#1UNITY FREEDOM JUSTICE Country experiences with pre-referral interventions and referrals August 2023 COUNTRY PRESENTATION By Anitta Kamara - NMCP - SIERRA LEONE#2Presentation outline • Introduction- country profile • SLNMESP Objectives • Malaria Burden in Sierra Leone • Summary of programme's performance • Rectal Artesunate Malaria Suppository (RAMS) strategy • RAMS implementation experiences • Specific lessons learned and experiences • Challenges • Recommendations •Way forward 10#3INTRODUCTION COUNTRY PROFILE 2020 Population Estimate: 8,282,553 (projected from 2015 national census) Key Health Indicators 92/1000 Live Births Infant Mortality Rate Child Mortality Rate 156/1000 Live Births Among the highest five countries globally •Malaria is still the leading cause of morbidity and mortality Leading causes of <5 deaths: malaria, pneumonia, diarrhoea •Malaria is endemic with stable and perennial transmission in Sierra Leone •Current Slide Positive Rate is 22% (MIS, 2021) West Area Urban 6% Bombali 38% Koinadugu 58% Kambla Port Loka 59% Tonkolili 56% Kono 38% West Area Rural 35% Moyamba 4099 Во 40% Kenema 38% 6%-30% | 31% - 40% Bonthe 26% 41% - 50% Pujehun 47% SOURCE: SLMSP 2021 - 2025; SLMIS 2021 51% -59% Kailahun Sierra Leone Malaria Prevalence: 22%#4www - There are 1.894 million annual malaria-related outpatient visits, I million of which are from CU5 • 22% of children ages 6-59 months tested positive for malaria via microscopy (SLMIS 2021) 3% of children age 6-59 months has severe anemia (SLMIS, 2021) Severe Malaria cases 2.2% - 2020 Jan - Dec (HMIS-MOHS 2020). Malaria burden#5VISION SLNMESP 2021 – 2025: Sierra Leone has Committed to Reduce New Malaria Infections Vision: Accelerate the implementation of Malaria Control Interventions towards a Malaria-free Sierra Leone. Mission To direct and coordinate efforts towards a malaria-free Sierra Leone through effective partnership This will require concerted actions from government, health professionals, partners, communities, families and individuals to ensure uptake of preventive measures and timely treatment for all#6SLNME Strategic Plan objectives 1. Reduce malaria mortality rates by at least 75% by 2025 2. Reduce malaria case incidence by at least 75% by 2025 3. Increase the percentage of the population practicing at least three recommended malaria prevention and control behaviors to 90% by 2025 4. strengthen malaria surveillance and use of malaria information to improve decision-making for programme performance 5. Ensure timely and adequate supply of quality-assured malaria commodities to public and private health facilities at all levels by 2025 6. strengthen and maintain capacity for programme management, coordination, and partnership to achieve malaria programme performance at all levels by 2025 7. Improved mobilisation of resources and maximise the efficient use of available resources for greater public health impact by 2025#7Summary of programme's performance#8Items Parasite prevalence: Proportion of children aged 6-59 months (<5 years of age) with malaria infection Malaria case incidence: number and rate per 1000 people per year Baseline/Year Year and Result Source 2021 2022 40% (2016) 22% 22% SLMIS 2021 303 (2019) 222 HMIS Malaria admissions : number and rate per 10,000 persons per year 51 (2019) 18 18 HMIS Malaria test positivity rate 61.24 (2019) 62.3% 62.4% HMIS Proportion of admissions for malaria 38.3% (2019) 22% 27.5% HMIS Confirmed malaria cases (microscopy or RDT): rate per 1000 persons per year 296.6 (2019) 234 211 HMIS Reported malaria cases (presumed and confirmed) 2,432,609 (2019) 2,043,818 1,894,779 HMIS Inpatient malaria deaths per year: rate per 100,000 persons per year 17.8 (2019) 18 18 HMIS Malaria mortality: number and rate per 100,000 persons per year 34.5 (2019) 19 20 HMIS Proportion of inpatient deaths due to malaria 38.3% (2019) 11.8% 12.7% HMIS#9RAMS Strategy Implementation#10RAMS roll out nationwide GUINEA Koinadugu Karene Falaba Kambia North West Region Bombali Port Loko Western Alea Urb Western Area Urb Western Area Rur Western Area ATLANTIC OCEAN Northem Region Kono Tonkolili Eastern Region Kailahun Moyamba Bo Kenema Southern Region Bonthe Bonthe Pujehun 20 40 LIBERIA 00 N A 120 160 Kilometers#11RAMS Overall Strategy • The use of Rectal Artesunate Malaria Suppository (RAMS) as part of strengthened severe malaria case management systems through increased demand, thereby reducing severe malaria case fatality rates in children <6 years. The Guidelines for Malaria Case Management recommends the use of RAMS as pre-referral treatment for severe malaria for the <6 years old children at community and PHU levels.#12Pre-referral Treatment Single dose treatment Artesunate (i.m) ➤ Artesunate by rectal administration ➤ Artemether (i.m) RAMS is administered at the PHU and referred to a district hospital REFERRAL PATHWAY - HEALTH CENTRE Periphery Health Unit CHP/MCHP/CHC Referral facility#138,000 7,000 6,000 5,000 4,000 3,000 2,655 2,401 2,000 1,000 0 Referrals and deaths (2020-2023) 1,492 3,955 2,695 1,133 2020 2021 Referals RAMS Deaths 7,100 4,017 2022 1,339#14LMIS (reporting on logistics data) Reporting - Paper based at PHU level, Collation of Paper based reports from PHU at District level Use of DHIS2 at district and hospital level. Information from DHIS2 can be accessed by all managers. Data from DHIS2 is analyzed on a quarterly basis to compare forecast quantities to actuals#15RAMS implementation at PHU level Quantification and forecasting for 2021 to 2025 developed in August 2020. Review of supply plan on a quarterly basis. At least one PHU staff trained on the following: correct administration of RAMS to eligible children Effective referrals . · Severe malaria case management . Data entry and referral form best practices Onsite mentorship, coaching and supportive supervision of staff done by DHMTs when funds are available and by NMCP on a quarterly basis. Job aids and treatment algorithms are provided to health facilities SLISH W 9#16. CHWs issue referral tickets to take children to PHU PHU staff fills referral form and articulates referral process (counseling) Referring facility informs the ambulance staff with prompts about the patient that requires referral. - - Ambulance release requires a call from the referring facility, clarifying who is being referred, for what and what prior treatment already administered to the patient.#17Antimalaria commodities - At the PHU level (RAMS) Availability of RAMS in the facilities RAMS are provided based on % expected number of severe malaria cases out of the population - no consumption data - At the receiving health facility - hospital ● ● Antimalarial - Injectable artesunate, injectable artemether are available Laboratory and trained laboratory technicians experienced in performing malaria microscopy are available#18Key requirements to ensure RAMS is an effective part of the continuum of care Training of Hospital staff on severe malaria including referrals • Provision of requisite supplies - injectable artesunate, Artemether+Lumefantrine, laboratory supplies, supportive treatment (vein canula, IV infusion, etc) • Functional blood bank#19GUILF RFFCAME Specific lessons learned, experiences or innovations Arsenal RW#20Specific lessons learned and experiences • PHUS equipped with antimalarial commodities including severe malaria medicines to provide quality service. • Ambulance services available for referrals. Cost effective delivery- the RAMS is not bulky and so use the opportunity for the PHU staff to take them along after the training or PHU/DHMT in charges meeting. Community awareness and sensitization to support referrals. Quality training of staff increases health workers confidence and compliance to malaria case management treatment guidelines to allow for actualization of the impact of RAMS on U6 children. Setting up bye laws by community authorities for supporting referrals Village Savings and Loans (VSL):- use the fund to support families in case of referrals Supportive supervision: Regular Supportive supervision is key to ensure adherence to guidelines to prevent monotherapy and irrational utilization of RAMS.#21Key Challenges Health systems challenges 1. Only 30% functional ambulances per district to do referrals and are challenged with its operations - fuel???? Ambulance not always almost available when called upon. 2. Recording of case referrals not adequately done - a significant number of referrals are not recorded completely. - No tracker to follow-up on referrals. - Feedback mechanism is a challenge due to multiple reasons including PHU staff being overburdened. 3. Unavailability of adjuvant therapy at the hospital level 4. Partially functioning blood bank Transportation constraints result in missed opportunities and sometimes parents or caregivers take their children to traditional headers.#22Other challenges Key Challenges 2 Topography- difficult terrain, rivers, mountainous communities are major barriers to accessing treatment. -Patients walk on foot, use bike, cross bridges/rivers, use hammock to transport children to HF during rainy season. -Some MCHPs/CHPS cannot be reached due to bad road network • Men make decisions on referral but they are not always available to make such decisions - leading to delays in referrals. Poor connectivity makes communication challenging.#23● • Recommendations Continue mentorship and coaching of health staff Equip hospitals to manage severe malaria appropriately - provision of adjuvant therapy, etc Train health staff to manage severe malaria cases effectively. Engage the hospital management on how best to ensure the ambulances are working Functional referral system: Functional and robust referral systems are imperative for the survival of children. A functional ambulance system in place to ensure that children administered with RAMS are able to reach the health facility on time for further care and treatment. Blood bank should be up and running.#24• Way forward Invest in the health system - Build a robust and functioning health system#25COMMENTS CONTRIBUTIONS QUESTIONS ?2