1. NIATA MALARIA EPAI BA MAMA YA ZEMI CRUSH MALARIA IN PREGNANCY IN DEMOCRATIC REPUBLIC OF CONGO NIATA MALARIA

2. This Presentation will discuss: Background Information on DR Congo Background on prevalence of Malaria, international strategies Objectives and Intervention of NIATA MALARIA Evaluation and Structure

3. THE DEMOCRATIC REPUBLIC OF THE CONGO

4. DR Congo in Context Central African country of 55 million people Average annual per capita income of $110 US Only 1% of government budget is allocated to public health Over 9 Years of war and political instability have affected the population’s health No socialized healthcare Patients must pay or provide all materials, such as gloves

5. Health in DR Congo MMR: 940/100,000 with about 25% from Malaria CMR: 210/1000 IMR: 130/1000 < age 5 MR: 115/1000 LBW: 15% 68% of Women have antenatal visits Malaria is the leading cause of morbidity and mortality in the country

6. Structure of Health System National level: Public Health Minister Provincial Level: Provincial Health Inspector District Level: 3 divisions: General, Medicine, & Hygiene Zone Level: Local Directors for ~150,000 people, includes 1 hospital and 15 health clinics (Barumbu)

7. KINSHASA

8. BARUMBU

9. Barumbu, Kinshasa Barumbu is a health zone of 100,000 people Home to numerous social groups including: women’s groups, religious organizations, a hospital, and a community center In Kinshasa, population 5 million Kinshasa’s population has increased by 500,000 in 2 years because of people displaced by war in the east High population density, poor sanitation Malaria is the principal cause of morbidity and mortality in the city

10. Malaria in DR Congo 80% of pregnant women test positive for trophozoites Only 5% receive preventive care 1.5% of pregnant women use bednets (ITN) 45% of children under 5 receive anti-malarial drugs 95% of malaria is from p. falciparum Most patients with fever self-medicate at home with anti-malarial drugs Increased Resistance Beliefs that fevers are treatable with traditional remedies, or will run their course

11. National Malaria Control Program (NMCP) The control of malaria was deemed a priority health action and the following strategic plan was created: Train: - 39 physicians and 680 health workers in management of severe malaria - 70 laboratory technicians in diagnosis - Conduct operational research on chloroquine sensitivity and ITN utilization Implement Roll Back Malaria campaign (1999)

12. MALARIA AS A MATERNAL & CHILD HEALTH PROBLEM (WHO, 2003)

13. Agreement with 2000 Abuja Declaration African heads of state agreed that by 2005 the following could be achieved: At least 60% coverage of pregnant women at risk of malaria with the most suitable combination of personal and community protective measures At least 60% of all pregnant women at risk of malaria, especially those in their first pregnancies, should have access to intermittent preventive treatment

14. Strategic Framework for Malaria Control during Pregnancy Insecticide-Treated Nets (ITN) Intermittent Preventive Treatment (IPT) Effective case management of malarial illness

15. Intermittent Preventive Treatment (IPT) 2000 WHO Expert Committee on Malaria agreed All pregnant women should receive at least 2 doses of Sulphadoxine-pyrimethamine (SP or Fansidar) after “quickening,” during routinely scheduled antenatal clinic visits Reduces anemia and placental malaria infection at delivery

16. We Propose a Health Intervention for DR Congo that Will: Institute the Recommendations of the Abuja Conference and the World Health Organization Engage in the Global Roll Back Malaria Campaign Build upon the DR Congo’s own recognition of the gravity of malaria as a public health concern Recognize the efforts of the National Malaria Control Program (NMCP) Partner with existing anti-malarial campaigns, such as PSI and social marketing/distribution of ITN

17. NIATA MALARIA: CRUSH MALARIA IN DR CONGO Objective #1: By the end of the project, the percentage of antenatal health workers in 15 clinics in the district of Barumbu trained in the WHO’s recommended treatment regimen for IPT (intermittent preventive treatment) and in BCC strategies for promotion of ITNs (insecticide treated nets), will increase ~20% to at least 90%

18. INTERVENTION Training of Health Workers in Zone of Barumbu, Kinshasa, DR Congo Inputs: Project staff (see organizational chart); PSI personnel; teaching materials

19. PROCESS Initial training will be held at the zone hospital (10-15 minutes from farthest clinic) Training will occur in 5 waves, 1 worker from each clinic (total 15) per 2-day session, in order to respect the staffing requirements of each clinic Ultimately, 5 workers from each clinic (total 75) will receive training over a ten-day period.

20. PROCESS Training will consist of: review of BCC in prevention of malaria, particularly as it applies to pregnant women, instruction in IPT protocol and promotion of use of ITNs. Methodologies will include role-play with anticipated questions from both fellow health workers and patients. A pretest will be administered to assess baseline knowledge; a post-test will assess progress and competency. Should post-test performance be substandard, a decision by the Project Coordinators (Trainer of Trainers) will determine whether to pursue additional training or to seek a replacement.

21. OUTCOMES Increased number of health workers with knowledge in two areas, as measured by post-test performance, and observed competency : 1) Current recommendations for use of the IPT regimen 2) Counseling skills in promotion of ITN

22. OBJECTIVE #2 By the end of the project, the percentage of pregnant women seen for routine antenatal visits in Barumbu’s 15 antenatal clinics who receive at least one dose of intermittent preventive medication (IPT), sulphadoxine- pyrimethamine (SP) will increase from 5% to at least 80%.

23. INTERVENTION Delivery of IPT to Clinic Attendees in Zone of Barumbu Inputs: Program staff; Medication [Public/private partnership: Roche Pharmaceuticals, manufacturer of SP, is donating all medication for this pilot project in cooperation with the Ministry of Health of the Democratic Republic of Congo.]

24. PROCESS Training clinic health workers (30-50) at each of Barumbu’s 15 clinics: special training of 5 workers from each participating clinic in the use of ITP and ITN. They, in turn, will be responsible for training the health workers in their respective clinics, using techniques acquired during TOT sessions.

25. PROCESS Medication stock maintenance Adequate supplies of SP will be stocked in 15 clinics in Barumbu, DR Congo. Quantity stocked for each clinic will be calculated based on two doses per number of women who attend prenatal clinics, based on the previous year’s clinic records. Medication administration All pregnant women will be advised to take at least 1 dose of SP/ IPT after "quickening," 2 doses if possible, during routinely scheduled antenatal clinic visits, no matter how late in pregnancy they present to the clinic.

26. EVALUATION Baseline data Data gathered from TOT regarding Pre-test and Post-test of knowledge of trainees Number of clinic facilitators who attended training Number of trainees successfully trained Number of health workers receiving clinic training Percentage of women who visited the 15 antenatal clinics who received one dose of IPT Percentage of women who visited the 15 clinics who received 2 nd dose of IPT Percentage of women who used ITN to help evaluate PSI’s efforts

27. TIME FRAME Duration: 1 year 2 weeks : Training of Trainers, 2 work days per training, 5 waves 1 month: Trained workers train colleagues 10 months: application of intervention 2 weeks: evaluation

28. OUTCOMES Increased number of pregnant women in Barumbu receiving at least one dose of IPT during pregnancy Increased knowledge of medical prevention of malaria during pregnancy in Barumbu’s health workers and pregnant women

29. IMPACT Decrease incidence of malarial disease in pregnant women in Barumbu: Decrease incidence of anemia in pregnant women in Barumbu Decrease LBW and infant mortality rates in Barumbu Decrease the economic impact of malaria on families, health resources, and the community as a whole

30. CRUSH MALARIA IN PREGNANCY IN DR CONGO NIATA MALARIA

31. MONITORING Project Coordinators/Trainer of Trainers will make weekly site visits to observe implementation and adequacy of training at the individual clinic level and to troubleshoot. 1-day refresher course for clinic trainers will be held every 3 months, to incorporate feedback from the Multidisciplinary Advisory Board, including community input. The Multidisciplinary Advisory Board will meet bimonthly for progress reports, feedback, and troubleshooting. It will issue recommendations as indicated. Project manager will act as liaison between the District Director of Health, PSI and Project Coordinators/TOT as interim needs arise.

32. MONITORING Records will be kept of # of antenatal visits during which IPT was advised and taken. Project Leads will make weekly site visits to individual clinics to assess implementation, record keeping, medication supply and to troubleshoot. Records will be kept of # of antenatal visits when ITN was used the night prior to the visit, to Provide data for collaborative project with PSI.

33. PROGRAM STRUCTURE

34. Multidisciplinary Advisory Board Project Manager Project Administrative Assistant Financial Administrator Director, “Zone De Sante” PSI PSI Partnership Research Analyst (Contract Consultant) Public Relations Coordinator Project Coordinators (TOT) Project Coordinators (TOT) Project Coordinators (TOT) 25 Clinic Facilitators (5 from each clinic) 25 Clinic Facilitators (5 from each clinic) 25 Clinic Facilitators (5 from each clinic)

35. Sustainability Advantages of NIATA MALARIA Improves possibility of expanding scope of implementation of ITP and ITN through: Training of Trainers, antenatal clinic health workers and community workers (PSI) Utilization of established antenatal care delivery system Collaboration with established social marketing organization (PSI) with expertise in health promotion through community activities and media Involves community representatives on Advisory Board Works in conjunction with objectives of National Malaria Control Program

36. NIATA MALARIA is Cost-Effective Is a cost-effective intervention, as shown by studies in Kenya, Malawi, Tanzania (decision re: budgetary commitment must be decided by MOH after review of project evaluation report) Cost-Effectiveness of ITP: 2 Doses SP/ area with HIV seroprevalence < 10% (HIV/AIDS prevalence = 5.07%) Potential costs of malaria during pregnancy: Infant mortality, maternal mortality, anemia, hospital care of LBW, and ongoing health needs of LBW, including medication, special medical needs, home care, and lost productivity within family and community Dose of SP 0.10 -0.15 $US per dose in DRC, Analysis indicates cost savings if <0.40 $US per dose Calculated cost per DALY of IPT in area of no resistance is $12 (highly attractive if < $ 25)