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

摘要

The achievements of the health Millennium Development Goal of reducing childudmortality (MDG 4) depend on the massive scaling-up of new and available healthudinterventions. Evidence shows that effective interventions to attain MDG 4 areudavailable; however coverage rates are currently low. The health systems inuddeveloping countries lack the necessary capacity to deliver the interventions toudthose in need. These factors among others are the cause of millions ofudpreventable child deaths every year.udWorldwide it is estimated that there are 247 million cases of malaria and at leastud1 million deaths related to malaria each year (World Malaria Report 2008). Africaudbears the greatest burden of malaria – about 86% of the global burden – leadingudto over 800,000 deaths per annum. Children under five years of age andudpregnant women are the most affected groups. Malaria-endemic countries haveudlower rates of economic growth. The impact of malaria is manifested through lossudof working time when people are ill or taking care of family members, throughudloss of resources that are used to finance treatment, and through disabilities thatudresult from severe malaria. An episode of malaria results in loss of productivity inudadults and prevents children from developing to their full capacity by impairingudtheir cognitive ability, physical development, school attendance and performance.udThe average growth of income per capita for countries with severe malaria inud1965-1990 was 0.4% per year compared to 2.3% for other countries. In terms ofudcrop harvests, malaria-affected families harvest 40% that of families not affectedudby malaria. Malaria impacts on long term economic development in terms ofudimpediments on the flow of knowledge, trade, foreign investment, informationudtransfers and tourism as well as limiting the country’s ability to accumulateudhuman capital. All these imply that malaria is responsible for inflicting poverty onudpeople in developing countries through the vicious cycle of ill-health. Theseudhuman sufferings due to malaria could be averted if access to effective preventive and treatment interventions could be made available to all affectedudpeople.udThe health systems in developing countries have limited capacity to undertakeudappropriate health actions to improve population health. The main constraintsudinclude shortage of financial resources, lack of capacity to institutionalize healthudinterventions into routine health care delivery, severe human resource shortages,uddilapidated health facilities and lack of essential medical supplies and equipment.udThe distribution of health benefits provided by the health system is not fair either,udas the rate of health service utilization is lower among the poorer and moreudvulnerable groups.udThe aim of this research was to contribute to the understanding of health systemudissues and costs related to integrating a new strategy of Intermittent PreventiveudTreatment in infants (IPTi) into the routine district health system, with a focus onudproviding high quality but practical evidence to inform decision making and toudscaling up health services. The methodology involved using a collaborativeudapproach to develop a delivery strategy for IPTi, to implement the strategy and toudevaluate the strategy in terms of equity of intervention coverage and populationudbenefit. Researchers worked in partnership with the Ministry of Health and SocialudWelfare (MoHSW) to develop an IPTi strategy that could be implemented andudmanaged by routine health services. The Behaviour Change Communicationud(BCC) materials for IPTi were developed by observation studies and in-depthudinterviews with communities and health workers. To estimate how much it takesudto develop the IPTi strategy and to maintain routine implementation of theudstrategy, real activities costs were tracked. Also semi-structured interviews wereudconducted with key informants to record time and resources spent on IPTiudactivities. A detailed health facility survey collected data on staff employed, theirudavailability on the day of the survey, their main tasks and reasons for theirudcolleagues’ absenteeism. Information on supervisory visits from District HealthudManagement Teams (CHMTs) was also collected and health workers’ views solicited on how to improve the services. A time and motion study of nurses inudthe Reproductive and Child Health (RCH) clinics documented staff time use byudtask.udThe present study generated important knowledge to enable integration of healthudinterventions into routine delivery by frontline health workers and managed byudCouncil Health Management Teams. Using the collaborative approach, the IPTiudstrategy was developed to ensure that IPTi behaviour-change communicationud(BCC) materials were available in health facilities, that health workers wereudtrained to administer and to document doses of IPTi so that the necessary drugsudwere available in facilities and that systems were in place for stock managementudand supervision. A brand name (MKINGE in Swahili, which means protect him orudher) and two posters were developed as BCC. The posters contained key publicudhealth messages and images that explained the IPTi intervention itself, how andudwhen children receive it and safety issues. The strategy was integrated intoudexisting systems as far as possible and was well accepted by health staff. Thus,udthe collaborative approach effectively translated research findings into a strategyudfit for broader health system implementation in Tanzania.udThe costs of developing and implementing IPTi appeared to be affordable withinudthe budget line of the Ministry of Health and Social Welfare. The estimatedudfinancial cost to start-up and run IPTi in the whole of Tanzania in 2005 wasudUS$1,486,284. Start-up costs at the district level were US$7,885 per district,udmainly expenditure on training. There was no incremental financial expenditureudneeded to deliver the intervention in health facilities as supplies were deliveredudalongside routine vaccinations and available health workers performed theudactivities without working overtime. The economic cost was estimated at 23 USudcents per IPTi dose delivered. In terms of coverage, IPTi was not influenced byudsocio-economic status of a child, by ethnicity nor by child gender. However thereudwas disparity in coverage by distance whereby children from households livingudmore 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 healthudinterventions should therefore focus on increasing physical access and toudmonitoring equity outcomes. Vaccine coverage was more equitable across socioeconomicudgroups than had been reported from a similar survey in 2004.udThe evaluation of human resource for health in the study area revealed particularudproblems with staff shortages, low productivity and staff absenteeism. Only 14%udof the recommended number of nurses and 20% of the recommended number ofudclinical staff had been assigned to the facilities. These available health workers inudsouthern Tanzania are below the national average of 35%. Thus, the healthudsystem in the study area is working with less than a quarter of the recommendedudstaff by MoHSW, and combined with staff absenteeism, the available workingudstaff decreases further compared to the recommended staff numbers. The absentudhealth workers were away for seminar sessions (38%), long term training (8%) orudon official travels 25% and on leave (20%). Of those health workers present atudthe reproductive and child health clinic at the time of the survey, averageudproductive working time equaled 57% of their time present at work. In terms ofudmonthly supervision visits by the Council Health Management Teams, only 14%udof facilities had received the required number of supervisory visits during the 6udmonths preceding the survey.udThe findings of this thesis underline the importance of operational research as audsystematic way to establish how new interventions work under routine healthudsystem conditions. The lessons described in this thesis have great significanceudfor the future of public health strategies, both existing and new. The generatedudinformation on costs and experience with the issues surrounding design of theuddelivery mechanisms, training, supervision and development of implementationudguidelines created a strong institutional framework that could speed upudimplementation at country level whenever there is a policy recommendation. It isudexpected that the experience generated and the evidence gathered as part ofudthis thesis can contribute to an improved understanding of the issues that need to be considered and tackled in order to spearhead routine implementation ofudmalaria interventions and potentially other diseases to achieve high healthudservice access and improved quality care that is a foundation for improvedudpopulation health.udThis study recommends increased resources for funding operational studies toudprovide evidence of how proven effective tools to fight diseases of the poor workudunder real life application through routine health delivery system. Otherudrecommendations of this thesis are related to the need to strengthen supervisionudof health facilities by CHMTs and by higher levels to supervise the districtudsupervisors. There is also an urgent need to develop and test incentive packagesudin local settings. These measures are necessary to increase health workersudproductivity, increase staff moral and retention, curb absenteeism and realizeudhealth workers balance between urban and rural health facilities in developingudcountries. Only by exploring many of the factors highlighted above, andudthroughout this thesis, can the timely and high scale-up of health interventions beudachieved.