Christina Riley

: Geospatial tools are used to map populations to support microplanning and delivery of health campaigns. Although the value of geospatial tooling has been described, their costs and cost effectiveness is largely unknown. This study details the results of a cost-effectiveness analysis of a digital geospatial tool (‘Reveal’) added to a 2017 malaria control campaign [indoor residual spraying (IRS)] in Zambia. An economic evaluation of the costs for digital geospatial tooling to microplan and deliver IRS for malaria in Luapula Province, Zambia, was conducted using primary data collection methods in line with a recently developed methodology termed ‘Total Cost of Ownership’. A cost-effectiveness estimate was calculated for adding the geospatial tooling to standard IRS scaling over 5 years. Results indicate that use of Reveal attributed an average 21% reduction in cost per case averted (Ca) compared to IRS alone. Cost per Ca with IRS alone was estimated at $18.16 compared to cost per Ca when the geospatial tooling was added ($15.51 in year 1, $13.93 by year 5). Savings per Ca were realized through use of Reveal during IRS campaign deployment, likely through the mechanism of the tool, which supports field teams to use digital maps to find and spray houses. Analysis of current and ongoing cost for deployment does warrant further consideration and investment toward digitized geospatial tooling, especially considering the bearing these tools have on multiple health campaigns, globally. Further consideration on scaling strategies and expansion to other health campaigns and applications is also warranted. RESUMEN: Las herramientas geoespaciales se usan para ubicar poblaciones y apoyar la microplanificación y la distribución de campañas de salud. Aunque se ha descrito el valor de las herramientas geoespaciales, sus costos y la efectividad de los costos se desconocen en gran medida. Este estudio desglosa los resultados de un análisis de efectividad de costos de una herramienta geoespacial (‘Reveal’) agregada a una campaña de control de la malaria de 2017 (fumigación residual en interiores, [IRS por sus siglas en inglés]) en Zambia. Se llevó a cabo una evaluación de los costos para herramientas geoespaciales digitales con el propósito de microplanificar y distribuir la IRS para malaria en la provincia de Luapula, Zambia, usando métodos de recolección de datos primarios, alineados con una metodología desarrollada recientemente conocida como ‘Costo total de propiedad’. Se calculó un estimado de efectividad de costos respecto a agregar la herramienta geoespacial a IRS estándar con escalamiento a lo largo de 5 años. Los resultados muestran que el uso de Reveal contribuyó a una reducción promedio de 21% en el costo por caso evitado (CA, por sus siglas en inglés) en comparación con la IRS por sí sola. El costo por Ca con IRS por sí sola se estimó en $18.16, en comparación con el costo por Ca cuando se agregó la herramienta geoespacial ($15.51 el primer año, $13.93 para el quinto año). Los ahorros por Ca se cumplieron mediante el uso de Reveal durante la implementación de la campaña de IRS, posiblemente a través del mecanismo de la herramienta, el cual apoya a los equipos en campo que usan mapas digitales para encontrar y fumigar casas. El análisis de los costos actuales y en curso justifica una mayor consideración e inversión en herramientas geoespaciales digitalizadas, considerando especialmente el efecto de estas herramientas en múltiples campañas de salud a nivel global. También se justifica una mayor consideración en estrategias y expansión del escalamiento hacia otras campañas de salud y aplicaciones. RESUMO: As ferramentas geoespaciais são utilizadas para cartografar as populações, e apoiar o microplaneamento e a realização de campanhas de saúde. Embora o valor das ferramentas geoespaciais tenha sido descrito, os seus custos e a sua relação custo-eficácia são amplamente desconhecidos. Este estudo detalha os resultados de uma análise de custo-eficácia de uma ferramenta geoespacial digital (‘Reveal’) adicionada a uma campanha de controlo da malária de 2017 (pulverização residual interna, PRI) na Zâmbia. Foi realizada uma avaliação económica dos custos das ferramentas geoespaciais digitais para microplaneamento e aplicação da pulverização residual intradomiciliária contra a malária na província de Luapula, na Zâmbia, utilizando métodos de recolha de dados primários em conformidade com uma metodologia recentemente desenvolvida denominada ‘Custo Total de Propriedade’. Foi calculada uma estimativa da relação custo-eficácia para a adição das ferramentas geoespaciais ao escalonamento padrão da PRI durante cinco anos. Os resultados indicam que a utilização do Reveal atribuiu uma redução média de 21% no custo por caso evitado (CE) em comparação com o PRI isolado. O custo por CE apenas com o PRI foi estimado em 18,16 dólares em comparação com o custo por CE quando as ferramentas geoespaciais foram adicionadas (15,51 dólares no primeiro ano, 13,93 dólares no quinto ano). Foram realizadas poupanças por CE através da utilização do Reveal durante a implementação da campanha de PRI, provavelmente através do mecanismo da ferramenta que apoia as equipas de campo na utilização de mapas digitais para encontrar e pulverizar casas. A análise do custo atual e contínuo da implantação justifica uma maior consideração e investimento em ferramentas...

Background Malaria Mass Drug Administration (MDA) is recommended to reduce malaria in low transmission settings, with a target coverage of ≥80%. This study assesses the feasibility of a programmatic MDA (pMDA) pilot implementation in southern Mozambique. Methods The National Malaria Control Programme implemented pMDA in Chidenguele (Gaza Province), where the estimated population is 59,271. Two rounds of door-to-door distribution (using satellite maps with previously enumerated households (Reveal® platform)) with fixed points were conducted between December 2022 and February 2023. Household coverage was estimated with both district census data and satellite number of expected households. All eligible individuals ≥6 months received a full therapeutic 3-day-course of dihydroartemisinin-piperaquine. Individual data collection was conducted during round 1 (R1), which was changed to aggregated data at the household level in round 2 (R2). Community engagement and human resources were also strengthened between the two rounds. The target number of households to be reached by team/day was 25/30 in R1 and 15 in R2. Results When using census data, household coverage (households reached over targeted) increased from 59.4% (8799/14818) in R1 to 94.3% (13972/14818) in R2, while with the satellite estimates, it increased from 62.5% (8799/14075) to 99.3% (13972/14075). Population programmatic coverage (individuals treated over total population) increased from 40.9% (24237/59271) to 69.8% (41347/59271). Treatment rate among present individuals (operational coverage) decreased from 91.3% (24237/26541) to 85.1% (41347/48588). Conclusion Collecting aggregated data, decreasing the household target per day per team and using fixed-points at the end as a recovery strategy helped improve operational performance. However, reaching an 80% programmatic coverage is challenging even with high rates of household visitation and operational coverage, mainly due to absences and exclusions. Funding: This project is funded by the EDCTP2 Programme.

: Zambia’s National Malaria Elimination Program transitioned to Fludora Fusion in 2019 for annual indoor residual spraying (IRS) in Nchelenge District, an area with holoendemic malaria transmission. Previously, IRS was associated with reductions in parasite prevalence during the rainy season only, presumably because of insufficient residual insecticide longevity. This study assessed the impact of transitioning from Actellic 300CS to long-acting Fludora Fusion using active surveillance data from 2014 through 2021. A difference-in-differences analysis estimated changes in rainy season parasite prevalence associated with living in a sprayed house, comparing insecticides. The change in the 2020 to 2021 dry season parasite prevalence associated with living in a house sprayed with Fludora Fusion was also estimated. Indoor residual spraying with Fludora Fusion was not associated with decreased rainy season parasite prevalence compared with IRS with Actellic 300CS (ratio of prevalence ratios [PRs], 1.09; 95% CI, 0.89–1.33). Moreover, living in a house sprayed with either insecticide was not associated with decreased malaria risk (Actellic 300CS: PR, 0.97; 95% CI, 0.86–1.10; Fludora Fusion: rainy season PR, 1.06; 95% CI, 0.89–1.25; dry season PR, 1.21; 95% CI, 0.99–1.48). In contrast, each 10% increase in community IRS coverage was associated with a 4% to 5% reduction in parasite prevalence (rainy season: PR, 0.95; 95% CI, 0.92–0.97; dry season: PR, 0.96; 95% CI, 0.94–0.99), suggesting a community-level protective effect, and corroborating the importance of high-intervention coverage.

Foundational high‐resolution geospatial data products for population, settlements, infrastructure, and boundaries may greatly enhance the efficient planning of resource allocation during health sector interventions. To ensure the relevance and sustainability of such products, government partners must be involved from the beginning in their creation, improvement, and/or management, so they can be successfully applied to public health campaigns, such as malaria control and prevention. As an example, Zambia had an ambitious strategy of reaching the entire population with malaria vector control campaigns by late 2020 or early 2021, but they lacked the requisite accurate and up‐to‐date data on infrastructure and population distribution. To address this gap, the Geo‐Referenced Infrastructure and Demographic Data for Development (GRID3) program, Akros, and other partners developed maps and planning templates to aid Zambia’s National Malaria Elimination Program (NMEP) in operationalizing its strategy.

Nepali migration is longstanding, and increased from 2.3% of the total population in 2001 to 7.2% in 2011. The estimated 1.92 million migrants are predominantly men. Consequently, 32% of married women have husbands working abroad. Social structures are complicated as many married women live with their in-laws who typically assume decision-making power, including access to health services. This study compares access to reproductive health services, fertility awareness, and decision-making power among a sample of married women aged 15-24 years (n = 1123) with migrant husbands (n = 485), and with resident husbands (n = 638). Predictably, women with migrant husbands had significantly lower contraceptive use than other married women (9.3% vs 30.3%, respectively), and expressed a higher intention to become pregnant in the next year. Despite their intentions, women with migrant husbands scored lower on a fertility awareness index, were less likely to discuss pregnancy planning with their spouse, and less likely to describe their relationships positively. Decision-making for both groups of married women was dominated by both husbands and in-laws in different ways. Yet, across multiple normative scales, fewer women with migrant husbands felt pressure to conform to existing social norms. Married women with migrant husbands reflect a subset of women, with unique fertility issues and desires. Interventions that increase knowledge of fertility among this subset of women, promote healthy preconception behaviours. Linking women for counselling opportunities throughout the pre and postnatal periods may help improve health outcomes for mothers and children.

Prompt diagnosis and effective treatment of acute malaria in pregnancy (MiP) is important for the mother and fetus; data on health-care provider adherence to diagnostic guidelines in pregnancy are limited. From September to November 2013, a cross-sectional survey was conducted in 51 health facilities and 39 drug outlets in Western Kenya. Provider knowledge of national diagnostic guidelines for uncomplicated MiP were assessed using standardized questionnaires. The use of parasitologic testing was assessed in health facilities via exit interviews with febrile women of childbearing age and in drug outlets via simulated-client scenarios, posing as pregnant women or their spouses. Overall, 93% of providers tested for malaria or accurately described signs and symptoms consistent with clinical malaria. Malaria was parasitologically confirmed in 77% of all patients presenting with febrile illness at health facilities and 5% of simulated clients at drug outlets. Parasitological testing was available in 80% of health facilities; 92% of patients evaluated at these facilities were tested. Only 23% of drug outlets had malaria rapid diagnostic tests (RDTs); at these outlets, RDTs were offered in 17% of client simulations. No differences were observed in testing rates by pregnancy trimester. The study highlights gaps among health providers in diagnostic knowledge and practice related to MiP, and the lack of malaria diagnostic capacity, particularly in drug outlets. The most important factor associated with malaria testing of pregnant women was the availability of diagnostics at the point of service. Interventions that increase the availability of malaria diagnostic services might improve malaria case management in pregnant women.

An estimated 214 million women have unmet need for family planning in developing regions. Improved utilization of the private sector is key to achieving universal access to a range of safe and effective modern contraceptive methods stipulated by FP2020 and SDG commitments. Until now, a lack of market data has limited understanding of the private sector’s role in increasing contraceptive coverage and choice. In 2015, the FPwatch Project conducted representative outlet surveys in Ethiopia, Nigeria, and DRC using a full census approach in selected administrative areas. Every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, availability, and price. Excluding general retailers, 96% of potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods available. In Ethiopia, 41% of modern contraceptive stocking outlets were in the private sector compared with approximately 80% in Nigeria and DRC where drug shops were dominant. Ninety-five percent of private sector outlets in Ethiopia had modern contraceptive methods available; 37% had three or more methods. In Nigeria and DRC, only 54% and 42% of private sector outlets stocked modern contraceptives with 5% and 4% stocking three or more methods, respectively. High prices in Nigeria and DRC create barriers to consumer access and choice. There is a missed opportunity to provide modern contraception through the private sector, particularly drug shops. Subsidies and interventions, like social marketing and social franchising, could leverage the private sector’s role in increasing access to a range of contraceptives. Achieving global FP2020 commitments depends on the expansion of national contraceptive policies that promote greater partnership and cooperation with the private sector and improvement of decisions around funding streams of countries with large populations and high unmet need like Ethiopia, Nigeria, and DRC.

Although anti-malarial medicines are free in Kenyan public health facilities, patients often seek treatment from private sector retail drug outlets. In mid-2010, the Affordable Medicines Facility-malaria (AMFm) was introduced to make quality-assured artemisinin-based combination therapy (ACT) accessible and affordable in private and public sectors. Private sector retail drug outlets stocking anti-malarial medications within a surveillance area of approximately 220,000 people in a malaria perennial high-transmission area in rural western Kenya were identified via a census in September 2013. A cross-sectional study was conducted in September–October 2013 to determine availability and price of anti-malarial medicines and malaria rapid diagnostic tests (RDTs) in drug outlets. A standardized questionnaire was administered to collect drug outlet and personnel characteristics and availability and price of anti-malarials and RDTs. Of 181 drug outlets identified, 179 (99 %) participated in the survey. Thirteen percent were registered pharmacies, 25 % informal drug shops, 46 % general shops, 13 % homesteads and 2 % other. One hundred sixty-five (92 %) had at least one ACT type: 162 (91 %) had recommended first-line artemether-lumefantrine (AL), 22 (12 %) had recommended second-line dihydroartemisinin-piperaquine (DHA-PPQ), 85 (48 %) had sulfadoxine-pyrimethamine (SP), 60 (34 %) had any quinine (QN) formulation, and 14 (8 %) had amodiaquine (AQ) monotherapy. The mean price (range) of an adult treatment course for AL was $1.01 ($0.35–4.71); DHA-PPQ was $4.39 ($0.71–7.06); QN tablets were $2.24 ($0.12–4.71); SP was $0.62 ($0.24–2.35); AQ monotherapy was $0.42 ($0.24–1.06). The mean AL price with or without the AMFm logo did not differ significantly ($1.01 and 1.07, respectively; p = 0.45). Only 17 (10 %) drug outlets had RDTs; 149 (84 %) never stocked RDTs. The mean RDT price was $0.92 ($0.24–2.35). Most outlets never stocked RDTs; therefore, testing prior to treatment was unlikely for customers seeking treatment in the private retail sector. The recommended first-line treatment, AL, was widely available. Although SP and AQ monotherapy are not recommended for treatment, both were less expensive than AL, which might have caused preferential use by customers. Interventions that create community demand for malaria diagnostic testing prior to treatment and that increase RDT availability should be encouraged.

Although prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP. We conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information. Correct MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively. This study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.