Measuring access to diagnosis and treatment

RBM-CMWGJuly 9, 2009

Richard Steketee, MACEPA-PATHRBM-MERG Co-Chair

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

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

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)

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)

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

Introduced question on diagnosisinto surveys (DHS, MICS, MIS)

Child with Fever?

Yes

Seen by health worker?

Yes

Finger or heel stick?

But current question on treatment=

Child with Fever?

Yes

Seen by health worker?

Yes

Finger or heel stick?

Result positive?

Treated?

Drug?

Timing?

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

Data on Diagnostics among children with fever

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

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%

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%

A few additional thoughts

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.

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

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

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?