Improving access to malaria care through combined demand and supply

side interventions – The ACCESS Project

Flora Kessy

3rd June, 2011, MMV Access Symposium, Dar es Salaam

The ACCESS Project (2003-2011)

Partners: - Ifakara Health Institute - Swiss Tropical and PH Institute - Novartis Foundation Potential beneficiaries: Children under 5, pregnant women & general population

Analyze and improve access to effective malaria treatment and care;

First project phase with focus on identification of access obstacles using malaria as a tracer condition;

Applied research combined with interventions.

The Research & Intervention Area

0 100

Kilometers

200

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KilometersKilometersKilometersKilometersKilometersKilometersKilometersKilometersKilometers

100100100100100100100100100

TanzaniaTanzaniaTanzaniaTanzaniaTanzaniaTanzaniaTanzaniaTanzaniaTanzania

Kilombero Kilombero Kilombero Kilombero Kilombero Kilombero Kilombero Kilombero Kilombero

DistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrict

Ifakara DSS AreasIfakara DSS AreasIfakara DSS AreasIfakara DSS AreasIfakara DSS AreasIfakara DSS AreasIfakara DSS AreasIfakara DSS AreasIfakara DSS Areas

LOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillanceLOCATION OF IFAKARA DSS SITE, TANZANIA: 55,000 under surveillance

Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga

DistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrict

KilomberoKilomberoKilomberoKilomberoKilomberoKilomberoKilomberoKilomberoKilombero

District District District District District District District District District

Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga Ulanga

DistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrict

• Kilombero & Ulanga Districts, Morogoro Region (618,000 inhabitants); Kilosa/Gairo in 2010 • Demographic Surveillance System (about 94,000 inhabitants in 25 villages & Ifakara town)

Context 1/2

Access debate mainly concentrated on supply side factors (health systems factors),

• i.e. availability & affordability of healthcare services including safe & efficacious drugs

Context 2/2

Demand side factors regarding the patients often neglected (information on adequate diagnosis & treatment options, level of income & resources)

STI Malaria Symposium 2007 6

What is Missing…

…in health service research AND in health seeking behavior research:

Link between health and poverty

→Health system operates with scarce resources

→People live in a context of livelihood insecurity

Comprehensive evidence on access obstacles is limited.

Developed ACCESS Framework in light of supply side factors and livelihoods contexts (demand side factors)

7 | Access to Healthcare – Role of Business | Alexander Schulze | Novartis Foundation | Darden University | 22.04.2009

Framework for Community Access to Health Care in Context of Livelihoods

POLICIES, INSTITUTIONS, ORGANIZATIONS & PROCESSES

HEALTH CARE SERVICES

VULNERABILITY CONTEXT

LIVELIHOOD ASSETS / RESOURCES

HEALTH

STATUS

PATIENT

SATISFACTION

EQUITY

UTILIZATION

&

QUALITY OF CARE Availability

Accessibility

Affordability

Adequacy

Acceptability

ACCESS

DEMAND SIDE

SUPPLY SIDE

Source: Obrist et al. 2007

Provider Compliance

& Diagnostic Accuracy

Safety

of

Product

Patient

Compliance

8 | Access to Effective Malaria Treatment and Care | ACCESS Project| Novartis Foundation | 02.09.2009

Five Dimensions of Access

Access = Degree of Fit between Healthcare Services & Patients’ Resources

Availability

The existing healthcare services and products meet clients’ needs.

Accessibility

The location of supply is compatible with the location of clients.

Affordability

The prices of services fit the clients‘ resources and ability to pay.

Adequacy

The organization of healthcare services meets clients‘ expectations.

Acceptability

The characteristics of providers match with those of the clients.

Intervention Components

Supply side:

Improving healthcare delivery

• Quality of Care Improvement & Rewarding;

• Rapid Diagnostic Tests for malaria;

• Support to Accredited Drug Dispensing Outlets.

Demand side: strengthening patients‘ resources

• Social marketing on symptoms, causes & appropriate/timely treatment of malaria;

• Micro-credits & business support to women’s groups;

• Strengthen Community Health Funds.

Access Barriers to Effective Malaria Treatment

1. Delay in Treatment Seeking:

Resources must be mobilized and converted into cash for accessing treatment

Geographical distances to health facilities/ADDOs for remote villages and during cultivation period

2. Prevailing low quality of care in health facilities

• In 2008 only 39% of children and 12% of adults received the recommended anti-malarial (ALu) on same/next day & in correct dosage

• If allowing for SP as well, then the treatment according to RBM guidelines were 56% for children and 67% for adults

Improvements in Health Seeking

Improved Health Seeking Behavior

• Strong overlap between people’s illness concepts and those of Western medicine (malaria);

• Decreasing ratio of reported fevers in the community versus stable rate of fever cases diagnosed in health facilities -> suggests increased proportion of fever cases treated in health facilities.

THANK YOU

www.ihi.ac.tz

www.swisstph.ch

www.novartisfoundation.org

Ifakara Health Institute Flora Kessy Dominic Mboya Ahmed Makemba Christopher Mshana Angel Dillip Robert Tillya Iddy Mayamana Swiss Tropical and Public

Health Institute Christian Lengeler Brigit Obrist Sandra Alba Manuel Hetzel Novartis Foundation for

Sustainable Development Alexander Schulze