Malaria Treatment & Prevention

Worth noting also that such adherence has been achieved by well-run programmes on a national scale, without use of specific reminders etc, by good planning and messaging and allowing time for communities and health workers to understand and accept bne wways of amnagement Thiam et al. PLoS One. 2011 Apr 6;6(4):e18419.
Perhaps we are sometimes too impatient in allowing human behavious to change, people need to see that new algorithms are safe and make sense before adhering to them.

I'm Corine Karema, the Rwanda national Malaria COntrol Program Manager, I agree with David, we need sustainable mechanism to have health providers including NGOs to adhere and comply with national malaria treatment guidelines. in Rwanda today, 85.7% of malaria cases are correctly treated according to malaria treatment guidelines compared to 77.4 % in 2007, one ear after the change of malaria policy with use of ACTs. This has been possible with the establishment of the performance based financing whereby health providers get salaries based on their performance which is being evaluated according to set indicators, this is sustainable, cost effective, does not require technics and can be use nationwide on top of refresher training and formative supervision plus regular data quality audit and of course good management and supply of drugs & registers at all level of health care. Corine twitter: @ckarema

Dear Corine and David,
I fully agree with both of you that reminders for adherence to treatment protocol are not the only way, and perhaps not always the recommended and sustainable way either. Rwanda's success with PBF and other interventions is notable.
I still ask the question: Is there a way to speed up the rate at which adherence to treatment protocols improves? Higher frequency refresher training, better and higher frequency audits, text reminders are some ways. Are there other approaches to do this that we are not thinking of and perhaps the collective,innovative thinking of this online forum can point us to some of them?

Also, I agree that good management and supply of drugs at all level of the healthcare system is a pre-requisite for improved healthcare worker adherence to treatment guidelines. When there are frequent stockouts of ACTs, RDTs and SP for IPTp, adherence to treatment protocols is somewhat unachievable. At the same time without adherence to treatment protocols, estimating the needs for each level in the system and designing robust supply planning processes is also difficult. So we have a slight circular reference problem.

Mobile text messaging is currently catching up in a big way in all the spheres of public health. Enumerating the difficulties is needed. Only text ing and not giving the dosage has been found with some providers.
Speeding up the information for adherence is necessary but only focussing on text messaging would not be the correct way, as far as my field experience goes!
Some supervisory protocol at the end of the day through the attending physician /assistant/nursing can be thought of
OR
After a certain number it will be linked to coding protocol ( like some area has over 85% usage will be reflected GREEN , some area with coverage < 70 % will be BLUE and some other where the care giver was unable to provide the treatemnt at all / or extremely poor coverage due to so many reasons as war/conflict/natural disaster/their own illness - Showing RED/ORANGE ) So that a specific area can immediately attended to? Concern and issues could be highlighted and addressed in a focussed way?

Dear Prashant and All,
A few obtuse thoguhts... Perhaps the key to adherence is concetration on these underlying areas that adherence, such as inconsistent supply and concern over diagnostic quality (a good health worker will not comply with diagnostic results if they have good reason to believe the results are wrong). Countries like Rwanda, Senegal, and others in Asia have shown good adherence to results developing over a year or two, when these are addressed on a large scale, which is pretty good in terms of human behaviour change. Obviously text messaging is one way of ensuring that the necessary messages get through, but its applications may be stronger in ensuring good supply of commodities etc so that the underlyiing conditions are in place to enable a good health worker to comply. Whatever is introduced has to be scalable, applicable across diseases, and sustainable when the funds from Global Fund etc dry up. Sometimes it may be better therefore to innovatively strengthen the underlying health system weaknesses that prevent adherence rather than addressing on a case by case basis. Rwanda and Senegal probably show better adherence to anti-malarials than many developed country health systems to antibiotic thereapy, so we may ...

Dear Prashant and All,
A few obtuse thoguhts... Perhaps the key to adherence is concetration on these underlying areas that adherence, such as inconsistent supply and concern over diagnostic quality (a good health worker will not comply with diagnostic results if they have good reason to believe the results are wrong). Countries like Rwanda, Senegal, and others in Asia have shown good adherence to results developing over a year or two, when these are addressed on a large scale, which is pretty good in terms of human behaviour change. Obviously text messaging is one way of ensuring that the necessary messages get through, but its applications may be stronger in ensuring good supply of commodities etc so that the underlyiing conditions are in place to enable a good health worker to comply. Whatever is introduced has to be scalable, applicable across diseases, and sustainable when the funds from Global Fund etc dry up. Sometimes it may be better therefore to innovatively strengthen the underlying health system weaknesses that prevent adherence rather than addressing on a case by case basis. Rwanda and Senegal probably show better adherence to anti-malarials than many developed country health systems to antibiotic thereapy, so we may somoetimes be too impatient in malaria.
David

Dear David,

Excellence to set up sms system to monitor and feedback. In Cambodia, weekly report of Influenza like illness, weekly dengue database surveillance system, monthly malaria HIS ..etc are working very well.
sms report is useful for sending from ground levels to high level, a lot benefit from the system, however, need simple phone software template using code and training at beginning. Cheers!! Chanthap