SIXTH INTERCOUNTRY MEETING OF NATIONAL MALARIA PROGRAMME MANAGERS

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Malaria control programme in Afghanistan
challenges and experiences in integrating the
malaria control program in the BPHS
Kamal Mustafa TO/RBM WHO AFG
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The Basic Package of Health Services for
Afghanistan
 
 

• The BPHS is Intended to provide a foundation for
  the new Afghan health system and the key
  instrument in its development
• The BPHS goal is to provide a standardized
  package of basic services (having the greatest
  impact) that would form the core of service
  delivery in all PHC facilities
• Developed in 2002 and published and distributed
  in March 2003 (during the transitional
  government). Revised again in 2005 by the elected
  government
• The package is costed _at_ US 4.5/Capita/Annum
• To have an appropriate referral system, an
  essential package for hospital services (EPHS)
  was recently developed and published to support
  and compliment the BPHS
• Major donors World Bank, USAID and EC

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BPHS

• Implementation
• BPHS is implemented through contracting out the
  NGOs that win the bidding to deliver the
  required services (in the whole province or a
  cluster of districts in the province)
• MOPH bids like any other NGO. Out of 34 provinces
  MOPH won the biddings in only 3 provinces
  (MOPH-SM)
• Up-to-date the BPHS covers 77 of the country
  (Geographical vs population coverage ??)

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Types of Health facilities used by the BPHS

• BPHS is offered at 4 standard levels of
  facilities to be established primarily on the
  basis of the population size to be served
• Health Post (HP) At the community level,
  delivered by home-based CHWs (male and female).
  Offers limited curative care including malaria.
  Teaches communities to recognize danger signs and
  assists in referral . Covers catchment area of
  1000-1500 people
• Basic Health Center (BHC) Small facility
  offering the same services as HP but with more
  complex out patient care. Staffed with a nurse,
  CMW and 2 vaccinators. Supervises HPs in the
  area. Covers a population of 15000-30000

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Types of Health facilities used by the BPHS

• Comprehensive Health Center (CHC) Offers a wider
  range of services. Can handle some complications.
  Have a limited space for inpatient care and a
  laboratory. Staff include male and female
  doctors, male and female nurses, midwives lab and
  pharmacy technicians. Covers a catchment area of
  30000-60000 people
• District Hospital (DH) Handles all services in
  the BPHS, including the most complicated cases.
  The hospital will be staffed with doctors,
  including female OB/GYNs, surgeon, anesthetist,
  and pediatrician midwives lab and X-ray
  technicians pharmacist and dentist and dental
  technician. Each district hospital will cover
  apopulation of 100,000 to 300,000, servicing up
  to four districts, depending upon the geographic
  accessibility to the facility

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Future Challenges to the BPHS

• Further expansion of the BPHS, as measured by the
  percentage of the population with access to BPHS,
  will become increasingly difficult
• Sustainability
• Ensuring quality
• Integration of the BPHS with the EPHS to develop
  a single, unified, and community-based health
  system with appropriate linkages for referrals
  throughout the system
• Retaining the commitment to the BPHS (increasing
  attention is being paid to the hospital elements
  of the health system)

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The link between the BPHS and Hospital sector
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Entry and Flow of Patients at the District
Hospital
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Components of the basic package of health services

• Maternal and newborn health
• Antenatal, delivery and postpartum care family
  planning care of the newborn
• Child health and Immunisation
• EPI (routine, outreach and mobile) integrated
  management of childhood illness promotion of
  exclusive breast feeding for the first 6 months
• Public nutrition
• Micronutrient supplementation treatment of
  clinical malnutrition
• Communicable diseases Treatment and control
• Control of malaria tuberculosis and HIV/AIDS
• Mental health
• Community management of mental problems health
  facility-based treatment of outpatients and
  inpatients
• Disability
• Physiotherapy integrated in PHC services
  Orthopaedic services expanded in hospitals
• Supply of Essential Drugs

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The National Malaria and Leishmania Control
Program (NMLCP)

• The Ministry of Public Health decided in 2005 to
  keep the NMLCP, NTP and HIV/AIDS programs
  vertical at the central and provincial levels and
  fully integrated below the provincial level i.e.
  BPHS levels

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Control of Malaria in the BPHS HEALTH FACILITY
LEVEL INTERVENTIONS AND SERVICES PROVIDED
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Problems encountered in integrating malaria in
the BPHS

• ACT
• the 1st version of the BPHS was published in
  March 2003 while the national malaria treatment
  protocols were approved and published in August
  2003. Though both are national documents, erratum
  to include the ACT was strongly rejected.
• Arguments Too late to review, cost implications,
  ACT needs additional research (MSH/REACH)
• To promote the newly developed protocols i) WHO
  and unicef partially bridged the gap in 2004 and
  2005. ii) The national malaria strategic plan
  strongly advocated for the ACT. Iii) Submission
  to R5 of GFATM proposal appealed for gap bridging
  for 5 years (2006-2010)
• Finally ACT was included in the revised 2nd
  version (2005).

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Antimalarial Drugs for the BPHS by type of
facilities (in 2005 version)
¹ Presumptive treatment for unconfirmed malaria
is chloroquine and sulfadoxine/Pyrimethamine,
before referral to CHC for confirmatory
diagnosis. ² Quinine -2nd line treatment and
treatment for severe/complicated malaria require
laboratory confirmation ³ Artemesinin combination
therapy Artesunate SP (fansidar) as first line
treatment for laboratory confirmed falciparum
malaria. 4 In BHCs where diagnostic services are
available.
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Problems encountered in integrating malaria in
the BPHS

• Laboratory services
• HP and BHC levels do not include lab services.
  Cost implication is the main reason.
• Valid arguments from malaria people to bring
  down the lab services to BHC level i) the
  majority of malaria victims live in remote
  underserved areas ii) very high degree of PF
  resistance to CQ (80) and moderate resistance to
  SP (12) iii) ACT requires lab confirmation iv)
  Afghanistan is predominantly a vivax malaria
  country (almost 90 of the malaria burden)
• The national malaria strategic plan strongly
  called for lab services at the BHC level. The CCM
  agreed to pilot the expansion of the lab service
  to 10 BHCs in 3 malarious provinces (to be
  established and run from GF R5)
• Suggestion from MSH/REACH to research the use of
  RDTs (technically as well as financially) as an
  alternative for the lab services

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Training on malaria

• Contracts with the BPHS implementers do not
  include funds for upgrading the knowledge and
  skills of the staff.
• With the start of the BPHS in 2003, the NMLCP in
  collaboration with WHO AFG organized national
  master trainers (TOT) programs for in-service and
  pre-service training on malaria for senior
  physicians, university lecturers and lab
  technicians. Two WHO visiting consultants
  facilitated the training programs (Prof. H.
  Gilles and Prof. M. Nateghpour)

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Training on malaria

• Planned
• Formulation of a national plan for MCP capacity
  development (Dr. Beales, August 06)
• Training on operational research for
  evidence-based interventions (Dr. Amal Bassile,
  Nov. 06)
• Intensive training program for BPHS providers
  (from R5 of the GFATM)

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(No Transcript)
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Strengthening malaria surveillance and ME
(example for smooth integration)

• Nomination of 3 doctors from NMLCP, HMIS and GFMU
  as national focal points for Malaria/ME in the
  BPHS and EPHS
• Development of Malaria/ME indicators for BPHS
  and EPHS by the ME advisory group (MOPH,WHO,
  GFMU, JHU and MSH/REACH)
• Development of integrated monitoring and
  supervision checklist for malaria, TB and
  HIV/AIDS (jointly by the relevant taskforces)
• .
• Development of integrated database for Malaria,
  TB and HIV/AIDS by WHO for the national HMIS

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Other aspects where NMLCP and BPHS are expected
to smoothly collaborate

• Promotion of Home-based Management of malaria (to
  be piloted in 3 BDN) projects
• The integrated Quality Control for laboratory
  services (malaria, TB and HIV/AIDS)
• Collaboration in the detection, reporting and
  response to malaria outbreaks
• The routine monitoring of the therapeutic
  efficacy of the anti-malarial drugs
• IEC
• Distribution of ITNs