1. Measuring access to diagnosis and treatment RBM-CMWG July 9, 2009 Richard Steketee, MACEPA-PATH RBM-MERG Co-Chair

2. 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

3. 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

4. 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)

5. 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)

6. 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

7. Introduced question on diagnosis into surveys (DHS, MICS, MIS) Child with Fever? Yes Seen by health worker? Yes Finger or heel stick?

8. But current question on treatment= Child with Fever? Yes Seen by health worker? Yes Finger or heel stick? Result positive? Treated? Drug? Timing?

9. 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

10. Data on Diagnostics among children with fever

11. 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

12. 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%

13. Children <5 yrs with fever 10.9% had finger or heel stick Age:<12m10.1% 12-23m 7.0% 24-35m12.4% 36-47m12.6% 48-59m15.1% Quintile: lowest 9.9% highest 19.5%

14. A few additional thoughts

15. 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.

16. 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

17. 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

18. 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?

20. But current question on treatment= Child with Fever? Yes Seen by health worker? Yes Finger or heel stick? Result positive? Treated? Drug? Timing?