 mg tablets 36.49% 35.14% 28.38% 74 SP, 500 mg/25 mg tablets 41.43% 7.14% 51.43% 70 Quinine, 300 mg tablets 29.17% 5.56% 65.28% 72 Quinine, 200 mg injectables 12.99% 24.68% 62.34% 77 Quinine, 400 mg injectables 19.74% 22.37% 57.89% 76 Artesunate, 60 mg injectables 6.58% 0.00% 93.42% 57 LLINs 73.97% 0.00% 26.03% 73 RDTs 41.79% 11.94% 46.27% 67 a. Number of facilities where information was available for each commodity.
5 Stock-outs longer than three days experienced during the three months preceding the date of the visit.
8 Results
Few distribution facilities (less than 15%) had stock levels within the Essential Medicines Supply and Distribution Plan (Schéma Directeur d’Approvisionnement et de Distribution en Médicaments Essentiels, or SDADME) guidelines (table 4). 50% of the distribution facilities were understocked in AL (6×4) and RDTs.
Table 4. Percentage of distribution facilities (DRCs) with stock levels within SDADME min/max guidelines Out of stock or Appropriate Number of Commodities understocked stock levels Overstocked facilitiesa AL (6×1), 20 mg / 120 mg dispersible tablets 12.50% 8.33% 79.17% 24 AL (6×2), 20 mg / 120 mg dispersible tablets 37.50% 20.83% 41.67% 24 AL (6×3), 20 mg / 120 mg tablets 20.83% 25.00% 54.17% 24 AL (6×4), 20 mg / 120 mg tablets 50.00% 12.50% 37.50% 24 SP, 500 mg/25 mg tablets 25.00% 8.33% 66.67% 24 Quinine, 300 mg tablets 20.83% 20.83% 58.33% 24 Quinine, 200 mg injectables 25.00% 4.17% 70.83% 24 Quinine, 400 mg injectables 20.83% 12.50% 66.67% 24 Artesunate, 60 mg injectables 0.00% 0.00% 100.00% 24 RDTs 50.00% 12.50% 37.50% 24 LLINs 54.17% 12.50% 33.33% 24 a. Number of facilities where information was available for each commodity.
Expired commodities
Expired commodities were found in the Ségou and Mopti Regions during the data collection period. The Ségou Region had the most expired commodities, with expired AL (6×18), 60 mg injectable artesunate, and quinine (tablets and 200 mg injectables). The Mopti Region had a significant amount of expired 500/25 mg SP tablets (2012 expired tablets) (figure 3).
AL, cp dispersible, pl18 Quinine, cp 300 mg Quinine, inj 200 mg Artesunate, inj 60 mg SP, cp 500/25 mg
2500
2000
1500
1000
500
0 Segou Mopti
Figure 3. Quantity of expired commodities observed during data collection [AL dispersible tablets, 18-pack, Quinine, 300 mg tablets, Quinine, 200 mg injectables, Artesunate, 60 mg injectables , SP, 500/25 mg tablets]
9 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Storage conditions
All hospitals and CSRéf DVs visited (except in Mopti) and at least 60% of the CSCom DVs in the regions visited met standard storage conditions (except in Ségou, where only 46% met standard storage conditions) (figure 4).
CSCom CSRéf Hopitaux
100% 100% 100% 100% 100% 100% 92% 90% 80% 67% 70% 63% 60% 60% 46% 50% 40% 30% 20% 10% 0% Kayes Koulikoro Sikasso Ségou Mopti
Figure 4. Percentage of DVs meeting standard storage conditions [Hopitaux = Hospitals]
All PPM stores (100%) and at least 50% of the DRCs in all five regions met standard storage conditions (figure 5).
DRC PPM
100% 100% 100% 100% 100% 100% 90% 75% 80% 67% 70% 60% 50% 50% 40% 30% 20% 10% 0% Kayes Koulikoro Sikasso Ségou Mopti
Figure 5. Percentage of distribution facility sales points meeting standard storage conditions, by region
10 Results
In the District of Bamako, Gabriel Touré University Hospital Center (CHU), the Commune VI CSRéf, and Mutuelle de Magnambougou met standard storage conditions. The Badalabougou CMIE does not have a pharmaceutical depot (DV).
Reference document availability
Malaria case management referral guidelines were available at all hospitals, CSComs, and CSRéfs visited in the Kayes, Ségou, and Mopti Regions. All CSComs visited in the Koulikoro Region and all CSRéfs visited in the Sikasso Region also had these guidelines (figure 6).
In the District of Bamako, the Commune VI CSRéf, Gabriel Touré CHU, and Badalabougou CMIE had the referral guidelines.
CSCom CSRef Hopital
100% 100% 100% 100% 100% 100% 90% 80% 83% 80% 70% 60% 50% 40% 30% 20% 10% 0% Kayes Koulikoro Sikasso Segou Mopti
Figure 6. Percentage of facilities with malaria case management referral guidelines, by type of health facility and region [Hopital = Hospital]
Pharmaceutical management manuals were available at all hospitals and PPM stores visited. These manuals were also available at all CSRéfs visited in the regions, except in the Koulikoro Region, where only 60% of the CSRéfs had these documents. While all CSComs in the Kayes Region and at least 50% of the CSComs visited in the Sikasso, Ségou, and Mopti Regions had these reference documents, this figure was only 33% in Koulikoro (figure 7). In the District of Bamako, these manuals were available at the Commune VI CSRéf and Gabriel Touré CHU but not at the Badalabougou CMIE.
11 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
CSCom CSRéf Hopital PPM 100% 100% 100% 100% 100% 100% 90% 83% 80% 67% 70% 60% 60% 50% 50% 40% 33% 30% 20% 10% 0% Kayes Koulikoro Sikasso Ségou Mopti
Figure 7. Percentage of facilities with pharmaceutical management manuals, by type of health facility and region [Hopital = Hospital]
Logistics Management Information System
Stock record availability and management
RDT stock records were up-to-date at all CSComs in Koulikoro and Ségou and at more than 60% of them in Kayes, Sikasso, and Mopti (figure 8). They were also up-to-date at more than 80% of the CSRéfs in Sikasso. However, RDT stock records were up-to-date at less than 50% of the CSRéfs in Kayes and Mopti, and at only 50% of the facilities in Ségou. The Kayes and Mopti hospitals did not have any RDT stock records even though they manage RDTs.
In Bamako, the Badalabougou CMIE and Mutuelle de Magnambougou did not have any RDT stock records. At Gabriel Touré CHU, RDTs are managed in the laboratory and not the pharmacy, and the laboratory did not have any RDT stock records.
12 Results
CSCom CSRef Hopital 100% 100% 100% 100% 100% 90% 83% 80% 67% 70% 63% 60% 60% 50% 50% 40% 33% 25% 30% 20% 10% 0% 0% 0% Kayes Koulikoro Sikasso Segou Mopti
Figure 8. Percentage of health facilities with up-to-date RDT stock records [Hopital = Hospital]
AL (6×1) stock records were up-to-date at all the CSComs in the Koulikoro Region and at 80% of the CSRéfs in Koulikoro and Sikasso. AL (6×1) stock records were not up-to-date at any of the regional hospitals visited, except in Segou, which shows 100% (figure 9).
In the District of Bamako, AL (6×1) stock records were not available at the Badalabougou CMIE.
CSCom CSRéf Hopital 100% 100% 100% 92% 83% 80% 80% 67% 63% 60% 50%
40% 33% 25% 20% 0% 0% 0% 0% Kayes Koulikoro Sikasso Ségou Mopti
Figure 9. Percentage of health facilities with up-to-date AL (6×1) stock records [Hopital = Hospital]
AL (6×3) stock records were up-to-date at more than 60% of the CSComs visited, except in Mopti, where only 33% of the CSComs had up-to-date stock records. They were also up-to-
13 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
date at most health facilities in Ségou. AL (6×3) stock records were also up-to-date in at least 60% of the CSRéfs in Koulikoro, Sikasso, and Ségou. However, the only hospital with up-to- date AL (6×3) stock records was the one in Ségou (figure 10).
Of the facilities visited in Bamako, only the Commune VI CSRéf had up-to-date AL (6×3) stock records. The quasi-public facilities visited and Gabriel Touré CHU do not manage AL (6×3).
CSCom CSRéf Hopital 100% 100% 100% 83% 75% 80% 67% 63% 60% 63% 60% 33% 40% 25% 20% 0% 0% 0% 0% Kayes Koulikoro Sikasso Ségou Mopti
Figure 10. Percentage of health facilities with up-to-date AL (6×3) stock records [Hopital = Hospital]
Submission of stock management reports
Table 5 shows that 91.14% of the facilities submit stock level reports on time using the SMR form.
Table 5. Percentage of facilities having submitted an AL stock management report (n = 79) Proper and timely submission Percentage On time 91.14% Late 7.59% Not submitted 1.27%
Malaria case management
Out of a total of 20,631 patients examined, 12,817 (62.12%) reported fever as a symptom. Of those cases, 10,709 (83.55%) were tested for parasites (thick smear or RDT), of which 8,961 cases (83.6%) came back positive. However, some cases of fever that tested negative or were not tested were treated as cases of uncomplicated or severe malaria (table 6).
14 Results
Table 6. Number of cases of fever by type of diagnosis Number of cases tested Diagnosis Positive Negative Number of untested cases Total Uncomplicated malaria 5,209 101 642 5,952 Severe malaria 3,504 34 529 4,067 Unspecified malaria 205 21 259 485 Other condition 43 1,592 678 2,313 Total 8,961 1,748 2,108 12,817
In addition, 110 out of 1,748 cases (6.29%) of fever that tested negative were treated with ACT.
During the period covered by the survey, 5,952 cases (28.85% of the consultations) were diagnosed with uncomplicated malaria (table 6). Among those, 2,178 (36.59%) were children under five and 3,774 (63.41%) were patients over five.
Most cases of uncomplicated malaria (85%) were diagnosed by RDT, while 5% were diagnosed using microscopy and 11% were diagnosed clinically.
Of all the cases of uncomplicated malaria, 89.90% were treated with ACT. Most patients under five diagnosed with uncomplicated malaria (90%) were treated with ACT, while 89.35% of patients over five were treated with ACT.
However, 4.60% of the cases of uncomplicated malaria were not properly treated. In these cases, patients were prescribed SP tablets, injectable quinine or quinine tablets, injectable artemether or injectable artesunate, as follows:
• Cases of uncomplicated malaria treated with quinine tablets: 0.94% • Cases of uncomplicated malaria treated with injectable quinine: 1.56% • Cases of uncomplicated malaria treated with artemether and artesunate: 0.13% • Cases of uncomplicated malaria treated with SP tablets: 1.97%
19.71% of patients, over half of whom (56.45%) were patients over five, were diagnosed with severe malaria. Moreover, 49.75% of the cases of severe malaria in children under five were treated with injectable artemether, 18.75% with injectable quinine, and 17.11% with injectable artesunate.
15
CHALLENGES AND CONSTRAINTS ENCOUNTERED IN THE FIELD
• Some consultation records were poorly kept (illegible, incomplete). The following are examples of insufficient completion of consultation records and/or a failure to follow the malaria case management protocol:
o In the Douentza CSRéf's records, the "diagnosis" section had not been completed, especially when the thick smear result was positive, which excluded several cases from the survey.
o In the Mopti hospital's consultation records, the results of biological diagnoses (RDT and thick smear) and the treatments prescribed were not indicated for most cases.
o Djénné Central CSCom: RDTs were not systematically used for cases of fever even though they were in stock.
o Koutiala CSRéf: Treatments prescribed were not recorded in the outpatient consultation record for severe and uncomplicated malaria, combined with other conditions for children under five, who were systematically referred to Médecins Sans Frontières (MSF) for treatment.
• Actual consumption data were not available due to the management of some free commodities received outside the pharmaceutical supply chain described in the SDADME or the standard operating procedures manual:
o At the Djénné CSRéf, RDTs go directly from the DRC to case management units, none of which keep stock records.
o At the Douentza CSRéf, LLINs, RDTs, injectable artesunate, and SP go directly from the DRC to treatment units (maternity and medical clinics), which do not keep stock records for these commodities.
o The Douentza CSRéf's DV had no stock records for ACT 6.
o The Sikasso regional PPM was delayed in providing injectable artesunate to health districts.
o The Yorosso and Niena DRCs in the Sikasso Region did not keep oxytocin refrigerated.
o The Yanfolila DRC does not manage free malaria commodities.
• Internet connection problems prevented the submission of EUV survey data in some districts (Yanfolila, Kolondièba, Niéna, and Yorosso).
• There were problems accessing the Kolondieba health district during the rainy season, especially during the month of August (risk of getting stuck for several days).
16
CORRECTIVE MEASURES TAKEN IN THE FIELD
Several corrective measures were taken in the field, mainly to address malaria commodity availability at the health facilities, remove expired commodities from shelves, and ensure compliance with new national treatment guidelines. Technical assistance was also provided to managers who had difficulties completing stock records and SMRs, and to health workers who needed help administering RDTs and completing consultation records.
The survey team also raised health worker awareness of good stock management practices, including how to keep management records (for example, each commodity should have an up-to-date stock record), store commodities, and rotate stocks.
Corrective actions taken in the field included the following:
• On the surveyors' advice, the Bankass CSRéf sent 200 packs of ACT 6 that were scheduled to expire in late August 2016 from the CSRéf DV back to the central CSCom. A distribution plan for injectable artesunate supplies, which had been received a few days before the team's arrival, was also developed on the team's recommendation, and the CSComs were immediately informed so that they could collect their allotment.
• The EUV survey team took the RDT stock from the Sikasso regional PPM to the Kignan health district DRC.
• The Center Technical Director (DTC) at the Diéma Central CSCom was informed of the existence of a significant quantity of nearly expired injectable artesunate (303 bottles) and packs of ACT 6 in his DV. The team also discussed the management of oxytocin and vitamin K1 in the maternity clinic and reminded the DTC that these commodities are like all others that should be managed in the DV.
• The new manager of the Tichitt CSCom had some difficulties completing stock records, so the team helped retrain her.
• In every facility visited, the team presented its results to managers in order to share its observations and make recommendations.
17
RECOMMENDATIONS
This seventh edition of the EUV survey was conducted from August 9-31, 2016 in southern Mali (Kayes, Koulikoro, Sikasso, Ségou, and Mopti Regions) and the District of Bamako, with the participation of the NMCP and SIAPS officials and regional pharmacists. It was conducted at 85 health and distribution facilities at every level of Mali's health system.
While the availability of all malaria commodities has improved, findings in the results section show several persistent challenges concerning the supply chain, malaria case management, and the Logistics Management Information System (LMIS). The following recommendations were made to help overcome these challenges.
For the National Health Department:
• Strengthen malaria control measures, including commodity management, during integrated supervisory activities.
For the Pharmacy and Pharmaceuticals Department:
• Continue distributing the revised SDADME manual to health facilities at all levels of the health system.
• Continue bi-annual SDADME supervisory visits.
For the PPM:
• Continue informing regions/districts of the availability of malaria commodities in the retail sector (AL [6×3] and AL [6×4]).
• Implement distribution plans within one month of delivery.
• Provide the Regional Health Department and NMCP with copies of all delivery slips for malaria commodities delivered to health centers.
For the NMCP:
• Continue distributing referral guidelines and malaria information materials at all levels.
• Continue training providers in the new national malaria control policy guidelines.
• Continue monitoring the supply and distribution of free commodities, particularly at DRCs and DVs.
• Continue conducting EUV surveys to further improve the availability and use of malaria commodities.
• Include a questionnaire in the survey tools to measure patient satisfaction with the quality of services offered at health facilities.
18 Recommendations
For Regional Health Departments:
• During supervisory visits, highlight the importance of following the malaria case management protocol, correctly filling out reports, and managing pharmaceuticals.
• Make malaria referral guidelines and information materials available at all levels.
• Continue training workers in the LMIS.
• Update or create a list of personnel trained in malaria case management, biological diagnosis, and focused antenatal care.
• Continue bi-annual SDADME supervisory visits.
• Verify the sending of commodity delivery slips by the CSRéf.
• Regularly monitor malaria commodity distribution plans.
For CSRéfs:
• Ensure that management documents, including consultation records, are filled out correctly.
• Submit logistics information to ensure the proper functioning of the LMIS.
• Include the results of biological tests (RDT, thick smear/thin smear) in the appropriate records column.
• Update or create a list of personnel trained in malaria case management, biological diagnosis, and focused antenatal care.
• Continue quarterly SDADME and malaria worker supervisory visits.
• Ensure proper storage conditions at the Douentza DRC.
• Install a fire alarm system in all DVs.
• Find a permanent solution to the problem of frequent absences and the lack of clarity in the Boudofo DTC's management of the CSComs (Kayes Region).
For public hospitals:
• Ensure that management documents, including consultation records, are filled out correctly.
• Follow the malaria case management protocol.
• Submit logistics information to ensure the proper functioning of the LMIS.
19 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
• Use LMIS data for decision making.
• Include the results of biological tests (RDT) and thick smears/thin smears in the appropriate records column.
• At the Mopti hospital, specify whether cases of malaria are uncomplicated or severe in the pediatric consultation record.
• Update or create a list of personnel trained in malaria case management, biological diagnosis, and focused antenatal care.
• Verify the quality of logistical data in the OSPSANTE tool (enter actual data).
• Make all malaria commodity management materials available to the DVs.
For the CSComs:
• Properly complete management materials (curative consultation, prenatal consultation, and laboratory records, stock records, stock management reports).
• Ensure that stock records are available for all managed commodities (including free commodities).
• Archive management materials properly.
• Submit stock management reports to the next level of the health system in a timely manner.
• Take free commodities into account when preparing orders.
• Include RDT and thick smear results in the "Notes" column of outpatient consultation records.
• Follow the malaria case management protocol.
• Submit logistics information to ensure the proper functioning of the LMIS.
• Follow good storage practices at all CSComs.
• Install a fire alarm system at all DVs.
20
ANNEX A: KAYES REGION RESULTS
Supply results
Malaria commodity availability on the date of the visit
AL (6×1), AL (6x2), AL (6x4), and 200 mg and 400 mg quinine injectables were available at all health facilities visited in the Kayes Region (table A1).
All CSComs had RDTs on the date of the visit. Quinine (injectables and tablets) and all four AL treatments were available at the CSRéf visited. 83% of the health facilities in Kayes had 60 mg injectable artesunate (table A1).
Table A1. Percentage of health facilities with commodities on the date of the visit Facility CSCom CSRéf Hospital Total Sample 7 4 1 12 Commodities Number Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible tablets 7 4 1 12 100% AL (6×2), 20 mg/120 mg dispersible tablets 7 4 1 12 100% AL (6×3), 20 mg/120 mg tablets 5 4 1 10 83% AL (6×4), 20 mg/120 mg tablets 7 4 1 12 100% SP, 500 mg/25 mg tablets 7 4 NA 11 92% Quinine, 300 mg tablets 5 4 1 10 83% Quinine, 200 mg injectables 7 4 1 12 100% Quinine, 400 mg injectables 7 4 1 12 100% Artesunate, 60 mg injectables 5 4 1 10 83% RDTs 7 4 1 12 100% LLINs 7 4 1 12 100% NA: Not applicable: these commodities are not managed by the facility/facilities.
Table A2 shows that the PPM regional store in Kayes had all four AL treatments, quinine (injectables and tablets), artesunate, and RDTs on the date of the visit. It does not manage the other malaria commodities (SP and LLINs). AL (6×4) and 200 mg and 400 mg quinine injectables were available at all DRCs visited.
Table A2. Percentage of distribution facilities with commodities on the date of the visit Facility DRC PPM Total Sample 4 1 5 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible tablets 4 1 5 100% AL (6×2), 20 mg/120 mg dispersible tablets 4 1 5 100% AL (6×3), 20 mg/120 mg tablets 4 1 5 100% AL (6×4), 20 mg/120 mg tablets 4 1 5 100% SP, 500 mg/25 mg tablets 4 NA 4 100% Quinine, 300 mg tablets 3 1 4 80% Quinine, 200 mg injectables 4 1 5 100% Quinine, 400 mg injectables 4 1 5 100% Artesunate, 60 mg injectables 4 1 5 100% RDTs 4 1 5 100% LLINs 4 NA 4 100% NA: Not applicable; these commodities are not managed by the facility/facilities.
21 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
ACT (AL) availability on the date of the visit
All health facilities in Kayes had at least three ACT treatments. More than half (75%) had all four treatments (figure A1).
3 Présentations 4 présentations
75%
25%
Figure A1. ACT availability at Kayes health facilities [présentations = treatments]
All distribution facilities in Kayes (100%) had all four ACT treatments (figure A2).
100%
Figure A2. ACT availability at Kayes distribution facilities
Worker training results
Table A3 shows that all personnel met at the Kayes health facilities had been trained in malaria case management (new treatment guidelines); 100% of the workers in all types of health facilities had been trained in the new treatment guidelines.
At least 92% of the workers at the CSComs and CSRéfs had received other types of training.
22 Annex A: Kayes Region Results
At the Kayes hospital, all workers had participated in one or more trainings in the four relevant fields (IPT, RDT, microscopy, and stock management).
Table A3. Worker training in Kayes Region facilities CSCom (8) CSRéf (4) Hospital (1) Training Number % Number % Number % New treatment guidelines (37/37) 100% (106/106) 100% (67/67) 100% IPT (29/29) 100% (42/42) 100% (13/13) 100% RDT (44/46) 96% (114/114) 100% (9/9) 100% Microscopy (1/1) 100% (12/12) 100% (9/9) 100% Stock management (16/17) 94% (11/12) 92% (6/6) 100%
Malaria case management results
Treatment of uncomplicated malaria
Table A4 shows that 22.10% of the consultations at Kayes health facilities were cases of uncomplicated malaria. Uncomplicated malaria cases were most frequently managed at the CSComs (28.01%).
Table A4. Rates of uncomplicated malaria among the total numbers of patients in the Kayes Region Health facility Uncomplicated malaria rate CSCom 28.01% CSRéf 7.05% Hospital 11.93% Total 22.10%
According to Table A5, uncomplicated malaria cases observed at the CSComs in the Kayes Region were diagnosed by clinical examination (5.60%) or RDT (93.68%). At the Kayes hospital, 86.27% of uncomplicated malaria cases were clinically diagnosed.
Table A5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Kayes Region Uncomplicated malaria cases diagnosed Health facility By clinical examination By RDT By microscopy CSCom 5.60% 93.68% 0.72% CSRéf 17.65% 79.41% 5.88% Hospital 86.27% 5.88% 7.84% Total 12.68% 85.92% 1.41%
At the CSComs in Kayes, 85.44% of children under five with uncomplicated malaria received ACT. 79.08% of the cases in patients over five were treated with ACT (table A6).
23 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
At the CSRéfs in Kayes, most cases of uncomplicated malaria in children under five (66.67%) were treated with ACT. 58.06% of patients over five admitted to the CSRéf received ACT.
However, the Kayes hospital did not record ACT treatment in children under five and patients over five.
Table A6. Percentage of cases of uncomplicated malaria treated with ACT in the Kayes Region Uncomplicated malaria cases treated with ACT
Health facility Children under five Patients over five CSCom 85.44% 79.08% CSRéf 66.67% 58.06% Hospital 0% 0% Total 85.17% 77%
Treatment of severe malaria
In the Kayes Region, 10% of the consultations were cases of severe malaria. Of those, 35% were children under five (table A7).
Table A7. Cases of severe malaria in patients in the Kayes Region % of severe malaria cases among % of severe malaria cases in Health facility patients children under five CSCom 12.13% 36.67% CSRéf 9.75% 23% Hospital 1.83% 62.50% Total 10% 35%
As shown in table A8, 23.8% of the cases of severe malaria in children under five were treated with injectable quinine and 15.4% were treated with injectable artesunate.
Table A8. Treatment of severe malaria cases in children under five in the Kayes Region Severe malaria cases in children Severe malaria cases in children under five treated with injectable under five treated with injectable Health facility quinine artesunate CSCom 35.23% 20.45% CSRéf 6% 9% Hospital 0% 0% Total 23.8% 15.4%
24
ANNEX B: KOULIKORO REGION RESULTS
Supply results
Malaria commodity availability on the date of the visit
Three AL treatments ([6×1], [6×3], and [6×4]), 300 mg quinine tablets and injectables, and RDTs were available at all CSComs in the Koulikoro Region (table B1).
All CSRéf DVs in Koulikoro had AL (6×1) and injectable quinine. 60 mg injectable artesunate and RDTs were available at all CSRéfs on the date of the visit (table B1).
Table B1. Percentage of health facilities with commodities on the date of the visit Facility CSCom CSRéf Hospital Total Sample 9 5 0 14 Commodities Number Number Number Number Percentage AL (6×1), 20 mg/120 mg 9 5 NA 14 100% dispersible tablets AL (6×2), 20 mg/120 mg 8 4 NA 12 86% dispersible tablets AL (6×3), 20 mg/120 mg 9 4 NA 13 93% tablets AL (6×4), 20 mg/120 mg 9 4 NA 13 93% tablets SP, 500 mg/25 mg tablets 8 5 NA 13 86% Quinine, 300 mg tablets 9 4 NA 13 93% Quinine, 200 mg injectables 9 5 NA 14 100% Quinine, 400 mg injectables 9 5 NA 14 100% Artesunate, 60 mg injectables 8 5 NA 13 93% RDTs 9 5 NA 14 100% LLINs 8 3 NA 11 79% NA: Not applicable; we did not visit any hospital in Koulikoro.
All four ACT treatments, quinine tablets, and quinine injectables were available at all distribution facilities in the Koulikoro Region on the date of the visit. Only the Nara CSRéf did not have RDTs. The PPM had all malaria commodities, except SP and RDTs; it does not manage LLINs (table B2).
25 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Table B2. Percentage of distribution facilities with commodities on the date of the visit Facility DRC PPM Total Sample 5 1 6 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible tablets 5 1 6 100% AL (6×2), 20 mg/120 mg dispersible tablets 5 1 6 100% AL (6×3), 20 mg/120 mg tablets 5 1 6 100% AL (6×4), 20 mg/120 mg tablets 5 1 6 100% SP, 500 mg/25 mg tablets 5 NA 5 100% Quinine, 300 mg tablets 5 1 6 100% Quinine, 200 mg injectables 5 1 6 100% Quinine, 400 mg injectables 5 1 6 100% Artesunate, 60 mg injectables 5 1 6 100% RDTs 4 NA 5 80% LLINs 5 NA 5 100% NA: Not applicable; these commodities are not managed by the facility/facilities.
ACT availability on the date of the visit
All health facilities in the Koulikoro Region had at least one ACT treatment on the date of the visit. All four treatments were available at 86% of the health facilities visited (figure B1).
1 présentation 3 Présentations 4 présentations
7%
86% 7%
Figure B1. ACT availability at Koulikoro health facilities [présentation = treatment]
Every distribution facility had all four ACT treatments, so all four ACT treatments were available at 100% of the distribution facilities visited in the Koulikoro Region (figure B2).
26 Annex B: Koulikoro Region Results
100%
Figure B2. ACT availability at Koulikoro distribution facilities
Worker training results
Microscopic diagnosis is less common at the CSComs visited in the Koulikoro Region, where the survey team did not find any worker who had been trained to perform it (table B3). More than 80% of the CSCom workers responsible for each of the five relevant areas (new guidelines, IPT, RDT administration, microscopy, and stock management) had been trained. 87% of those responsible for RDT administration and 93% of those who perform microscopic diagnosis at the CSRéfs visited had been trained (table B3).
Table B3. Worker training in Koulikoro Region facilities CSCom (9) CSRéf (5) Training Number % Number % New treatment guidelines (38/39) 97% (124/124) 100% IPT (22/23) 96% (43/46) 93% RDT (49/49) 100% (134/154) 87% Microscopy (0/0) (14/15) 93%
Stock management (21/25) 84% (26/29) 90%
Malaria case management results
Treatment of uncomplicated malaria
Table B4 shows that a higher percentage of the cases of uncomplicated malaria were observed at the CSComs (33.44%) than at the CSRéfs (32.41%).
Table B4. Rates of uncomplicated malaria among the total numbers of patients in the Koulikoro Region Health facility Uncomplicated malaria rate CSCom 33.44% CSRéf 32.41% Total 33.15%
27 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Table B5 shows that most cases at the CSComs in the Koulikoro Region were diagnosed by RDT (97.69%). The CSRéfs use all three methods of diagnosis, with 91.85% of the cases diagnosed by RDT.
Table B5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Koulikoro Region Uncomplicated malaria cases diagnosed Health facility By clinical examination By RDT By microscopy CSCom 2.31% 97.69% 0% CSRéf 3.43% 91.85% 4.72% Total 2.63% 96.06% 1.31%
Table B6 shows that more than 90% of children under five and patients over five admitted to the health facilities with uncomplicated malaria were treated with ACT. At the CSComs, 96.30% of children under five received ACT, compared to 95.56% at the CSRéfs.
Table B6. Percentage of cases of uncomplicated malaria treated with ACT in the Koulikoro Region Uncomplicated malaria cases treated with ACT
Health facility Children under five Patients over five CSCom 96.30% 95.54% CSRéf 95.56% 82.64% Total 96.11% 91.67%
Treatment of severe malaria
In the Koulikoro Region, 15.07% of patients examined were cases of severe malaria; 48.56% of those were children under five (table B7).
Table B7. Cases of severe malaria in patients in the Koulikoro Region % of severe malaria cases among % of severe malaria cases in Health facility patients children under five CSCom 16.09% 47.77% CSRéf 12.52% 51.11% Total 15.07% 48.56%
Table B8 shows that fewer than half of the cases of severe malaria among children under five were treated with injectable quinine (2%) or injectable artesunate (27%).
28 Annex B: Koulikoro Region Results
Table B8. Treatment of severe malaria cases in children under five in the Koulikoro Region
Severe malaria cases in children Severe malaria cases in children under five treated with injectable under five treated with injectable Health facility quinine artesunate CSCom 0.72% 30.94% CSRéf 4% 17% Total 2% 27%
29
ANNEX C: SIKASSO REGION RESULTS
Supply results
Malaria commodity availability on the date of the visit
All four ACT treatments were available at all the CSRéfs and at most of the CSComs visited (table C1).
All malaria commodities were available at the Sikasso hospital except for AL (6×3). The hospital does not manage SP and LLINs.
Table C1. Percentage of health facilities with commodities on the date of the visit Facility CSCom CSRéf Hospital Total Sample 12 6 1 19 Commodities Number Number Number Number Percentage AL (6×1), 20 mg/120 mg 12 6 1 19 100% dispersible tablets AL (6×2), 20 mg/120 mg 12 6 1 19 100% dispersible tablets AL (6×3), 20 mg/120 mg tablets 9 6 0 15 79% AL (6×4), 20 mg/120 mg tablets 12 6 1 19 100% SP, 500 mg/25 mg tablets 11 5 NA 16 88% Quinine, 300 mg tablets 12 6 1 19 100% Quinine, 200 mg injectables 12 6 1 19 100% Quinine, 400 mg injectables 12 6 1 19 100% Artesunate, 60 mg injectables 4 2 1 7 37% RDTs 12 6 1 19 100% LLINs 12 6 NA 18 100% NA: Not applicable; these commodities are not managed by the facility/facilities.
Table C2 shows that AL (6×1), AL (6×4), and quinine (tablets and injectables) were available at all DRCs in the Sikasso Region.
All four ACT treatments and quinine (tablets and injectables) were available at the regional PPM store on the date of the visit (table C2).
30 Annex C: Sikasso Region Results
Table C2. Percentage of distribution facilities with commodities on the date of the visit Facility DRC PPM Total Sample 6 1 7 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible tablets 6 1 7 100% AL (6×2), 20 mg/120 mg dispersible tablets 5 1 6 86% AL (6×3), 20 mg/120 mg tablets 5 1 6 86% AL (6×4), 20 mg/120 mg tablets 6 1 7 100% SP, 500 mg/25 mg tablets 5 NA 6 83% Quinine, 300 mg tablets 6 1 7 100% Quinine, 200 mg injectables 6 1 7 100% Quinine, 400 mg injectables 6 1 7 100% Artesunate, 60 mg injectables 3 1 4 57% RDTs 5 NA 6 83% LLINs 5 NA 6 83% NA: Not applicable; these commodities are not managed by the facility/facilities.
ACT availability on the date of the visit
More than half (79%) of the health facilities in the Sikasso Region had all four ACT treatments. However, 21% of the health facilities in the Sikasso Region had only three ACT treatments on the date of the visit (figure C1).
3 Présentations 4 présentations
79%
21%
Figure C1. ACT availability at Sikasso health facilities [présentations = treatments]
All distribution facilities in the Sikasso Region had at least three ACT treatments (figure C2).
31 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
3 Présentations 4 présentations
71%
29%
Figure C2. ACT availability at Sikasso distribution facilities [présentations = treatments]
Worker training results
Among the CSComs visited in the Sikasso Region, at least 92% of personnel responsible for IPT had been trained, as had 100% of those responsible for administering RDTs and 50% of those responsible for performing microscopic diagnosis of malaria.
Among the CSRéfs, 100% of the workers responsible for malaria case management had been trained in the new treatment guidelines.
Table C3. Worker training in Sikasso Region facilities CSCom (12) CSRéf (6) Hospital (1) Training Number % Number % Number % New treatment guidelines (58/58) 100% (152/152) 100% No data (ND) IPT (34/37) 92% (56/58) 96% ND RDT (64/64) 100% (157/173) 90% ND Microscopy (1/2) 50% (17/18) 94% ND Stock management (10/21) 47% (29/32) 90% ND
Malaria case management results
Treatment of uncomplicated malaria
Table C4 shows that most cases of uncomplicated malaria in the Sikasso Region were observed at the CSComs, with 36.76%, compared to 21.16% at the CSRéfs and 6.96% at the hospital.
32 Annex C: Sikasso Region Results
Table C4. Rates of uncomplicated malaria among total numbers of patients in the Sikasso Region Health facility Uncomplicated malaria rate CSCom 36.76% CSRéf 21.16% Hospital 6.96% Total 31.47%
Table C5 shows that the majority of cases (92.97%) of uncomplicated malaria observed at the CSComs in the Sikasso Region were diagnosed by RDT. Most cases observed at the hospital were diagnosed by either RDT (53.13%) or microscopy (43.75%).
Table C5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Sikasso Region Uncomplicated malaria cases diagnosed Health facility By clinical examination By RDT By microscopy CSCom 7.03% 92.97% 0,00% CSRéf 26.04% 70.64% 3.60% Hospital 9.38% 53.13% 43.75% Total 9.92% 89.08% 1.13%
At the health facilities in the Sikasso Region, more than 90% of the cases of uncomplicated malaria in children under five and patients over five were treated with ACT. At the Sikasso hospital, 95.24% of patients under five with uncomplicated malaria received ACT (table C6).
Table C6. Percentage of cases of uncomplicated malaria treated with ACT in the Sikasso Region Uncomplicated malaria cases treated with ACT
Health facility Children under five Patients over five CSCom 93.81% 93.75% CSRéf 83.33% 80.81% Hospital 95.24% 81.82% Total 92.76% 91.37%
Treatment of severe malaria
26.29% of the consultations in the Sikasso Region were cases of severe malaria. Of those, 45.04% were children under five (table C7).
Table C7. Cases of severe malaria in patients in the Sikasso Region
% of severe malaria cases among % of severe malaria cases in Health facility patients children under five CSCom 24.73% 40.22% CSRéf 30.36% 51.93% Hospital 29.78% 66.42% Total 26.29% 45.04%
33 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Table C8 shows that less than half of the cases of severe malaria in children under five were treated with injectable quinine (19.05%) or injectable artesunate (6.87%).
Table C8. Treatment of severe malaria cases in children under five in the Sikasso Region Severe malaria cases in children Severe malaria cases in children under five treated with injectable under five treated with injectable Health facility quinine artesunate CSCom 27.26% 4.24% CSRéf 5.20% 14.50% Hospital 10.99% 6.59% Total 19.05% 6.87%
34
ANNEX D: SÉGOU REGION RESULTS
Supply results
Malaria commodity availability on the date of the visit
The Ségou hospital had all malaria commodities, except SP and AL (6×2). 200 mg and 400 mg quinine injectables were available at all the CSComs and CSRéfs visited (table D1).
Table D1. Percentage of health facilities with commodities on the date of the visit Facility CSCom CSRéf Hospital Total Sample 13 5 1 19 Commodities Number Number Number Number Percentage AL (6×1), 20 mg/120 mg 13 5 1 19 100% dispersible tablets AL (6×2), 20 mg/120 mg 13 5 0 18 95% dispersible tablets AL (6×3), 20 mg/120 mg 12 5 1 18 95% tablets AL (6×4), 20 mg/120 mg 13 5 1 19 100% tablets SP, 500 mg/25 mg tablets 13 3 0 16 84% Quinine, 300 mg tablets 12 3 1 16 84% Quinine, 200 mg injectables 13 5 1 19 100% Quinine, 400 mg injectables 13 5 1 19 100% Artesunate, 60 mg 10 5 1 16 84% injectables RDTs 12 4 1 17 89% LLINs 11 1 1 13 68%
Table D2 shows that the regional PPM store had all four ACT (AL) treatments and quinine (tablets and injectables). All the DRCs visited had all four ACT and quinine treatments (300 mg tablets and 200 mg injectables), 60 mg injectable artesunate, and RDTs.
35 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Table D2. Percentage of distribution facilities with commodities on the date of the visit Facility DRC PPM Total Sample 6 1 7 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible 6 1 7 100% tablets AL (6×2), 20 mg/120 mg dispersible 6 1 7 100% tablets AL (6×3), 20 mg/120 mg tablets 6 1 7 100% AL (6×4), 20 mg/120 mg tablets 6 1 7 100% SP, 500 mg/25 mg tablets 6 NA 6 86% Quinine, 300 mg tablets 6 1 7 100% Quinine, 200 mg injectables 6 1 7 100% Quinine, 400 mg injectables 6 1 7 100% Artesunate, 60 mg injectables 6 1 7 100% RDTs 6 1 7 100% LLINs 4 NA 6 67% NA: Not applicable; these commodities are not managed by the facility/facilities.
ACT availability on the date of the visit
All health facilities in the Ségou Region had at least two ACT treatments on the date of the visit. More than half (89%) had all four treatments (figure D1).
2 Présentations 3 Présentations 4 présentations
5% 5%
89%
Figure D1. ACT availability at Ségou health facilities [présentations = treatments]
36 Annex D: Ségou Region Results
Figure D2 shows that all distribution facilities (100%) had all four ACT treatments on the date of the visit.
100%
Figure D2. ACT availability at Ségou distribution facilities
Worker training results
In the areas listed in table D3, other than malaria case management (new treatment guidelines), at least 66% of the workers responsible for each area had been trained. All CSCom workers who administer RDTs and perform microscopic diagnosis of malaria had been trained.
Table D3. Worker training in Ségou Region facilities CSCom (12) CSRéf (6) Hospital (1) Training Number % Number % % New treatment guidelines (88/88) 100% (152/152) 100% (50/50) 100% IPT (39/39) 100% (40/40) 100% (19/19)100% RDT (83/83) 100% (161/161) 100% (50/93) 54% Microscopy (6/6) 100% (15/16) 93% (9/9)100% Stock management (16/24) 66% (17/24) 71% (5/6) 83%
Malaria case management results
Treatment of uncomplicated malaria
Table D4 shows that 28.348% of the consultations at the health facilities in the Ségou Region were cases of uncomplicated malaria.
Much higher percentages of cases of uncomplicated malaria were observed at the CSComs (30.40%) and at the CSRéfs (25.75%), as compared to the hospital (8.91%).
37 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Table D4. Rates of uncomplicated malaria among total numbers of patients in the Ségou Region Health facility Uncomplicated malaria rate CSCom 30.40% CSRéf 25.75% Hospital 8.91% Total 28.348%
Table D5 shows that the CSRéfs diagnosed a higher percentage of cases of uncomplicated malaria by RDT as compared to the CSComs (80.66% and 74.18%, respectively). Cases of uncomplicated malaria observed at the hospital were diagnosed by either clinical examination (5.56%) or microscopy (94.44%).
Table D5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Ségou Region Uncomplicated malaria cases diagnosed Health facility By clinical examination By RDT By microscopy CSCom 8.64% 74.18% 17.19% CSRéf 17.40% 80.66% 1.93% Hospital 5.56% 0% 94.44% Total 10.71% 74.85% 14.44%
Most cases of uncomplicated malaria (91.65%) in children under five in the Ségou Region were treated with ACT (table D6).
Table D6. Percentage of cases of uncomplicated malaria treated with ACT in the Ségou Region Uncomplicated malaria cases treated with ACT
Health facility Children under five Patients over five CSCom 93.01% 42.01% CSRéf 95.68% 92.09% Hospital 0% 0% Total 91.65% 50.82%
Treatment of severe malaria
In the Ségou Region, 19.14% of patients examined were cases of severe malaria. Of those, 40.69% were children under five (table D7).
Table D7. Cases of severe malaria in patients in the Ségou Region % of severe malaria cases in Health facility % of severe malaria cases among patients children under five CSCom 18.68% 35.80% CSRéf 19.91% 51.07% Hospital 22.28% 51.11% Total 19.14% 40.69%
38 Annex D: Ségou Region Results
Table D8 shows that less than half of the cases of severe malaria in children under five were treated with injectable quinine (7.51%) or injectable artesunate (32.93%).
Table D8. Treatment of severe malaria cases in children under five in the Ségou Region Severe malaria cases in children Severe malaria cases in children under five treated with injectable under five treated with injectable Health facility quinine artesunate CSCom 9.72% 23.48% CSRéf 4.90% 53.85% Hospital 0% 4.35% Total 7.51% 32.93%
39
ANNEX E: MOPTI REGION RESULTS
Supply results
Malaria commodity availability on the date of the visit
All CSComs visited in the Mopti Region had at least two ACT treatments [AL (6×1) and AL (6×2)], 200 mg injectable quinine, and SP (table E1).
All four ACT treatments, 200 mg and 400 mg quinine injectables, and RDTs were available at the CSRéfs.
The Mopti hospital did not have AL (6×3) or AL (6×4) on the date of the visit (table E1).
Table E1. Percentage of health facilities with commodities on the date of the visit Facility CSCom CSRéf Hospital Total Sample 6 2 1 9 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg 6 2 1 100% dispersible tablets AL (6×2), 20 mg/120 mg 6 2 1 100% dispersible tablets AL (6×3), 20 mg/120 mg tablets 4 2 0 67% AL (6×4), 20 mg/120 mg tablets 4 2 0 67% SP, 500 mg/25 mg tablets 6 0 1 78% Quinine, 300 mg tablets 5 0 0 56% Quinine, 200 mg injectables 6 2 1 100% Quinine, 400 mg injectables 5 2 1 89% Artesunate, 60 mg injectables 4 1 1 67% RDTs 4 2 1 78% LLINs 4 0 NA 44% NA: Not applicable; these commodities are not managed by the facility/facilities.
All four ACT treatments, quinine (tablets and injectables), and 60 mg injectable artesunate were available at the regional PPM store on the date of the visit (table E2). All malaria commodities were available at the DRCs visited.
40 Annex E: Mopti Region Results
Table E2. Percentage of distribution facilities with commodities on the date of the visit Facility DRC PPM Total Sample 3 1 4 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible tablets 3 1 4 100% AL (6×2), 20 mg/120 mg dispersible tablets 3 1 4 100% AL (6×3), 20 mg/120 mg tablets 3 1 4 100% AL (6×4), 20 mg/120 mg tablets 3 1 4 100% SP, 500 mg/25 mg tablets 3 NA 3 100% Quinine, 300 mg tablets 3 1 4 100% Quinine, 200 mg injectables 3 1 4 100% Quinine, 400 mg injectables 3 1 4 100% Artesunate, 60 mg injectables 3 1 4 100% RDTs 3 NA 3 100% LLINs 3 NA 3 100% NA: Not applicable; these commodities are not managed by the facility/facilities.
ACT availability on the date of the visit
Figure E1 shows that most health facilities had all four AL treatments.
All health facilities in the Mopti Region had at least two ACT treatments. 67% of them had all four treatments.
2 Présentations 4 présentations
67%
33%
Figure E1. ACT availability at Mopti health facilities [présentations = treatments]
100% of the distribution facilities in the Mopti Region had all four ACT treatments on the date of the visit (figure E2).
41 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
100%
Figure E2. ACT availability at Mopti distribution facilities
Worker training results
Table E3 shows that 100% of the CSCom workers had been trained in the new treatment guidelines and RDT administration.
All personnel at the Mopti hospital and the CSRéfs visited who were responsible for malaria case management (new treatment guidelines), IPT, and microscopic diagnosis of malaria had been trained.
Table E3. Worker training in Mopti Region facilities CSCom (6) CSRéf (3) Hospital (1) Training Number % Number % Number % New treatment guidelines (40/40) 100% (54/54) 100% (22/22) 100% IPT (26/26) 100% (5/5) 100% (10/10) 100% RDT (42/42) 100% (63/63) 100% (10/10) 100% Microscopy (6/6) 100% (8/8) 100% (12/12) 100% Stock management (16/18) 89% (20/20) 100% (4/4) 100%
Malaria case management results
Treatment of uncomplicated malaria
Cases of uncomplicated malaria made up 25.13% of the consultations at health facilities in the Mopti Region. 12.66% of the consultations at the Mopti hospital were cases of uncomplicated malaria (table E4).
42 Annex E: Mopti Region Results
Table E4. Rates of uncomplicated malaria among total numbers of patients in the Mopti Region Health facility Uncomplicated malaria rate CSCom 28.36% CSRéf 15.68% Hospital 12.66% Total 25.13%
As shown in table E5, most cases of uncomplicated malaria (74.69%) in the Mopti Region were diagnosed by RDT. Some cases of uncomplicated malaria observed at the CSComs in Mopti were diagnosed by clinical examination (22.69%).
Table E5. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the Mopti Region Uncomplicated malaria cases diagnosed Health facility By clinical examination By RDT By microscopy CSCom 22.69% 79.32% 0.00% CSRéf 6.67% 71.11% 22.22% Hospital 83.33% 3.33% 16.67% Total 24.61% 74.69% 2.62%
As shown in table E6, more than 79.23% of the cases of uncomplicated malaria in children under five and patients over five were treated with ACT.
Table E6. Percentage of cases of uncomplicated malaria treated with ACT in the Mopti Region Uncomplicated malaria cases treated with ACT
Health facility Children under five Patients over five CSCom 92.76% 90.75% CSRéf 66.67% 79.49% Hospital 0 16.67% Total 79.23% 88.49%
Treatment of severe malaria
In the Mopti Region, 18.77% of the consultations were cases of severe malaria. Of those, 8.55% were children under five (table E7).
Table E7. Cases of severe malaria observed in patients in the Mopti Region % of severe malaria cases in Health facility % of severe malaria cases among patients children under five CSCom 21.30% 43.05% CSRéf 6.27% 38.89% Hospital 15.19% 75.00% Total 18.77% 8.55%
43 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
As shown in table E8, 35.38% of the cases of severe malaria in children under five were treated with injectable quinine.
Table E8. Treatment of severe malaria cases in children under five in the Mopti Region Severe malaria cases in children under five treated with injectable Severe malaria cases in children under Health facility quinine five treated with injectable artesunate CSCom 42.86% 5.59% CSRéf 0% 28.57% Hospital 0% 0% Total 35.38% 5.64%
44
ANNEX F: DISTRICT OF BAMAKO RESULTS
Supply results
Malaria commodity availability on the date of the visit
At Gabriel Touré CHU in Bamako, only AL (6×1), AL (6×2), and 60 mg injectable artesunate were available on the date of the visit (table F1).
Except for 60 mg injectable artesunate, SP, 300 mg quinine tablets, and LLINs, all other malaria commodities were available at the Commune VI CSRéf.
Table F1. Percentage of health facilities with commodities on the date of the visit Facility CSRéf Hospital Total Sample 1 1 2 Commodities Number Number Number Percentage AL (6×1), 20 mg/120 mg dispersible tablets 1 1 2 100% AL (6×2), 20 mg/120 mg dispersible tablets 1 1 2 100% AL (6×3), 20 mg/120 mg tablets 1 NA 1 100% AL (6×4), 20 mg/120 mg tablets 1 NA 1 100% SP, 500 mg/25 mg tablets 0 NA 0 0% Quinine, 300 mg tablets 0 NA 0 0% Quinine, 200 mg injectables 1 0 1 50% Quinine, 400 mg injectables 1 0 1 50% Artesunate, 60 mg injectables 0 1 1 50% RDTs 1 NA 1 100% LLINs 0 NA 0 0% NA: Not applicable; these commodities are not managed by the facility/facilities.
ACT availability on the date of the visit
At least two ACT treatments were available at all health facilities visited in Bamako. 50% of the health facilities in the District of Bamako had all four AL treatments on the date of the visit (figure F1).
2 présentations 4 présentations
50% 50%
Figure F1. ACT availability at Bamako health facilities
45 Report on the Malaria Commodity End-Use Verification Survey for Mali, August 9-31, 2016
Worker training results
Among the centers visited in Bamako, all personnel had been trained in all areas listed in table F2, except microcopy and stock management.
At Gabriel Touré CHU, 100% of the personnel had been trained in the new treatment guidelines, IPT, and microscopy. All workers responsible for stock management and RDT administration had also been trained.
All workers at the Commune VI CSRéf had been trained in the different areas listed in table F2.
Table F2. Worker training in Bamako facilities Center (1) CSRéf (1) Hospital (1) Training Number % Number % Number % New treatment guidelines (4/4) 100% (75/75) 100% (23/23) 100% IPT (2/2) 100% (30/30) 100% (29/29) 100% RDT (2/2) 100% (3/3) 100% (16/16) 100% Microscopy (0/0) 0% (12/12) 100% (16/16) 100% Stock management (0/0) 0% (7/7) 100% (12/12) 100%
Malaria case management results
Treatment of uncomplicated malaria
Table F3 shows that 21.27% of the consultations at medical centers in Bamako were cases of uncomplicated malaria. This was the case for 18.40% of the consultations at the Commune VI CSRéf and 9.09% of those at Gabriel Touré CHU.
Table F3. Rates of uncomplicated malaria among total numbers of patients in the District of Bamako Health facility Uncomplicated malaria rate Quasi-public center 29.03% CSRéf 18.40% Hospital 9.09% Total 21.27%
Table F4 shows that 46.07% of the cases of uncomplicated malaria observed at medical centers were diagnosed by clinical examination. Most cases of uncomplicated malaria (96.81%) observed at the Commune VI CSRéf were diagnosed by RDT.
Gabriel Touré CHU diagnosed 42.86% of the cases of uncomplicated malaria by clinical examination and 57.14% by microscopy.
46 Annex F: District of Bamako Results
Table F4. Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy in the District of Bamako Uncomplicated malaria cases diagnosed Health facility By clinical examination By RDT By microscopy Quasi-public center 93.33% 5.56% 1.11% CSRéf 1.06% 96.81% 2.13% Hospital 42.86% 0% 57.14% Total 46.07% 50.26% 3.66%
Most cases of uncomplicated malaria in children under five (77.5%) were treated with ACT. All patients admitted to Gabriel Touré CHU with uncomplicated malaria were treated with ACT (table F5).
Table F5. Percentage of cases of uncomplicated malaria treated with ACT in the District of Bamako Uncomplicated malaria cases treated with ACT
Health facility Children under five Patients over five Quasi-public center 58.06% 60.34% CSRéf 88.89% 91.84% Hospital 100% 100% Total 77.5% 75.23%
Treatment of severe malaria
9.36% of the consultations in the District of Bamako were cases of severe malaria. Of those, 40% were diagnosed in children under five (table F6).
Table F6. Cases of severe malaria in patients in the District of Bamako % of severe malaria cases among % of severe malaria cases in Health facility patients children under five Quasi-public center 5.81% 16.67% CSRéf 19.15% 44.44% Hospital 11.69% 77.78% Total 9.36% 40%
As shown in table F7, 16.67% of the cases of severe malaria in children under five were treated with injectable quinine, while 44.44% of the cases received injectable artesunate.
Table F7. Treatment of severe malaria cases in children under five in the District of Bamako Severe malaria cases in children Severe malaria cases in children under five treated with injectable under five treated with injectable Health facility quinine artesunate Quasi-public center 100.00% 0% CSRéf 0% 100% Hospital 0% 0% Total 16.67% 44.44%
47
ANNEX G: DEFINITION OF INDICATORS
Percentage of facilities with commodities available on the date of the visit
This indicator is calculated by commodity and by type of facility and is used to measure the availability of commodities on the date of the visit. It is calculated separately for health and distribution facilities (DRCs, PPM stores).
ACT availability on the date of the visit
This indicator refers to the four types of AL treatments that should be available at health facilities. It is used to measure the simultaneous availability of the different AL treatments.
Percentage of facilities having experienced a stock-out longer than three days
This indicator is calculated by commodity and is used to measure the uninterrupted availability of commodities at facilities. It is calculated separately for health and distribution facilities (DRCs, PPM stores).
Percentage of health facilities with stock levels within SDADME min/max guidelines
This indicator is calculated based on months' worth of stock available for each commodity. The stock record for each commodity must have been kept up-to-date during the three months preceding the survey in order to calculate average monthly consumption. This indicator is used to calculate the percentage of facilities that comply with the following SDADME max/min guidelines:
• Max: two months' worth of stock for DVs and four months' worth of stock for DRCs. • Min: one month's worth of stock for DVs and two months' worth of stock for DRCs.
This indicator also shows the number of facilities that were understocked or overstocked according to the max/min guidelines.
Quantity of expired commodities recorded during data collection
This indicator is calculated by commodity and is used to measure the quantity of commodities that were expired on the date of the visit.
Availability of pharmaceutical management manuals and malaria case management and pharmaceutical management referral guidelines
This indicator is assessed for each health facility visited to measure the availability of malaria case management and pharmaceutical management referral guidelines. It is also assessed at distribution facilities to measure the availability of pharmaceutical management manuals.
Percentage of health facilities with up-to-date stock records
This indicator is calculated based on three commodities out of the list of ten for which data are collected: AL 6-packs, AL 18-packs, and RDTs.
48 Annex H: Definition of Indicatgors
Health facility pharmaceutical depots meeting standard storage conditions
This indicator is calculated based on a certain number of criteria that the DVs must meet to be considered as meeting standard storage conditions. The indicator is assessed as follows:
• There are 13 criteria for DVs and hospital pharmacies, of which at least 11 must be met.
• There are 16 criteria for DRCs and PPM stores, of which at least 14 must be met.
Timely submission of stock management reports
This indicator shows the number of facilities that report their AL stock levels to the next level of the health system. According to the SDADME, the DV must submit SMRs monthly and the DRC must submit them quarterly.
Percentage of cases of uncomplicated malaria among the total numbers of patients
This indicator is calculated using data from the consultation records at the health facilities visited (CSComs, CSRéfs, hospitals). It shows the percentage of uncomplicated malaria cases compared to the total number of patients examined during the month preceding the date of the visit.
Rates of uncomplicated malaria diagnosed by clinical examination, RDT, or microscopy
This indicator shows the use of biological diagnosis (RDT or microscopy) to confirm suspected cases of malaria. It is used to measure compliance with the malaria case management policy, which requires that any case of fever must be biologically confirmed before any treatment is given.
Percentage of cases of uncomplicated malaria not properly treated (i.e., treated with anything other than AL)
This indicator shows the percentage of cases of uncomplicated malaria that were not treated according to the new treatment guidelines.
Percentage of cases of uncomplicated malaria treated with ACT
This indicator shows the percentage of cases of malaria that were treated with ACT (AL tablets). It is calculated for children under five and patients over five.
49
ANNEX H: FACILITIES VISITED
Region Health District Facility Kayes Kayes Fousseyni Daou Hospital Regional PPM Kita Kita CSRéf Boudofo CSCom Kassaro CSCom Kenieba Kenieba CSRéf Dabia CSCom Tabakoto CSCom Diema Diema CSRéf Diéma Central CSCom Fassoudebe CSCom Nioro Nioro CSRéf Fosse Kaarta CSCom Tichitt CSCom Koulikoro Koulikoro Regional PPM Kangaba Kangaba CSRéf Kangaba Central CSCom Salamalé CSCom Banamba Banamba CSRéf Banamba Central CSCom Kiban CSCom Nara Nara CSRéf Nara Central CSCom Dioïla Dioïla CSRéf Dioïla Central CSCom Kola CSCom Ouelessebougou Ouelessebougou CSRéf Ouelessebougou Central CSCom Tinkele CSCom Sikasso Sikasso Sikasso Hospital Regional PPM Bougouni Bougouni CSRéf Bougouni Est CSCom Bougouni Ouest CSCom Niena Niena CSRéf Niena Central CSCom Zaniena CSCom Koutiala Koutiala CSRéf Medinacoura CSCom Zangasso CSCom Yanfolila Yanfolila CSRéf Yanfolila Central CSCom Kalana CSCom Kolondieba Kolondieba CSRéf Kolondieba Central CSCom Tousséguéla CSCom Yorosso Yorosso CSRéf Yorosso Central CSCom Koury CSCom
50 Annex H: Facilities Visited
Region Health District Facility Ségou Ségou Nianankoro Fomba Hospital Regional PPM Bla Bla CSRéf Bla Central CSCom Yangasso CSCom Niono Niono CSRéf Dougouba CSCom Niono CSCom - annex Barouéli Baroueli CSRéf Konobougou CSCom Barouéli Central CSCom San San CSRéf Tene CSCom San Central CSCom Markala Markala CSRéf Sansanding CSCom Dougabougou CSCom Tominian Tominian CSRéf Benena CSCom Tominian Central CSCom Mopti Mopti Sominé Dolo Hospital Regional PPM Douentza Douentza CSRéf Douentza Central CSCom Boré CSCom Bankass Bankass CSRéf Lessagou CSCom Bankass Central CSCom Djenné Djenné CSRéf Djénné Central CSCom Mougna CSCom Bamako Commune III Gabriel Touré Hospital Central PPM Commune V Badalabougou CMIE Commune VI Mutuelle de Magnambougou Commune VI CSRéf
51