Quality Assurance, Malaria Control Programme Challenges

1. Quality Assurance,Malaria Control ProgrammeChallenges NVBDCP, Orissa Presentation by : Dr. Madan Mohan Pradhan

2. Malaria in Orissa,2008 Total population: 41 million (4%) of the countryTotal land area : 3% of the country Total malaria cases around 3.7 lakh /years (24% of India) Total malaria deaths 239/years (24% of India) Data source: Malaria surveillance in Primary Health Care System

3. Malaria trend in Orissa Around 60% deaths in tribal blocks

4. Epidemiological situation, 2004 to 2009

5. 20 High Burden Districts

6. Challenges • In Orissa more than 85% is Pf malaria • Orissa contributes 43% Pf malaria to India • Pf is resistant to Chloroquine • Large % of population : ST & SC and • more so in remote/ cut-off areas [ST + SC (22% ST and 16% SC) = 38%] • Relative lack of health sector human resources. --

7. Challenges inDiagnosis at community level Diagnosis depends upon RDT and Microscopy • Use of RDT: So far 36340 ASHAs have been engaged which is expected to be 42000. • They will use RDTs, draw blood smears and fill up M1 form along with their other responsibilities • Use of microscopy: In Orissa microscopy clinics (MC) available upto Block level (Total 314 blocks) • To ensure diagnosis within 24 hrs MCs should be available at sector PHC level • There are around 1200 sector PHCs and accordingly trained LTs and microscopes are required

8. Challenges:Microscopy - processes • All malaria microscopy centres send: • 10% of +ve and 10% of –ve slides to the state level laboratories • Central Lab under the National Control Programme under the state Govt and • Laboratory of RD, ROH & FW , GoI office Both these labs are meant for cross checking. Accordingly random end nos. are given by the Central Malaria Laboratory.

9. Challengesin transportation of blood slides for cross checking • Blood slides for cross checking are transported from blocks to districts and then to state every month • Crosschecking labs at state level give feedback to the poorly performing labs • if discrepancy is > 2%, poor quality smear, delayed reporting etc., then feedback is sent to the districts for necessary action. • Poorly performing LTs are retrained at the Lab of RD,ROH & FW, GoI, BBSR.

10. Microscopy Quality Monitoring

11. Challenges:Monitoring the quality in microscopy • Desired numbers of slides are not received from MCs by the designated cross checking laboratories • Blood smears not received in time from a number of MCs • Defaulter MCs are alerted by letters from SPO and over telephone.

12. Assessment of Laboratory Processes Initiatives taken: • Questionnaire designed for lab. Assessment and being used by trained LTs to collect information on lab. processes • Newly appointed LTs under the new projects have been trained • They will be assigned with the job of assessing the malaria microscopy using the questionnaires.

13. Challenges with Diagnosis by RDT • Quality Assurance mechanisms not strongly established. • Guidelines for storage, transport and use of RDTs in the field has been sent to districts and district officials have been sensitized on the issue • Oriya pictorial information sheet developed to be used HW and ASHAs . • Possibilities of cross checking: • Sentinel site / block labs can be oriented to cross check RDTs comparing with microscopy

14. Drugs &Treatment State procured Drugs: • Drugs procured using state funds come with a manufacturer’s testing certificate. • After receiving these drugs, Districts send random samples from each stock to State Drug Management Unit (SDMU) • SDMU forwards these drugs to certified National Accredited Biological Lab (NABL) for quality testing. GoI supplied drugs: No such procedure is followed for GoI supply drugs Treatment Audit: • Not yet implemented the prescription/treatment audits

15. Surveillance- timeliness

16. Vector Control Indoor Residual Spray (IRS) • Monitoring teams for IRS: • Both state and dist. teams are oriented before each round of IRS • A predesigned checklists is used for Monitoring • Entomological studies : • State has no functional entomological teams • Initiatives taken to make the three zonal teams functional • Entomological studies are done by ICMR institutes like NIMR/RMRC/VCRC

17. IRS: Challenges Not done: • Insecticide quality testing is not done since insecticide supplied by GoI. • Spray quality testing – by bioassay / wall scrapings

18. Monitoring and supervision for spray • Village level - MPW/ MTS/ MO I/c sector PHC • Recently GKS are involved – shows improvement • After Village committee/ GKS certification of completion of spray, wages are paid to SFW, IFW • Post cards are sent from the community where IRS is done • Display boards for IRS schedule/ areas at block PHC/CHC. • CHC/ PHC level - MPW/MTS/ ADMO/ MO PHC/ CHC • District level - Jt. DHS/ CDMO • State level - SPO, other staff at state NVBDCP

19. Supervision report from ASHA & Sarpanch

20. Monitoring : Treatment of nets by insecticides • Govt supplied bednets/ community bednets are treated with deltamethrine ( SP flow) • Treatment is done by govt. staff/ NGO/ CBOs/ volunteers. • Supervision by govt. staff is done during the insecticide treatment. • Treatment is done at a common place in the community so that people can see and adopt later. .

21. Challenges :in treatment of plain net • Monitoring of re-impregnation of nets after each six month is a difficult task • Gaps in supply of nets: When GoI supply nets are inadequate and not supplied in time, it becomes difficult to mobilse community nets to give >60% household coverage in a high burden areas. Due to this it becomes difficult to utilise SP flow in time.

22. NGO/PPP involvement • 40 NGOs have been involved in IRS, especially in difficult to reach areas- they are monitored by health personnel in 8 districts. • ITN impregnation – NGOs involved in large numbers • Corporate sectors involvement started • Kalyani clubs, other CBOs • GKS, CBO and community based monitoring ongoing in a number of places

23. Training and Capacity building • Pre and post training test questionnaires are a part of all trainings conducted by the State VBDCP unit. • Assessment of staff competencies done during field visits. • It has been planned to have KAPB assessment of field level service providers – • MTS will conduct the study.

24. IEC/ BCC – QA assurance • IEC material being centrally developed to ensure standardisation and correct, to-the point messages. • Pictorial messages for lower literacy groups • Electronic media messages from state level to ensure uniformity • Greater focus on IPC for behavioural change. • Monitoring through field visits, documentation, photographs. • Issue based, area specific and outcome oriented IEC packages. • Use of multimedia approach for message dissemination

25. Indirect quality assurance mechanisms • Program checklists/ Supervisory checklists for ADMO-PH/ DMOs and CDMO, state officials and consultants • VBD consultants have recently joined in World Bank districts, who would be directly responsible for Quality Assurance in their districts.

26. Indirect quality assurance mechanisms • MTS submit monthly performance to district program officers using the designed checklist. • Communication from state NVBDCP to MTS over phone • District Collectors have been requested by Commissioner cum Secy, Health & FW to review malaria control program - Checklist provided. • Review by Secy Health in each month

27. Proposed Lot Quality Assurance Sampling (LQAS)

28. Lot Quality Assurance Sampling (LQAS) • LQAS is being planned for quality assurance for ITN/LLIN, RDT use, treatment, drug supply at the level of ASHAs/ FTDs • Technical support is being provided by The Liverpool School of Tropical Health & Hygiene • Preliminary round of training has been completed for core stakeholders like State NVBDCP, RMRC, and Medical college (SPM Deptt), T&MST • Questionnaires have been developed in the context of Orissa

29. What is LQAS? (1) • LQAS is a method of rapid assessment of interventions/ collecting baseline information for any programme. • Monitors progress towards targets and objectives set forth by the state. • Decentralized measurement of outcomes at district and PHC levels to support local decision-making and provide objective monitoring to the central level

30. What is LQAS? (2) • LQAS method uses a very small sample size of 19* in a supervision area/management unit • Supervision area/ management unit is a block PHC in our case. • LQAS can estimate with >90% accuracy whether a pre-established target is being reached or not. • Selection of villages and household • * 19 villages in a Block are selected randomly using a software. • From each village 1 household is selected randomly and interviewed. • From the same village one ASHA is also interviewed.

31. Plan in Orissa • To be piloted in 3 World Bank supported dists, in 2009 i.e. Mayurbhanj, Sundargarh and Nawarangpur • The first round of data collection is planned for Oct. 2009 (to capture data during a high transmission season) • Data collection to be done through MTS and other field staff in malaria control • Training before data collection • T&MST (OHSP) is coordinating implementation.

32. Small surveys for quality assurance • Community based survey in Mayurbanja and Sundargarh to assess the treatment seeking behaviour (with ACT) , coverage and use of ITN and IRS is being done in Sept- October,09 • Questionnaires developed and field tested • Such studies will be conducted for to assess the KAPB of filed level service providers ( ASHA, HW, MOs)

33. Other mechanisms to improve the quality assurance mechanisms • Capacity building and ensuring regular analysis on QA of blood slides and feedback to dist/ PHCs • Ensuring submission of blood slides to the designated laboratories within the fixed time period • Improving capacities of LTs in poorly performing districts. • Integrating QA into the M & E mechanism. • QA for treatment protocol after training of Medical officers • QA for vector control processes.

34. Thanks