An evaluation of integrated interventions to improve access to malaria treatment in Tanzania (access programme)

Malaria causes an estimated one million deaths annually although it is a curable disease if treated promptly and correctly. Most cases occur in young children in sub-Saharan Africa, supporting a vicious circle of disease and poverty. Hence, ensuring access to malaria treatment is a major public health and development priority.
The purpose of this research was to evaluate the ACCESS programme, which aimed at understanding and improving access to malaria treatment in rural Tanzania. This evaluation focuses on the first phase of implementation of the programme, which covered the years between 2004 and 2008. The ACCESS strategy is based on a set of integrated interventions at three levels: 1) community level; 2) public heath facilities; and 3) commercial drug sector. The interventions are accompanied by a comprehensive set of monitoring and evaluation activities.
Between 2004 and 2007 the ACCESS programme’s main intervention at community level was a social marketing campaign for improved recognition of the disease and more effective care seeking. Various communication channels were used and material developed to disseminate information on malaria transmission, symptoms and prevention as well as to stress the importance of prompt and effective treatment. Road shows were the main activity and included role plays, public lectures and quizzes. In addition, promotional materials (e.g. stickers, leaflets, t-shirts) were distributed, and billboards and posters displayed in public places.
In health facilities the ACCESS programme intervened to improve quality of care. The main activity was refresher training for health facility staff based on Integrated Management of Childhood Illness (IMCI) algorithms conducted in 2004 and 2005. In addition the study period saw the change of the first line treatment for malaria. In 2006 the Government of Tanzania switched from Sulphadoxine Pyrimethamine (SP) to the highly efficacious Artemether Lumefantrine (ALu), due to the high levels of resistance to SP.
In parallel the Accredited Drug Dispensing Outlets (ADDOs) programme was rolled out in the study area from 2006 onwards to improve access to treatment and quality of care in commercial drug shops. The private retail sector plays a very important role in the delivery of antimalarial treatment in most African countries as retailers tend to be more accessible and flexible, especially with regards to opening hours and charges. However, unqualified staff invariably sell drugs they are not allowed to stock, which often includes antimalarials. The aim of the ADDO programme is to improve access to quality care in drug shops with a mix of dispenser training, incentives, accreditation and regulation. ALu was made available to the programme at a highly subsidised price towards the end of 2007.
Findings from the monitoring and evaluation activities showed that access to malaria treatment improved following the interventions in health facilities and drugs shops. Drug shops became more available to the community (from 24 shops for every 100,000 people in 2004 to 39 in 2008) and more accessible (from 71% of households within 5km of a shop in 2004 to 87% in 2008) following the ADDO roll-out. In addition, the 2006 change of treatment policy from SP to ALu led to an increase in the availability of antimalarial drugs in health facilities (from 40% to 80% of months in stock of the drug). Treatment was generally more expensive in drug shops compared to health facilities and prices increased by 50-80% in shops between 2004 and 2008. Nevertheless, antimalarial sales in private retail grew (from 49% to 59% of market shares). This is likely to be a result of increased availability and accessibility of shops but better quality of care may also have played a role. Unfortunately the ADDO programme was not able to promote widespread availability of ALu in its outlets (only one third of outlets were found to stock the drug in 2008). This resulted in a low uptake of the new drug (19% of all malaria treatments sold or dispensed) despite the fact that it was available in almost all the health facilities in the area.
Results from treatment seeking surveys conducted in the community showed an improvement in malaria treatment between 2004 and 2008. This was ascribed to: 1) improved access to treatment; and 2) a better understanding of the importance of prompt treatment thanks to social marketing campaigns. The proportion of fever cases treated with an antimalarial increased (from 86% to 96% between 2004 and 2008) as well as the proportion of cases treated promptly (80% to 93-97% doses started within 24 hrs). However, the proportion of cases taking a recommended treatment was only 53% in 2008 since many cases were treated in the private retail sector where the first line treatment ALu was not widely available.
Improved treatment appears to have had an impact on malaria morbidity and mortality. Community surveys showed a 28% decrease in the incidence of fever (from 2.5 to 1.8 average cases per person per year between 2005 and 2008). Under-five mortality decreased by 17% after the ACCESS interventions (from 28.4 cases per 1000 person years in the period 1997-2004 to 18.9 cases in 2008). However, due to the absence of a control it is difficult to know how much the ACCESS interventions contributed to this decrease compared to other malaria control strategies implemented in the area.
In conclusion this thesis has shown that an integrated approach tackling both users and providers can lead to tangible improvements in access to malaria. This can in turn have a substantial impact on morbidity and mortality. Interventions targeting providers in sub-Saharan Africa should recognise the important role of the private sector. Social marketing has proven to be a successful strategy to sensitise users on the importance of prompt treatment.