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

Abstract

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.