Transcript Health worker or Facility routine data

Measuring access to
diagnosis and treatment
RBM-CMWG
July 9, 2009
Richard Steketee, MACEPA-PATH
RBM-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:
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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 diagnosis
into 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?
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
Result positive?
Treated?
Drug?
Timing?
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 stick
Age:
<12m
12-23m
24-35m
36-47m
48-59m
Quintile: lowest
highest
10.1%
7.0%
12.4%
12.6%
15.1%
9.9%
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 RBMCMWG (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?