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Malaria Elimination Planning for Huambo Province Angola Background

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Malaria Elimination Planning for Huambo Province Angola Background Malaria Elimination Planning for Huambo Province Angola Notes and Activities – ForçaSaúde/USAID – September 2015 Jhpiego Malaria Team and Colleagues in Luanda1 Background Huambo Province Health Ministry Officials have expressed interesting in working toward elimination of malaria in the province because they have seen a major drop in cases and deaths from malaria over the years. Cases have dropped steadily from 620,300 in 2008 to 68,547 in 2014. Likewise deaths have declined from 1,559 to 17 in the same period. An elimination effort needs to account for local epidemiology. In Huambo Province, parasitological studies of malaria show that 85% of cases are falciparum, and 15% are vivax. There is variation among municipalities in test positivity rates with Bailundo, Londuimbali, Mungo and Chicala in the northern part of the Province having moderate rates of RDT (rapid diagnostic test at health centers) positivity, between 24-44%, and the remaining municipalities in the central and southern part of the Province (Caala, Ekunha, Huambo, Cachiungo, Longonjo, Chinjenje and Ukuma) having rates between 3-16%. The Province as a whole has benefitted from a reduction in cases and deaths over the past seven years, and the challenge now it to move toward the pre-elimination phase of malaria control wherein test positivity is less than 5% during the high transmission season. With this in mind, and as part of malaria activities for Year 4 of the ForçaSaúde work plan, the malaria team and MOH counterparts planned an assessment in Huambo to determine learning and programming needs of health workers for achieving pre-elimination status of malaria. The overall aim of the assessment is to determine the extent to which municipality and frontline health center staff in Huambo Province understand and are experienced with the tools and procedures for achieving pre-elimination status for malaria in the Province and move the Province forward toward malaria elimination. To this end, Jhpiego’s Senior Malaria Specialist traveled to Huambo to work with the ForçaSaúde malaria team to conduct the malaria assessment mentioned above. The assessment consisted of two main parts, an analysis of HMIS data on malaria testing and confirmed cases and a series of interviews with health staff at various levels of the Province. The height of the transmission season in Huambo is between November and January, and three complete years of HMIS data were available (2012-13, 2013-14, 2014-15). Using RDT testing results, which are the main form of diagnostic testing in the health centers and posts of the Province, a test positivity rate (TPR) was calculated for each municipality. There was a distinctive difference between the northern and southern parts of the Province, with come in the south approaching pre-elimination status while those in the north needed more intensified scale up of control measures. These findings are summarized below and maps mentioned within this report are appended. 1 Adolfo Sampaio, William Brieger, and Gilberto Jolomba with steadfast support from Margarita Gurdian. 1 Table 1: RDT Test Positivity Rates RDT Results Municipality Location Positive Negative Total Test Positivity Rate Bailundo North 8015 13302 21317 38% Caala S-Central 188 3238 3426 5% Ekunha S-Central 789 4209 4998 16% Huambo S-Central 3835 24586 28421 13% Cachiungo S-Central 107 3509 3616 3% Londuimbali North 3454 8602 12056 29% Longonjo S-Central 88 2901 2989 3% Mungo North 8347 10512 18859 44% Chicala North 828 2567 3395 24% Chinjenje S-Central 134 1792 1926 7% Ukuma S-Central 341 4022 4363 8% TOTAL 26126 79240 105366 25% Since the health worker interviews were focused on a finite time period, it was decided to interview in the two highest TPR Municipalities and the two lowest. The table below shows the make-up of those to be interviewed. Interviews focused on health staff knowledge and experience with a variety of malaria elimination concepts and processes including surveillance, reactive case detection, WHO’s test, treat and track approach, working with hotspots, and use of community volunteers. A version of the interview guide is appended. Table 2: Health Workers to Be Interviewed Health Workers to be Interviewed: Numbers Select 4 Municipalities, two in higher and two in lower TPR (transmission) areas On Municipal Health Teams interview two people • malaria focal person 4 • one other 4 At Health Facility – select at least 3 facilities per municipality • health worker in charge 12 • health worker providing diagnosis and treatment 12 TOTAL Health Workers 32 Discussion Group Interview with Governmental and NGO 6-10 Stakeholders in Huambo (as available) 2 Fie ld Work Wednesday 2/9/15 A preliminary strategy session was held among Luanda ForçaSaúde staff to review the context and plan activities. The M&E office provided detailed maps of health facilities for each Province to facilitate interview site selection. We discussed the current context and its implications including the current lack of Global Fund grants and concern by other donors serious about serious malaria treatment commodity loss over the years. We met with USAID staff to review processes of the assessment, including assurances that this was an assessment, not research. Armando Cotrina is the SASH/ ForçaSaúde USAID AO, and Eliane Mbounga is the PMI Malaria Program Management Specialist. Test Positivity Maps were shared and procedures explained. USAID stressed the need to involve NMCP. National Malaria Control Program We also met with Dr Filomeno Fortes, Director NMCP. We shared the malaria test positivity rate (TPR) with him. He explained that the malaria unit has been severely downsized due to expiration of Global Fund grant. At present a consultant from Uganda is on board to assist with developing a concept note for application to the Global Fund’s New Funding Mechanism. Work is underway to finalize the updated national malaria strategy, which much accompany the submission of concept note. Dr Fortes had special interest in including elimination activities in the national strategy and encouraged Huambo to pilot test new approaches, especially the use of community agents to adequately extend malaria testing and treatment. He thought that they could make enough RDTs available for CHWs. Treatment coverage is only about 46% now, and CHWs could play a big role in improving this. CHW involvement in treatment is still a political issue in the MOH, and Dr Fortes is trying to resolve it. The malaria unit is including pilot case management by CHWs as part of their global Fund Concept Note. Because government is decentralized now, Provinces in theory can propose new ideas such as CHW involvement. He was concerned about border areas and people seeking treatment on either side from health facilities close to provincial borders. This could influence statistical reports for a particular municipality. The idea of cross border meetings among provinces as has been the practice between countries in the region was raised. Discussions are underway with one of the cell phone companies about setting up mHealth. USAID is interested, but discussions have not progressed far. This would aid overall monitoring and surveillance which is needed for entomology, epidemiology and pharmacovigilance. For diagnostics there is worry that donors may be reluctant to buy dual action RDTs that detect both falciparum and vivax, although both are present, with the latter being more difficult to control. 3 Although the MOH has publicized its three approved malaria drugs, ASAL, ASAQ and ASPQ, there are still people prescribing SP for treatment. There is also concern about differential diagnosis of fevers, especially when malaria cases drop due to interventions. Also there are staff who after using RDT and finding a positive test, still request for microscopy. These issues will require intensive training and re-training. Thursday 3/9/15 Met with Dr Juliana and his team at the Provincial Ministry of Health and shared the Test Positivity Map, concepts of elimination and plan for the assessment. He ensured that members of his staff including the officers in charge of pharmacy/laboratory and malaria, would assist. The two highest and two lowest TPR. Contact was then made with the four choses municipalities to ensure they were prepared for the visiting interview teams. Friday/Saturday 4-5/9/15 Activities included preparations for logistics, review, updating and translation of remaining materials, and continuing contact with municipalities in preparation of the visits. Note that two handouts and the basic interview guide had been translated prior to commencement of the activity while these were reviewed and additional materials were translated by the ForçaSaúde team (Dr. Sampaio and Gilberto Jolomba). Monday 7/9/15 Orientation of the team took place in a morning-long session covered the following agenda: Table 3: Orientation Schedule/Agenda Time Topic Responsible 08.30 Check in 08.45 Introductions Dr Vida 09.10 Overview of Malaria Elimination Drs. Brieger 09.35 Purpose and Procedures of Interviews Drs. Brieger, Sampaio 10.00 Review of Interview Guide and accompanying handouts Drs. Sampaio, Brieger 10.30 Practice Session Using Interview Guide All Participants 11.30 Final Review, Planning and Questions All Participants The session was led by four SASH/Jhpiego staff. Four interviewers were present along with three Ministry of Health staff including the provincial malaria coordinator. After review of the questionnaire several additions and modifications were made. At the
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