measuring access to diagnosis and treatment rbm-cmwg july 9, 2009 richard steketee, macepa-path...
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Measuring access to diagnosis and treatment
RBM-CMWGJuly 9, 2009
Richard Steketee, MACEPA-PATHRBM-MERG Co-Chair
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Measuring access to Dx and Tx
• “If you choose to measure it, you value it”• “If you choose not to measure it, you don’t value it”
• But, not everything needs to be measured and we should first pay attention to:– What we want to do/accomplish– Who is responsible for doing the work– Who needs to measure– Who needs to respond to the data
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Measuring access to Dx and Tx
• Information needs at Global, Country, and Local levels differ:– Time and frequency– Precision and consistency of methods, etc.
• Methods should therefore differ based on differing needs– Population-based surveys, routine reporting,
administrative systems, special studies
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Measuring access to Dx and Tx
• “Prompt effective treatment of children <5yrs old with fever or malaria”– Prompt = “within 24 hours of illness onset” (or other
definitions)– Effective = “ACT” or “nationally-recommended regimen”
(or other definitions)– Treatment = “full course”? or “any dosing”– Children <5yrs old – ok (but in some places wider age
group?)– Fever or Malaria (but fever ≠ malaria, and this is a
changing relationship as malaria control improves)
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Measuring access to Dx and Tx
• RBM-MERG (and many others) recognized that the population based surveys had a real problem:– Surveys had a standard of determining if a child had a fever within
the past 2 weeks and then assessed their access to treatment (home, health care worker, facility)
– So, if the frequency of treatment changes, is this good or bad?
– If the program promotes diagnosis, they should have a lower proportion of febrile children treated (so a decrease would be good)
– If the program promotes treatment of all febrile children, they should try to get a higher proportion treated (so an increase would be good)
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2006-2008 MICS, DHS and MIS compared to previous surveys 2000-2005
• At the Global perspective, the surveys showed essentially no change in the proportion of children with fever receiving malaria treatment
• Countries showing more progress in malaria prevention coverage (ITN and IRS coverage) had a tendency to have lower rates of malaria treatment of children with fever– They were also more likely to be introducing diagnosis
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Introduced question on diagnosisinto surveys (DHS, MICS, MIS)
Child with Fever?
Yes
Seen by health worker?
Yes
Finger or heel stick?
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But current question on treatment=
Child with Fever?
Yes
Seen by health worker?
Yes
Finger or heel stick?
Result positive?
Treated?
Drug?
Timing?
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Introduced question on diagnosis – can extend to diagnosis + treatment
Child with Fever?
Yes
Seen by health worker?
Yes
Finger or heel stick?
Result positive?
Treated?
Drug?
Timing?
As these are children who have been seen by a health worker, information from routine health facility data and special studies may be particularly helpful
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Data on Diagnostics among children with fever
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Children <5 yrs with fever
• 3218 children: 843 (28%) with fever in the last 2 weeks– 35% in 12-23 month age group– 30% in rural, 24% in urban
• 64% went to a facility or provider
• 43% took an antimalarial
• 29% took antimalarial within 24hrs of onset
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Among the 843 Children <5 yrs with fever in the last 2 weeks
• 64% went to a facility or provider
• 10.9% had finger or heel stick(17% of those seeing a provider)– Male = Female – By Province: range 0% to 29%
(up to ~45% for those seeing a provider)
-- Urban vs Rural: 15.3% vs 9.5%
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Children <5 yrs with fever
• 10.9% had finger or heel stickAge: <12m 10.1%
12-23m 7.0%
24-35m 12.4%
36-47m 12.6%
48-59m 15.1%
Quintile: lowest 9.9%
highest 19.5%
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A few additional thoughts
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Measuring access to Dx and Tx
• Survey data: – Population-based, national monitoring, relevant to
country and multi-country decision making
• Health worker or Facility routine data:– Only population seeing HW, district monitoring for
management, stock-in/out (note this is a problem that needs immediate response, not a monthly assessment)
• Special study data:– Answering specific questions in access, health worker
performance, etc.
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Common challenges assessing Diagnostics and Treatment issues
• Denominator– Child with fever; child seen by health provider; child
with diagnosis; child with positive diagnosis
• Numerator– Child treated with proper drug, in proper time, with full
course
• Diagnosis type– Microscopy, RDT, other diagnostic
• Diagnosis result– Ability to examine Tx based on reported result versus
laboratory documented result
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Conclusions
• Measurement of Dx and TX is not easy
• Standards will never be perfect, but they will likely help programs
• Good communication about the choice of standards and their appropriate use in countries will be critical
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Relevance to RBM-CMWG
• RBM-MERG has done much thinking about this and there is some progress
• A specific link between RBM-MERG and RBM-CMWG (a joint “task force” of a few committed people?) could allow the link between standards of program advice and standards of program monitoring– Produce a white paper on “current and anticipated
needs and approaches to measuring malaria diagnosis and treatment” for both WGs to review?
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