Improving Access to treatment in Myanmar

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1 MMV Stakeholders Meeting, New Dheli, 7-8 November, 2012 Improving Access to treatment in Myanmar Dr. Thar Tun Kyaw Deputy Director ( Malaria ) Programme Manager National Malaria Control Programme Ministry of Health, Myanmar

2 History 1950 Anti-malaria Programme Malaria Control Demonstration Project Malaria Eradication Programme Eradication Programme Implemented Malaria Control Programme Vector Borne Disease Programme

3 Malaria Mortality Rate per 100,000 population in Myanmar ( )

4 Population living under malaria risk areas in Myanmar, % 20% High Risk 18% Modrate Risk Low Risk 23% Free

5

6

7

8 These are the population at risk National Races Pregnant Women & <5 yr Children Children Seasonal Migrant Workers/ Farmers Miners Forest-related workers

9 Malaria Species in Myanmar (6 Years Average ) P.ovale % 6, 0.004% P.malariae 0.19 % 313, 0.190% Mix % 2843, 1.723% P.vivax % P.falciparum % Pf Pv Pm Po Mix

10 Malaria Vector in Myanmar Main Vector An. minimus An. dirus Local Vector An. Annularis (in Rakhine) An. Sundaicus (in Rakhine & Taninthayi) Secondary vector An. culicifacies An. aconitus An. philippinensis An. hyrcanus An. maculatus

11 Community based Malaria Control in Myanmar Treatment seeking behavior among malaria patients in village level Before intervention Shop to buy medicine Yanku(Quack) Home Medicine After intervention Shop to buy medicine Yanku (Quack) Home Medicine Fever Patient Health Center Fever Patient Health Center Incomplete treatment Relapse, recrudescence Complete treatment Fake Medicine High Cost Drug resistance High Mortality Low Cost Low Mortality Reliability of BHS and National Malaria Control

12 Malaria Volunteers in NMCP Malaria control programme started Malaria Volunteer since In the Eastern Shan State near the border with Thailand. Firstly, PDP ( Primary Drug Provider ) and then CORP ( Community Owned Resource Person ). Now, already trained 6100 malaria volunteers and trainings for volunteer is on going.

13 Criteria for selection of villages 1. Stratum 1 a high malaria risk area 2. Village in which health staff is non-residential 3. Crash immunization area with highly endemic malaria 4. Village in high risk area in where Developmental project is being carried out

14 Criteria for selection of volunteers who participate in malaria control 1. Must be resident of village 2. Acceptability by community 3. Willingness of volunteers 4. Priorities are given to volunteers (CHW, AMW, Ten household worker, ANMW, RH promoter, local NGOs, other primary health care providers etc.) 5. No gender preference years to 50 yrs of age 7. Can read and write Myanmar language and can speak local dialect 8. Occupation not specify ( family has primary source of income )

15 Key activities of volunteers Provision of health education to community Impregnation of bed nets owned by community Assists the health staff during the distribution of LLIN in the village Provision of early diagnosis and treatment of uncomplicated malaria cases Referral of severe and complicated malaria patients to nearest hospital To report immediately to the health centre when there is unusually high occurrence of malaria or febrile patients in the community.

16 Early diagnosis and treatment of Allow to use RDT malaria cases Allow to treat the uncomplicated malaria cases according to national treatment guidelines Encourage to refer the cases (complicated malaria, malaria with pregnancy and <1yr old) But it is too far to reach within 24 hrs allow to treat <1yr and pregnant women

17 Community Involvement for sustainability of Volunteer Community cannot support in regular basis Sometimes in kinds Incentives like perdiem and travel allowance when they came to town for submission of report or referral of patients Some INGOs give award (in cash or in kind) depending on their performance (especially PSI)

18 Challenges in Sustaining the Volunteers Long term sustainability is very hard Because of many reasons such as; - economic reasons change of work/ change of work place - social reasons married and move to other village - very remote area very low education level to be trained as new volunteer

19 Private Medical Practitioners Myanmar Medical Association Quality Diagnosis and Standard Treatment of Malaria (QDSTM) Project 120 townships through Medical practitioners Fixed and Mobile clinics in endemic areas PSI Franchising clinics 220 townships Not only malaria but also reproductive health

20 Myanmar Artemisinin Resistance Containment Myanmar Artemisinin Resistance Containment frame work was developed MARC frame work was endorsed in April 2011 In line with the WHO Global Plan of Artemisinin Resistance Containment ( GPARC )

21 Target Areas

22 Goal of MARC To prevent or at minimum, significantly delay the spread of artemisinin resistance parasites within the country and beyond its border To reduce transmission, morbidity and mortality of Plasmodium falciparum malaria, with priority to areas threatened by artemisinin resistance

23 Objectives 1. To strengthen and improve access to and use of early diagnosis and quality treatment according to the national treatment guidelines 2. To decrease drug pressure for selections of artemisinin resistance malaria parasites by stopping the use of Artesunate Monotherapies and sub-standard/fake drugs

24 3.To limit the transmission of malaria by intense mosquito control and personal protection 4.To increase migrant/mobile populations access to and use of malaria diagnosis, treatment and vector control measures including personal protection 5. To support containment of artemisinin resistant through advocacy and behavioural change communication/ information, education and communication 6.To conduct studies and do operational research to support the development of evidence- based policies and strategies 7.To provide effective management and coordination to enable rapid and high quality implementation of containment strategy

25 Expected Output 1. Achieve 100 % coverage of risk population priority to resistant areas, through multisectoral approach 2. Decrease drug pressure through rapid elimination of AMT by replacement with ACT 3. Maximize effectiveness of transmission reduction by IRS, ITN/LLINs and other personal protection and aims at 100% coverage of ITN/LLINs

26 Expected output 4. Target interventions at all age groups of migrants 5. Intensify malaria surveillance to detect new foci of artemisinin resistance and mapping of migrants.

27 Village-wise Microstratification Malaria is focal disease; thus, it is essential control to identify the areas and population at risk, which must be prioritized preventive measures NMCP, WHO and UNICEF developed approached to microstratification 150 townships were finished microstratification activities

28 Stratum in Microstratification Stratum 1a. High malaria risk area Stratum 1b. Moderate malaria risk area Stratum 1c. Low malaria risk area Stratum 2. Potential malarious area Stratum 3. Non malarious area

29 National Anti-malaria Treatment Policy Artemisinin based Combination Therapy (ACT) was endorsed as a first line drug for P. falciparum malaria since Revised in 2008 and Recommended ACT Artemether+Lumefantrine, Artesunate+Mefloquine DHA + PPQ

30 Treatment Policy ( cont: ) Single dose of Primaquine is recommended as a gametocidal drug for falciparum malaria P. vivax malaria is treated with Chloroquine 3 days followed by Primaquine for 14 days. For severe and complicated malaria parentral artemisinin is choiced and this should be replaced by oral admi the patient administration as soon as patient is able to swallow drug without vomiting

31 Treatment Policy ( cont: ) treatment guidelines for Malaria volunteers in the villages was developed For the referral of severe and complicated cases pre-referral treatment should be given by the health care providers including Volunteers and BHS

32 Key Challenges NMCP Availability of Timely reporting and analysis Logistic issues with seasonal and remote geographical settings Sharing Information and updates among partners Population mobility producing many malaria problems including outbreaks Emergence of drug resistance Pf malaria Adequate & Continuous funding

33 Best Practices in NMCP Team spirit well practiced as VBDC team Deeply inspired with PHC approach most of the key interventions go through BHS staff Community based malaria control interventions take place Well cooperated with the research institutions for TES and other studies Good collaboration with national and international Partners

34 Thank You

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