A Presentation to

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Expanding Access To Treatment Through
Community-health worker Initiatives An update
on evolving trends George Jagoe, Global Access
TeamMedicines for Malaria Venture

• A Presentation to
• The All-Party Parliamentary Group on Malaria and
  Neglected Tropical Diseases (APPMG)November 10,
  2009

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10 second reminder about MMV our portfolio of
drugs in discovery and development in 3Q 2009
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What are the implications of expanding
community-based management of malaria as improved
treatments become available?

• Why It Matters 1
• Current evidence suggests that most of those who
  need the drugs do not get them.
• It is essential that as much effort is put into
  investigating new ways of delivering drugs to
  those who need them, as has gone into developing
  the drugs in the first place.
• At present, in much of Africa, it is possible to
  target most activities (eg HMM) to children under
  five years of age and pregnant women.

• In most countries, HBMF is still in early stages
  of planning / implementation as a malaria case
  management strategy
• We believe there is a lack of comprehensive
  knowledge about existing and planned HBMF
  activities at the country level
• There is general uncertainty about the potential
  to integrate new therapy options and formulations
  into HBMF programs

1 Malar J. 2008 7(Suppl 1) S7. Published online
2008 December 11. doi 10.1186/1475-2875-7-S1-S7.P
MCID PMC2604871 Deployment of ACT antimalarials
for treatment of malaria challenges and
opportunities Christopher JM Whitty,1 Clare
Chandler,1,2 Evelyn Ansah,3 Toby Leslie,1,4 and
Sarah G Staedke1,5
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HBMF is a bridge to expand access and
increasingly to deliver quality ACTs
HBMF Basics

• Strategy developed by WHO based on studies
  supported by TDR first published by WHO in
  20051
• Concept Community workers/volunteers deliver
  antimalarials to families directly in the home
• Goal improve access to life-saving medicines for
  people who currently lack adequate access
• Intended target population children lt5 living in
  highly endemic rural areas in Africa, where most
  fevers can be presumed to be P. falciparum
• Guiding assumption Effective treatment,
  delivered at home by caregivers soon after
  symptoms appear, will reduce malaria morbidity
  and mortality with a very low costeffectiveness
  ratio2

1 WHO (2005) The roll back malaria strategy for
improving access to treatment through home
management of malaria. World Health Organization,
WHO/HTM/MAL/2005.1101 (http//whqlibdoc.who.int/hq
/2005/WHO_HTM_MAL_2005.1101.pdf) 2 Pagnoni,
Franco. Malaria Treatment No place like home.
Trends in Parasitology Vol.25 No.3, 2008.
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HBMF has advanced through a series of research
and pilots, and the approach continues to evolve
Evolution of HBMF Programs and Research Focus
CQ pilots
ACT pilots
RDT pilots
Inclusion in ICCM
Beginning in mid-2000s
Beginning in 2007-2008
Gaining focus in 2009-2010
1998 - 2003
Best-known Burkina Faso, Ghana, Nigeria, Uganda
E.g., Sudan, Zambia
17 countries (PSI/TDR, others)

• Goal
• Evaluate the process by which HBMF can be
  effectively implemented in rural settings

• Goal
• Determine whether ACTs can be appropriately
  distributed and used within existing HBMF
  structures

• Goal
• Assess RDT quality
• Determine whether CHWs can effectively utilize
  RDTs to distinguish cases requiring ACT treatment
• Challenges identified
• Lack of compelling product
• Community acceptance (esp. in absence of
  treatments for negative test results)
• Potential for many false positives in endemic
  areas

• Goal
• Integrate CHW-delivered community health
  activities
• Provide range of treatments for all major
  childhood diseases
• Challenges identified
• Lack of plan for expanding CHW training and
  managing drug supply
• Should CHWs be trusted to manage multiple
  resistance-prone therapies (including
  antibiotics)?

• Challenges identified
• Need for community buy-in
• Importance of prepacking
• CHW incentive structures and attrition rates
• Need for simple training materials and
  re-training on ACTs

CQ chloroquine ACT artemisinin-based
combination therapy RDT rapid diagnostic test
ICCM integrated community case management
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We are advocating for a country database of HBMF
tracking the seed has been planted
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This data should track

• HBMF status classification
• Details on HBMF programs/efforts
• HBMF policy status
• Context of HBMF programs including use of RDTs
  and integration with IMCI
• Key HBMF players (i.e., funders and implementers)
• Current malaria treatment guidelines
• Country demographics (e.g., of population lt5,
  in rural areas)
• Malaria incidence and burden (total incidence,
  incidence in gt5, lt5 affected)
• Government malaria expenditure (total and
  per-case)
• Notes on resistance
• Global Fund grants received (and amounts for
  HBMF, where available)
• Notes on supply chain and private sector (where
  available)
• Notes on CHW incentives (where available)

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As of 2009, most countries have included HBMF in
their national malaria control strategic plans

• However, the status of existing and planned HBMF
  initiatives is highly variable across countries,
  with few having achieved significant scale to date

Status of HBMF Program Implementation
Mauritania
Mali
Eritrea
Senegal
Niger
Sudan
Chad
Gambia
Djibouti
Nigeria
Guinea Bissau
Somalia
South Sudan
Ethiopia
CAR
Cameroon
Guinea
Uganda
BurkinaFaso
Benin
Kenya
SierraLeone
Rwanda
Gabon
DR Congo
Burundi
Congo
Ghana
Tanzania
Liberia
Zanzibar
Togo
Malawi
CotedIvoire
Comoros
Angola
Eq. Guinea
Zambia
Mozambique
Madagascar
Mauritius
Namibia
AL is current 1st line treatment in national
guidelines
Botswana
Swaziland
E.g., mention in NMCP plan, request for funds
in recent round of Global Fund or PMI (but
details of implementation not known)
Zimbabwe
South Africa
Lesotho
Note Refer to file HBMF Countries
database_Sept09.xls for details and full
citations.
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HBMF appears to be a promising access mechanism,
but efforts to scale up have been slow
Success Stories
Barriers to Scaling Up

• The most successful HBMF programs have been
  established in countries that have simultaneously
  improved their other malaria control efforts
• E.g., Zambia has built up traditional health
  facilities in parallel with a strong HBMF
  initiative
• HBMF pilot research has demonstrated that CHWs
  can deliver correct treatment1

• Insufficient drug supply
• E.g., due to Global Fund grant delays
• Inability to retain and guide CHWs (motivation /
  incentives supervision monitoring)
• Resulting training backlog
• Lack of quality of care data in HBMF setting

Result scaling up process takes years and
multiple rounds of funding
1 For example Ajayi IO et al 2008 Tiono AB et
al 2008
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There are also questions about long-term HBMF
viability
Objections to HBMF

• HBMF is a risky and wasteful approach to malaria
  control
• Accelerates resistance due to lack of proper use
  / adherence
• Wastes drug due to lack of diagnostic tool
  availability

• HBMF cannot be scaled up
• Long timelines, insufficient CHW retention will
  prevent programs from attaining substantial reach
• HBMF may not be equally appropriate in all
  settings
• Recently published evidence against use in urban
  areas1

• HBMF should be viewed as a stopgap measure
• In the long run, countries should move AWAY from
  HBMF and toward the building of sustainable
  health infrastructure

• Addressing Objections
• Pagnoni studies already suggest high adherence
  rates (84-94) however, these were pilots
• Future studies could compare compliance rates for
  treatment provided at home vs. in public health
  facilities
• RDTs can be incorporated into HBMF strategy (will
  require more evidence)
• HBMF should be applied in a targeted manner and
  is primarily appropriate for rural villages
  without alternative means of access to care

1 Staedke SG et al. Home management of malaria
with artemether-lumefantrine compared with
standard care in urban Ugandan children a
randomised controlled trial. Lancet. 2009 May
9373(9675)1623-31. Epub 2009 Apr 9
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Though some questions remain to be answered, HBMF
is likely to be key to access going forward
Outstanding Questions

• Should RDTs be incorporated into home-based
  management?
• Are HBMF efforts duplicating the work of ICCM
  programs? If so, how can they be integrated?
• How can CHWs be appropriately motivated and
  rewarded for their work?
• How (if at all) should HBMF programs address
  adult malaria cases?
• How should funding and efforts to support HBMF be
  targeted based on establishing health equity or
  health impact?

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Acknowledgements

• Thanks to all the individuals who participated in
  this research, and to our research associate
  Susan Bobulsky who carried the ball on this
  effort!

References

• PMI country operating plans (2006-2009)
• Global Fund proposals (Rounds 1-8)
• WHO publications

• World Bank programs
• UNICEF programs
• Ministry of Health websites

• UNICEF Naawa Sipilanyambe
• SFH Uzo Gilpin
• World Bank Noel Chisaka
• USAID Larry Barat
• UNICEF Angus Spiers (planned)

• WHO Peter Olumese, Philipe Vanstraete
• RBM Richard Carr, Betty Udom, Jan Van Erps
• WHO/TDR Franco Pagnoni
• WHO Pediatric Meds List Suzanne Hill