Seasonal Malaria Chemoprevention:
Understanding of current SMC practices was investigated by interviewing a total of nine NMCP representatives, KOLs and in country partners from Cameroon, Ghana, Senegal, and Nigeria. According to the nine key informants the SMC intervention implementation was facilitated by the fact that good results were obtained during trials and local pilots. Engagement of policy makers and community leaders was mentioned as the key driver of implementation and acceptance of the intervention. The hurdles encountered were mainly linked to adherence to the program and administration of the second and third dose of SPAQ, as well as limited funding in Nigeria. In Senegal, extension of SMC to children 5 to 10 years of age was triggered by the early SMC trials which demonstrated that children in this older age group were just as affected by malaria as the younger children. According to the key informants from other SMC-implementing countries interviewed for this survey, a similar extension to 5 to 10 years old did not occur mainly because of limited funding, and the absence of a pilot study in their countries to demonstrate the same benefit in the older age category.
Results from the interviews with 37 health center managers, 46 CHWs and 20 parents in Cameroon, Ghana, Nigeria and Senegal showed that SMC was generally positively perceived by the survey participants thanks to its efficacy in preventing malaria (figure 1).
Efficiency:
“The drug is very effective. The reason I said this is because before the start of this chemoprevention, during raining season, facilities are usually congested with sick people. All of the beds for admission would have been occupied. But due to the effectiveness of the chemoprevention such congestion is now a thing of the past.” Health center manager, Nigeria.
Cost:
“SMC reduces expenses for us parents. There are too many mosquitoes here, without prevention it would be too expensive to treat children. Malaria access requires spending in health centers, yet prevention is free.” Mother of 2 children, Cameroon.
The main barriers to SMC implementation mentioned by health care professionals were the side effects, driven by respondents from Senegal; a number of staffing issues including lack of staff, transportation to households, and absence or delay in payment of incentives to staff; and poor acceptance from parents (figure 2).
Adverse effects:
“During the first day we had less problems but on the second day, third day we had all the problems in the world because it was at that moment that the side effects started and we had many cases of refusal because the parents could not bear these effects in the children and they said that the drugs are not good. In the second passage, it was even worse, we had many cases of refusal; when we went to discuss with the parents, they said downright ‘’no, all the children were sick’’, we tried to talk to them but there was nothing to do” Health center manager, Senegal
The three main ways to improve SMC delivery, according to health care professionals who participated in the survey were: 1) Better education of parents to increase their acceptance of SMC (Senegal), 2) In time payment of incentives, (Cameroon), offering a better incentive plan to cover the transportation fee, or offering a small incentive to parents (Nigeria and Ghana), and 3) Improvement of side effects associated with the treatment (Senegal). For parents involved in the survey, the main improvements were extension of SMC (to older children and even adults, and to regions that are not currently covered and extended duration (coverage for a longer period than the current 4 months) (figure 3).
Several potential barriers to SMC were specifically investigated during the survey. These included issues around drug stocks; staffing and workload; inadequate coverage; and potential conflicts with other public health campaigns.
Availability of drug:
Health center managers and CHWs who participated in this study anecdotally reported SPAQ out-of- stock situations. Most of these situations were corrected within 24 hours and had no impact on children’s malaria protection.
Staffing and workload:
Health center managers with the lowest number of CHWs were those most in need of an increase in staff, requesting on average 36% more CHWs. Half of the CHWs who had participated in the survey said the workload associated with SMC was fine, while the other half thought it was too much. In terms of turnover, most parents who participated in the survey in Nigeria and Cameroon mentioned that CHWs varied frequently, while parents from Senegal and Ghana reported that it was steadier.
Coverage:
According to health center managers and CHWs who participated in the survey, 88% and 92% of eligible children received the first dose of SMC each month, respectively. In terms of second and third dose, an estimated 11% of children did not receive it according to one health center manager. This number increased to 22% of children according to CHWs. Respondents from Cameroon, Ghana and Nigeria indicated that the main reasons for not providing SMC to children was absence or illness, while in Senegal it was parental refusal. A number of measures have been put in place by respondents to ensure that children in Cameroon, Ghana and Nigeria receive the second and third doses of SMC, including providing advice to mothers, collecting empty blisters as proof of administration, and the use of recording cards to keep track of administration.
“… without lying to you, officially almost all the children received. But unofficially, those who have actually received are few, given the demotivation of CHWs on the field. Hence, it can be estimated that 25% of children have not received their SPAQ dose.” Health center manager, Cameroon.
Conflicting campaigns:
Lastly, although conflicting interventions were mentioned as a potential barrier, it was noted that SMC campaigns tend to run in isolation, according to most health center managers and CHWs interviewed. On the rare occasions when other interventions took place at the same time as SMC, these caused no conflict. Some anecdotal comments pointed to possible benefits of running net distribution, nutrition education programs or vaccination campaigns at the same time as SMC.
Intermittent preventive treatment of infants (IPTi):
IPTi was investigated by interviewing two key informant respondents from Sierra Leone, the only country where IPTi is currently routinely performed. In addition, experience with IPTi was investigated in the three countries that piloted IPTi, namely DRC, Ghana and Senegal, by interviewing two key informants per country. Finally, the general perception of IPTi was obtained from three key informant respondents from Cameroon and Uganda. In Sierra Leone, the main drivers to implementing IPTi were the very high mortality rate in infants and the absence of seasonal transmission that made SMC unsuitable. IPTi adoption was facilitated by the good perception of SP thanks to the malaria prevention in pregnancy program and the important role played by CHWs in sensitizing the community to the intervention. The main hurdles related largely to logistic issues such as availability of clean water, drug shortage, nurse turnover, and poor attendance to EPI visits.
DRC, Ghana and Senegal piloted IPTi but decided not to implement it for the following reasons: lack of involvement of policy makers from the start of the process, logistics issues around synchronization with other programs, the belief of some health care professionals that infants are protected by their mothers’ antibodies at the beginning of life, unconvincing results at the end of the trial, fear of SP side effects, overexposure to SP in infants due to their mother receiving SP during pregnancy, absence of solutions past the age of one, and the gap between two vaccination programs leading to a gap in coverage. Cameroon and Uganda did not pilot IPTi and do not plan to implement it because they are concerned about resistance to SP, they foresee difficulties in integrating it into the EPI program, the acceptance of parents is expected to be low, and the gap between two administrations does not provide full coverage. Nigeria is the only country that envisages implementing IPTi to reduce malaria burden in infants.
In addition to key informant interviews, IPTi was investigated by interviewing 15 health-center managers and five parents in Sierra Leone. According to the former, the advantages of IPTi were its effectiveness in reducing the number of malaria cases, the absence of side effects, and the good supply of SP. The main barriers were the difficulties in preparing the drug, with crushing the tablets being the hardest and most time consuming step of the treatment; the limited access to commodities such as clean water and cups; and the lack of training of staff/nurses due to high turnover rates. Participating parents were largely satisfied with IPTi because they perceived it as efficacious in protecting infants from malaria, and having no side effects. The main areas for improvements highlighted were increase in drug stocks to avoid having to return to the facility, access to clean water, and availability of a pediatric formulation.
Expanded Programme on Immunization (EPI):
Perception, drivers, and barriers of EPI program were investigated by interviewing 91 health center managers involved in the EPI program in all eight countries: Cameroon, DRC, Ghana, Nigeria, Senegal, Sierra Leone, Tanzania, and Uganda. The EPI program was largely well perceived by communities and parents according to health-center managers who participated in the survey. The stated main hurdles fell into five broad categories: logistics-related issues such as out-of-stock or inadequate storage of product; lack of knowledge or understanding of the program by parents and lack of endorsement by community leaders; children not showing; staffing issues such as lack of staff and high staff turnover; and transportation difficulties both for parents to come to the EPI center, and for staff to travel to communities (figure 4).
Reported attendance to vaccination visits ranged from 66% to 93% of eligible children at 10 weeks, 68% to 90% of eligible children at 14 weeks and 54% to 88% at 9 months. The measures put in place to increase attendance to EPI visits by survey participants included having a system that tracks the no-shows, raising awareness amongst parents, developing outreach services, and providing an incentive to parents.
Post-discharge malaria chemoprevention (PMC):
Post-discharge malaria chemoprevention is currently being investigated in several clinical trials in Uganda, Kenya and Malawi. We evaluated the degree of knowledge and interest in this intervention amongst the 14 NMCPs, KOLs and in-country malaria organizations included in our survey. Very little knowledge about this intervention was observed amongst all 14 participants, even in Uganda where it has been evaluated in a clinical trial.
In addition, our evaluation shows that of the 94 health-center managers who participated in the research were largely unfamiliar with PMC. Therefore, the focus was on capturing some basic information about the management of patients under 5 years of age presenting with severe anemia who required hospitalization. Forty-three percent of health-center managers we interviewed said they either do not see or do not manage these patients. The remaining 57% who do take care of these patients claimed they performed malaria tests in 94% of children with 66% coming back positive. Transfusion was needed for 77% of children with 86% of them receiving it as reported by our sample. The biggest issues faced by interviewed health-center managers regarding treatment of children under 5 years of age with severe anemia were parents’ financial difficulties, lack of blood for transfusion, artesunate out of stock, delay in seeking treatment and poor adherence with treatment.