The development and implementation of a public health strategy : cost and health system analysis of intermittent preventive treatment in infants

The achievements of the health Millennium Development Goal of reducing child
mortality (MDG 4) depend on the massive scaling-up of new and available health
interventions. Evidence shows that effective interventions to attain MDG 4 are
available; however coverage rates are currently low. The health systems in
developing countries lack the necessary capacity to deliver the interventions to
those in need. These factors among others are the cause of millions of
preventable child deaths every year.
Worldwide it is estimated that there are 247 million cases of malaria and at least
1 million deaths related to malaria each year (World Malaria Report 2008). Africa
bears the greatest burden of malaria – about 86% of the global burden – leading
to over 800,000 deaths per annum. Children under five years of age and
pregnant women are the most affected groups. Malaria-endemic countries have
lower rates of economic growth. The impact of malaria is manifested through loss
of working time when people are ill or taking care of family members, through
loss of resources that are used to finance treatment, and through disabilities that
result from severe malaria. An episode of malaria results in loss of productivity in
adults and prevents children from developing to their full capacity by impairing
their cognitive ability, physical development, school attendance and performance.
The average growth of income per capita for countries with severe malaria in
1965-1990 was 0.4% per year compared to 2.3% for other countries. In terms of
crop harvests, malaria-affected families harvest 40% that of families not affected
by malaria. Malaria impacts on long term economic development in terms of
impediments on the flow of knowledge, trade, foreign investment, information
transfers and tourism as well as limiting the country’s ability to accumulate
human capital. All these imply that malaria is responsible for inflicting poverty on
people in developing countries through the vicious cycle of ill-health. These
human sufferings due to malaria could be averted if access to effective preventive and treatment interventions could be made available to all affected
people.
The health systems in developing countries have limited capacity to undertake
appropriate health actions to improve population health. The main constraints
include shortage of financial resources, lack of capacity to institutionalize health
interventions into routine health care delivery, severe human resource shortages,
dilapidated health facilities and lack of essential medical supplies and equipment.
The distribution of health benefits provided by the health system is not fair either,
as the rate of health service utilization is lower among the poorer and more
vulnerable groups.
The aim of this research was to contribute to the understanding of health system
issues and costs related to integrating a new strategy of Intermittent Preventive
Treatment in infants (IPTi) into the routine district health system, with a focus on
providing high quality but practical evidence to inform decision making and to
scaling up health services. The methodology involved using a collaborative
approach to develop a delivery strategy for IPTi, to implement the strategy and to
evaluate the strategy in terms of equity of intervention coverage and population
benefit. Researchers worked in partnership with the Ministry of Health and Social
Welfare (MoHSW) to develop an IPTi strategy that could be implemented and
managed by routine health services. The Behaviour Change Communication
(BCC) materials for IPTi were developed by observation studies and in-depth
interviews with communities and health workers. To estimate how much it takes
to develop the IPTi strategy and to maintain routine implementation of the
strategy, real activities costs were tracked. Also semi-structured interviews were
conducted with key informants to record time and resources spent on IPTi
activities. A detailed health facility survey collected data on staff employed, their
availability on the day of the survey, their main tasks and reasons for their
colleagues’ absenteeism. Information on supervisory visits from District Health
Management Teams (CHMTs) was also collected and health workers’ views solicited on how to improve the services. A time and motion study of nurses in
the Reproductive and Child Health (RCH) clinics documented staff time use by
task.
The present study generated important knowledge to enable integration of health
interventions into routine delivery by frontline health workers and managed by
Council Health Management Teams. Using the collaborative approach, the IPTi
strategy was developed to ensure that IPTi behaviour-change communication
(BCC) materials were available in health facilities, that health workers were
trained to administer and to document doses of IPTi so that the necessary drugs
were available in facilities and that systems were in place for stock management
and supervision. A brand name (MKINGE in Swahili, which means protect him or
her) and two posters were developed as BCC. The posters contained key public
health messages and images that explained the IPTi intervention itself, how and
when children receive it and safety issues. The strategy was integrated into
existing systems as far as possible and was well accepted by health staff. Thus,
the collaborative approach effectively translated research findings into a strategy
fit for broader health system implementation in Tanzania.
The costs of developing and implementing IPTi appeared to be affordable within
the budget line of the Ministry of Health and Social Welfare. The estimated
financial cost to start-up and run IPTi in the whole of Tanzania in 2005 was
US$1,486,284. Start-up costs at the district level were US$7,885 per district,
mainly expenditure on training. There was no incremental financial expenditure
needed to deliver the intervention in health facilities as supplies were delivered
alongside routine vaccinations and available health workers performed the
activities without working overtime. The economic cost was estimated at 23 US
cents per IPTi dose delivered. In terms of coverage, IPTi was not influenced by
socio-economic status of a child, by ethnicity nor by child gender. However there
was disparity in coverage by distance whereby children from households living
more than 5 kms from the nearest health facility had lower IPTi coverage than those living nearer (41% vs 58%, p=0.006). Efforts to scale-up health
interventions should therefore focus on increasing physical access and to
monitoring equity outcomes. Vaccine coverage was more equitable across socioeconomic
groups than had been reported from a similar survey in 2004.
The evaluation of human resource for health in the study area revealed particular
problems with staff shortages, low productivity and staff absenteeism. Only 14%
of the recommended number of nurses and 20% of the recommended number of
clinical staff had been assigned to the facilities. These available health workers in
southern Tanzania are below the national average of 35%. Thus, the health
system in the study area is working with less than a quarter of the recommended
staff by MoHSW, and combined with staff absenteeism, the available working
staff decreases further compared to the recommended staff numbers. The absent
health workers were away for seminar sessions (38%), long term training (8%) or
on official travels 25% and on leave (20%). Of those health workers present at
the reproductive and child health clinic at the time of the survey, average
productive working time equaled 57% of their time present at work. In terms of
monthly supervision visits by the Council Health Management Teams, only 14%
of facilities had received the required number of supervisory visits during the 6
months preceding the survey.
The findings of this thesis underline the importance of operational research as a
systematic way to establish how new interventions work under routine health
system conditions. The lessons described in this thesis have great significance
for the future of public health strategies, both existing and new. The generated
information on costs and experience with the issues surrounding design of the
delivery mechanisms, training, supervision and development of implementation
guidelines created a strong institutional framework that could speed up
implementation at country level whenever there is a policy recommendation. It is
expected that the experience generated and the evidence gathered as part of
this thesis can contribute to an improved understanding of the issues that need to be considered and tackled in order to spearhead routine implementation of
malaria interventions and potentially other diseases to achieve high health
service access and improved quality care that is a foundation for improved
population health.
This study recommends increased resources for funding operational studies to
provide evidence of how proven effective tools to fight diseases of the poor work
under real life application through routine health delivery system. Other
recommendations of this thesis are related to the need to strengthen supervision
of health facilities by CHMTs and by higher levels to supervise the district
supervisors. There is also an urgent need to develop and test incentive packages
in local settings. These measures are necessary to increase health workers
productivity, increase staff moral and retention, curb absenteeism and realize
health workers balance between urban and rural health facilities in developing
countries. Only by exploring many of the factors highlighted above, and
throughout this thesis, can the timely and high scale-up of health interventions be
achieved.