Training health workers and operational research from policy makers to good clinical practice

Training Health Workers, Operational Research: From policy makers to good medical practice using ACTs Ambrose O. Talisuna Assistant Commissioner Epidemiological Surveillance, Ministry of Health Uganda Malaria symposium, Kampala, Uganda 27rd, June, 2006 (Based on talk at DNDi meeting, Geneva, 2006) Background: Malaria and poverty GNP per capita (1995) Malaria Index Source: Jeffrey Sachs (Harvard) Paradigm shift……  From demand creation to identification and quantification of needs  population at risk of malaria among the poorest  Cultural change in the way HWs manage malaria  Role of laboratory confirmation-one size does not fit all  Management of severe malaria-neglected population  Responsibly increasing access to effective treatment within 24 hours New drugs are just part of the solution……. ACT as first-line treatment in 2000 Countries with falciparum malaria Few countries deployed ACTs in selected provinces/districts 2002: Endemic countries where treatment was not efficacious 2003: Only 4 African countries has optimal AMDP January 2004- Sometimes researchers and public health experts have to turn into activists…… WHO, the Global Fund, and medical malpractice in malaria treatment. Attaran A, Barnes KI, Curtis C, d'Alessandro U, Fanello CI, Galinski MR, Kokwaro G, Looareesuwan S, Makanga M, Mutabingwa TK, Talisuna A, Trape JF, Watkins WM. January 2005 ….unprecedented AMDP change GFATM fund-catalyst AL = 19 AS +AQ = 15 AS + SP = 1 CQ = 2 SP = 3 CQ = 5 EMRO New policy uptake takes a long time-The need for lead planning……. Uganda June 2004 Policy change discussion Policy announcement Approval of GFATM proposal Treatment guidelines revised GFATM Funds remitted to country Drug ordered (Through WHO) TOT, sub national training and TG distribution Drug arrives at National medical stored Drug distributed Total time 6 0 8 8 12 4 5 6 ongoing 49+ Zambia (Dec 2003) 6 0 4 6 7 8 7 9 12 59+ Kenya (Apr, 2004) 6 0 2 14 15 16 24 19 26 122+ Modified from recent talk by Snow RWS in J-burg, RSA Treatment actions for febrile Kenyan children in 4 districts, 2001 No action Formal health care Retail sector Formal private sector 28 % 30 % 26 % 9% Of those receiving medication only 30% got antimalarial Amin et al 2004 Treatment actions and caretaker’s perceived outcome (not recovered) for febrile children in a Ugandan HBMF district Action Frequency Not recovered No action 0.01% 50 % Use herbs Drug shops Health centre (Govt. or NGO) Private clinic HBMF Total 1% 15 % 18.4% 55.7 % 54.6 % 15.0 % 20.6% 35.2% N=798 38.4 % 22.8 % Mugaga, MUK, Masters dissertation, 2006 Prompt case management for malaria, in Kenya 24 hours % fevers treated with antimalarial 48 hours 72 hours >72 hours Abuja target 100 90 80 70 60 50 40 30 20 10 0 60 30.3 15.8 5.3 24 hours 48 hours 72 hours >72 hours Abuja target 21.4 Amin et al, 2004 Timeliness of action for children in HBMF and Non HBMF districts, Uganda, 2003 Abuja target Non HBMF Raphouda B et al, in press Promptness of case management in HBMF and care takers’ perceived treatment outcome, Uganda Promptness Within 24 hours Within 48 hours 72 or more hours Frequency 57.6 % 28.1% 14.3 % Not recovered 10.5 % 32.9 % 52.5 % OR Reference 4.18 (2.1-8.32 9.43 (4.24-20.95) N=281 Mugaga, MUK, Masters dissertation, 2006 Adherence to treatment duration in HBMF and caretaker’s perceived treatment outcome, Uganda Duration of treatment One day Two days Three days Frequency 0.025% 13.5 % 84 % Not recovered 42.9 % 50.2 % 17.9 % OR 3.45 (0.74-15.98) 4.6 (2.24-9.47) reference Mugaga, MUK, Masters dissertation, 2006 Adherence to laboratory results by HWs Zambia 100 Kenya Percentage 80 60 40 20 0 Children with Fever + BS Negative BS 49 37 58 45 41 68 Negative BS administered an antimalarial Zurovac et al, 2005, Ndhlovu et al, in press From policy makers to good medical practice- Why train?  Poor Adherence (HWs and client)  Widespread inaccurate /mis-diagnosis-ARI  Inadequate counseling  Inappropriate dosing common  Patients without malaria get antimalarials  Training improves  health workers confidence, and  general disease management of the patients Health worker training and operational research-Goal To generate evidence on best approaches and feed it into practice Initial research Policy Practice Cycle/spiral Operational research Health worker training and operation researchCritical pillars Disease prevention and prompt care for cases •Early symptom recognition •Early treatment seeking •Training of mothers coordinators Strengthen research capacity facilitating faster uptake of research into policy •Consult policy makers to develop agendas •Innovative approaches to communication of research findings to policy maker Equity, gender, pro poor, capacity building, knowledge dissemination, policy dev Quality and responsiveness of health services •Lab confirmed diagnosis (RDTs/M-scopy )vs. syndromic treatment? Promoting better treatment outcomes •Adherence-provider/client •Different packs •Reducing pill burden •Changing culture of HW performance –VE BS •PSM-Pull vs. Push-(quantification), storage •Drug efficacy monitoring •PV and PMS Need new approaches……Why?  New drugs or new paradigm-combination therapy  New strategies in Africa:  Pharmacovigilance and post marketing surveillance  Fighting counterfeits  More emphasis on surveillance, information and research, performance assessment/monitoring and evaluation Need new approaches……Why?  Changing areas of focus  More community involvement - Community training/dialogue strategies for mother coordinators  Private sector involvement  Use malaria to fast track health systems development  Re-orient advocacy and social mobilization  Short shelf-life-More precise quantification  Drug delivery- Pull vs. push  Laboratory confirmation vs. presumptive Critical issues for discussion-Training Involvement of the private sector  How can the private sector be involved in the training programmes? Approaches to training  What is the appropriate content of training for the various levels (educational or health facilities)?  What type of training is appropriate for the private sector -abridged or same as public sector?  What is the optimal approach to training- Problem based vs. didactic learning?  How cost effective are the current training approaches  How do you institutionalise and integrate the training within the health sector? Critical issues for discussion-operational research Deployment and drug delivery  What deployment models should be used for ACTs at community, private sector and at home level?  What innovative approaches could be adopted to phase out oral artemisinin based monotherapies? Diagnosis  Is laboratory confirmation in children <5 years old in intense transmission cost effective?  What are the best ways to improve diagnosis in the private sector-Full subsidized RDTs or for a fee  How do we resolve the confusion of the different color codes for private and public sector? Critical issues for discussion-operational research agendas  How are operational research agendas developed and funded?Are policy makers and implementers involved?  What are the optimal channels for communication between researchers and policy makers?  sharing preliminary data  communicating results and their policy implications clearly  issues of 'ownership' of results  Are frameworks available for conducting large scale operational research – EDCTP, the Gates ACT consortium, NetworksEANMAT, WANMATI &II etc?)  How do we avoid policy and practice getting ahead of research ?-Case of CQ in East Africa and AL in Uganda Conclusion- the challenge of changing medical practice  Deciding new policy is arguably the easy part of a complex policy change process  Training or guidelines alone are not sufficient (Zurovac et al, 2006, WHO, 2001)  Training must be accompanied by other interventions to ensure good clinical practice From policy makers to good medical practice- A MIXED MODEL OF “TRAINING PLUS” ….  Non ambiguous policies  Treatment guidelines and job aids  Regular group processes  Functional clinical supervision systems  Performance audits and monitoring  Regular feedback  Regulatory interventions-aligning drug regulatory policies with malaria drug policies – Limiting importation of medicines outside AMDP Acknowledgements  Dr R. Azairwe, WHO Uganda  Dr Peter Olumese, WHO, Geneva  Dr Sarah G. Staedke, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, USA and Uganda Malaria Surveillance project  Dr Robert W Snow, Professor Tropical Public Health, University of Oxford  Malimbo Mugaga, Epidemiological Surveillance Division, MoH, Uganda One size does not fit all… need to adjust strategies Endemicity Unstable (PR-0) E-warn system IRS ITNs Prompt effective Rx IMCI without DX +++++ +++++ ++ ++++++ Hypo PR<0.1) +++ +++ +++ ++++++ Meso (PR0.11-0.5) ++ ++ ++++ ++++++ ++ + +++++ ++++++ +++ +++++ ++++++ +++ Hyper (PR0.51-75) Holo (PR>0.75) IMCI with DX +++++ ++++ +++ ++ + IPTp IPTi or c? Targeted MDA? Larviciding and biological control + ++ +++ ++ +++++ ++++ +++++ +++++ ++++ ++++ +++ +++ ++ ++