A new initiative will deliver enhanced malaria prevention to children under two across Africa through a WHO-recommended but under-implemented intervention

Posted septembre 15, 2021
Impact Area Malaria

Originally published on unitaid.org.

A safe, effective and affordable intervention for preventing malaria in infants (IPTi), has been recommended by the WHO since 2010, yet access remains limited.
The initiative seeks to maximize the benefits of the antimalarial intervention by increasing the number of doses administered and extending coverage beyond the currently recommended 9 months to protect children in their first two years of life.
Through a country-led, co-design process, the project will develop scalable IPTi delivery models and generate compelling evidence to catalyze wide-spread roll-out of this life-saving intervention in high-burden countries across Africa. Four countries, Benin, Cameroon, Côte d’Ivoire and Mozambique will initially be targeted by this initiative.

Geneva / Washington, DC, 15 September 2021 – To kick-start progress against malaria and improve child health in Africa, a new initiative, funded by Unitaid and led by Population Services International (PSI), will support widespread adoption of an effective but underutilized prevention method that could avert 6.7 million cases of malaria and anemia in children under two by 2030.

Intermittent Preventive Treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a safe, affordable and effective intervention shown to reduce rates of malaria and anemia in children under one year of age by 30 percent and 21 percent respectively. The World Health Organization (WHO) recommended IPTi for use in 2010, yet the intervention has not been widely adopted in Africa.

With a US $35 million investment from Unitaid, the Intermittent Preventive Treatment in infants – Plus (IPTI+) project will develop scalable models of IPTi+, an innovation on the WHO-recommended IPTi, that expands the number of preventive doses of SP administered to children and extends coverage of IPTi through a child’s second year of life. Over the life of the project, the IPTi+ project will administer an estimated 2.5 million doses of SP for IPTi+ protecting over half a million children under two years of age from malaria and anemia.

Brought to scale, IPTi+ will help reignite progress against malaria in the Africa region, where 94 percent of all malaria cases and deaths occur each year. Progress in reducing malaria rates has plateaued in recent years and the COVID-19 pandemic has caused additional setbacks and interruptions to malaria efforts across the continent.

IPTi+ targets a crucial population: children under the age of five accounted for nearly 70% of the estimated 409,000 malaria deaths globally in 2019. Children under two years of age are among the most vulnerable to malaria; half of child deaths from malaria (54%) are estimated to have occurred in children under the age of two.[1]

“We cannot afford to leave any effective tool unused in our fight against malaria, or we will see our hard-won progress slip away. Unitaid is pleased to announce this major effort to reach hundreds of thousands of young children with IPTi+ — a highly effective but greatly under-utilized intervention for malaria prevention. This latest investment rounds out Unitaid’s work to innovate on all the current antimalarial interventions and improve access we can reignite the fight against malaria and drive down the burden of disease,” said Dr. Philippe Duneton, Executive Director of Unitaid.

Widespread adoption of IPTi has faced challenges including misperceptions about the effectiveness of the recommended drug, sulfadoxine-pyrimethamine, a lack of evidence on its efficacy in areas of moderate to high resistance, and a lack of enabling policies. As administration of IPTi can fall within the remit of child health, malaria and immunization programs, unclear delineation of responsibilities has also contributed to unsuccessful adoption.

The IPTI+ project will address these challenges at a country and global level to accelerate adoption and scale-up of IPTi+ with sulfadoxine-pyrimethamine. At the country-level, the IPTi+ project will facilitate a country-led co-design process to design IPTi+ models specific to each country in Benin, Cameroon, Côte d’Ivoire and Mozambique. These four countries represent diverse health systems, malaria transmission, SP resistance, routine health service access and implementation of other seasonal antimalarial interventions.

“PSI is proud to be working with the Ministries of Health in Benin, Cameroon, Cote d’Ivoire and Mozambique, as well as county-level and global malaria partners, and the London School of Hygiene & Tropical Medicine, to accelerate adoption and scale-up of IPTi+. PSI and our partners will engage and convene communities and stakeholders to co-design country-specific IPTi+ models that overcome known barriers to uptake; shape mixed health systems to bring IPTi+ closer to Sara, PSI’s archetypal consumer, and her family; and generate evidence on the impact of IPTi+,” said Karl Hoffman, President and CEO of PSI.

To ensure scalability of the IPTi+ models being developed, Unitaid is also expanding the scope of an existing and complementary grant, implemented by the not-for-profit product development partnership Medicines for Malaria Venture (MMV). In addition to collaborating with the IPTi+ Project to deliver existing formulations of SP, MMV will work with selected African manufacturers to support local production of properly dosed, dispersible and quality-assured formulations of SP that are suitable for children to future-proof supply of the medicine.

The project will collect evidence on impact, cost-effectiveness and feasibility of IPTi+ across variable settings to inform scale-up in target countries and beyond. In addition to piloting implementation models in the four focus countries, the IPTi+ project will generate policy, economic and suitability evidence on IPTi+ in three additional countries.

“In the past five years, annually, there have been approximately 4 million malaria cases and 400,000 hospital admissions for malaria in children under 5 years in Cameroon. To address this, we hope that introducing IPTi+, in addition to the use of long-lasting insecticide nets, will enable us to further reduce the malaria incidence and hospital admissions contributing to healthier and happier families. The National Malaria Control Program is excited to work with the IPTi+ Project and two renowned public health institutions, PSI and LSHTM, to introduce and increase access to IPTi+ and ensure accurate monitoring and evaluation of IPTi+ in Cameroon,” said Dr. Dorothy Fosah Achu, Permanent Secretary, National Malaria Control Program, the Ministry of Public Health, Cameroon.

PSI will coordinate the project co-design and implementation in collaboration with Ministries of Health and country teams. The London School of Hygiene & Tropical Medicine (LSHTM) will lead research that will generate evidence to inform country and global-level adoption and scale-up of IPTi+.

[1] Malaria deaths among children under age 2 as a proportion of malaria deaths among children under age five estimated from Global Burden of Disease 2019 data.

About Unitaid
Unitaid is a global health agency engaged in finding innovative solutions to prevent, diagnose and treat diseases more quickly, cheaply and effectively, in low- and middle-income countries. Its work includes funding initiatives to address major diseases such as HIV/AIDS, malaria and tuberculosis, as well as HIV co-infections and co-morbidities such as cervical cancer and hepatitis C, and cross-cutting areas, such as fever management. Unitaid is now applying its expertise to address challenges in advancing new therapies and diagnostics for the COVID-19 pandemic, serving as a key member of the Access to COVID-19 Tools (ACT) Accelerator. Unitaid is hosted by the World Health Organization.

About Population Services International (PSI)
PSI is a global nonprofit organization focused on encouraging healthy behaviors and delivering affordable health products and services around the world. We bring innovation to scale through our presence in 40+ countries and a network of over 10,000 health clinics and pharmacies. PSI takes a business approach to saving lives, designing effective, scalable and sustainable solutions to the world’s biggest challenges in healthcare.

About the London School of Hygiene & Tropical Medicine (LSHTM)
LSHTM is a world-leading centre for research, postgraduate studies and continuing education in public and global health. LSHTM has a strong international presence with over 3,000 staff and 4,000 students working in the UK and countries around the world, and an annual research income of £180 million. LSHTM is one of the highest-rated research institutions in the UK, is partnered with two MRC University Units in The Gambia and Uganda, and was named University of the Year in the Times Higher Education Awards 2016. Our mission is to improve health and health equity in the UK and worldwide; working in partnership to achieve excellence in public and global health research, education and translation of knowledge into policy and practice.

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Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

By: Fana Abay, Marketing and Communications Director, PSI Ethiopia

In rural Ethiopia, women and girls often face significant barriers in accessing healthcare facilities, which can be located hours away. Moreover, there is a prevailing stigma surrounding the use of contraception, with concerns about potential infertility or the perception of promiscuity. To address these challenges, the Smart Start initiative has emerged, linking financial well-being with family planning through clear and relatable messaging that addresses the immediate needs of young couples—planning for the lives and families they envision. Smart Start takes a community-based approach, utilizing a network of dedicated Navigators who engage with women in their localities. These Navigators provide counseling and refer interested clients to Health Extension Workers or healthcare providers within Marie Stopes International-operated clinics for comprehensive contraceptive counseling and services.

In a significant development, PSI Ethiopia has digitized the proven counseling messaging of Smart Start, expanding its reach to more adolescent girls, young women, and couples. This approach aligns with the priorities set by the Ethiopian Ministry of Health (MOH) and is made possible through funding from Global Affairs Canada. The interactive and engaging digital messaging has revolutionized counseling services, enabling clients to make informed and confident decisions regarding both their finances and contraceptive choices.

Clients who received counseling with the digital Smart Start tool reported a higher understanding of their options and were more likely to choose contraception (74 percent) compared to those counseled with the manual version of Smart Start (64 percent). Navigators also found the digital tool more effective in connecting with clients, leading to higher ratings for the quality of their counseling.

By December 2023, PSI Ethiopia, working in close collaboration with the MOH, aims to reach over 50 thousand new clients by leveraging the digital counseling tool offered by Smart Start. This innovative approach allows for greater accessibility and effectiveness in providing sexual and reproductive health services, contributing to improved reproductive health outcomes for women and couples across the country.

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For example, in Mali, access to formal health services remains challenging, with four in ten people living several miles from the nearest health center, all without reliable transportation or access. In 2009, the Ministry of Health adopted a community health strategy to reach this population. The U.S. President’s Malaria Initiative (PMI) Impact Malaria project, funded by USAID and led by PSI, supports the Ministry with CHW training and supervision to localize health services.

In 2022, 328 thousand malaria cases were recorded by CHWs); 6.5 thousand severe malaria cases were referred to health centers, according to the national health information system.

During that time, the PMI Impact Malaria project (IM) designed and supported two rounds of supportive supervision of 123 CHWs in their workplaces in the IM-supported regions of Kayes and Koulikoro. This included developing and digitizing a standardized supervision checklist; and developing a methodology for selecting which CHWs to visit. Once a long list of CHW sites had been determined as accessible to supervisors for a day trip (including security reasons), the supervisors telephoned the CHWs to check when they would be available to receive a visit [as being a CHW is not a full-time job, and certain times of the year they are busy with agricultural work (planting, harvesting) or supporting health campaigns like mosquito net distribution].

Supervisors directly observed how CHWs performed malaria rapid diagnostic tests (RDTs) and administered artemisinin-based combination therapy (ACT). They recorded CHW performance using the digitized checklist, interviewed community members, reviewed records, and provided on-the-spot coaching. They also interviewed the CHWs and tried to resolve challenges they expressed, including with resupply of commodities or equipment immediately or soon afterwards.

Beyond the observed interactions with patients, supervisors heard from community members that they were pleased that CHWs were able to provide essential malaria services in the community. And the data shows the impact.

In IM-supported areas of Mali, 36% of CHWs in the first round were competent in performing the RDT, which rose to 53% in the second. 24% of CHWs in the first round compared to 38% in the second were competent in the treatment of fever cases and pre-referral counseling. Between both rounds, availability of ACT increased from 80 percent to 90 percent.

Supportive supervision with interviews and observations at sites improved the basic competencies of CHWs between the first and second rounds, and additional rounds will help to understand the longer-term programmatic benefits.

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To share the journey to market-based sanitation, representatives of the Ethiopian Ministry of Health and the USAID Transform WASH team took to the stage at the UN Water Conference in 2023.

“Rather than relying on traditional aid models that often distribute free or heavily subsidized sanitation products, market-based sanitation creates sustainable and affordable solutions, integrating market forces and supporting businesses to grow.”

— Michael Negash, Deputy Chief Party of T/WASH

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Here’s how we got there.

Seven years ago, the landscape of HIV self-testing lacked global guidelines, and only the U.S., the UK and France had policies in place that allowed for HIV self-testing. High disease burdened countries in low-and-middle-income-countries (LMICs) lacked evidence and guidance for HIVST despite major gaps in HIV diagnosis.

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PSI and Matchboxology first piloted the model in 2020 with implementing partners BroadReach Healthcare and Right to Care as well as the Department of Health in three districts of South Africa. Since then, the model has been rolled out by eight implementing partners in South Africa, employing more than 300 coaches and reaching tens of thousands of men living with HIV. To date, the model has linked 98 percent of clients to care and retained 94 percent of them, in sharp contrast to the estimated 70 percent of men with HIV in South Africa who are currently on treatment.

Given the success of the program, South Africa’s Department of Health and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) have each embraced the Coach Mpilo model in their health strategy and are embedding it in their strategies and programs.

“The men we spoke to [while I was traveling to South Africa for a PrEP project with Maverick Collective by PSI] were not only decidedly open to the idea of taking a daily pill…many were willing to spread the word and encourage friends to get on PrEP too. We were able to uncover and support this new way forward because we had flexible funding to focus on truly understanding the community and the root barriers to PrEP adoption. This is the philanthropic funding model we need to effectively fight the HIV epidemic, and it’s beneficial for all sorts of social challenges.”

– Anu Khosla, Member, Maverick Collective by PSI

simplifying consumers’ journey to care in Vietnam

By: Hoa Nguyen, Country Director, PSI Vietnam

In late 2022, with funding from the Patrick J. McGovern Foundation, PSI and Babylon partnered to pilot AIOI in Vietnam. By combining Babylon’s AI symptom checker with PSI’s health provider locator tool, this digital health solution analyzes symptoms, recommends the appropriate level of care, and points them to health providers in their local area. The main goal is to support people in low-income communities to make informed decisions about their health and efficiently navigate the healthcare system, while reducing the burden on the healthcare workforce. The free 24/7 service saves people time and subsequent loss of income from taking time off work and from having to pay unnecessary out-of-pocket expenses. Under our global partnership with Meta, PSI launched a digital campaign to put this innovative product in the hands of people in Vietnam. By the end of June 2023 (in the nine months since product launch), 210 thousand people accessed the AIOI platform; 2.4 thousand people created personal accounts on the AIOI website, 4.8 thousand triages to Symptom Checker and linked 2.2 thousand people to health facilities.

Babylon’s AI symptom checker and PSI’s health provider locator tool captures real-time, quality data that supports health systems to plan, monitor and respond to consumer and provider needs. But for this data to be effective and useable, it needs to be available across the health system. Fast Healthcare Interoperability Resources (FHIR) standard provides a common, open standard that enables this data exchange.
PSI’s first consumer-facing implementation of FHIR was launched in September 2022 as part of the Babylon Symptom Checker project in Vietnam, enabling rapid alignment between PSI and Babylon’s FHIR-enabled client records systems. PSI already has several other consumer health FHIR implementations under active development in 2023, including PSI’s collaboration with the Kenya MOH to launch a FHIR-enabled WhatsApp national health line for COVID-19 health information. PSI will also look to adopt and scale health workforce-facing FHIR-enabled tools, such as OpenSRP2, which will be piloted in an SRH-HIV prevention project in eSwatini in partnership with Ona by the end of 2023.

— Martin Dale, Director, Digital Health and Monitoring, PSI

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Building on our extensive private sector malaria surveillance work under the BMGF-funded GEMS project in the Greater Mekong Subregion, PSI implemented a case-based disease notification system using social media channels to overcome the limitations of paper-based and custom-built mobile reporting tools. These chatbots, accessible through popular social media platforms like Facebook Messenger and Viber, proved to be user-friendly and required minimal training, maintenance, and troubleshooting. The system was implemented in more than 550 clinics of the Sun Quality Health social franchise network as well as nearly 470 pharmacies. The captured information flows to a DHIS2 database used for real-time monitoring and analysis, enabling rapid detection of potential outbreaks. Local health authorities receive instant automated SMS notifications, enabling them to promptly perform case investigation and outbreak response.

In 2022, private clinics reported 1,440 malaria cases through the social media chatbots, while community mobilizers working with 475 private providers and community-based malaria volunteers reported more than 5,500 cases, leading to the detection of two local malaria outbreaks. Local health authorities were instantly notified, allowing them to take action to contain these surges in malaria transmission. During the same time, pharmacies referred 1,630 presumptive tuberculosis cases for confirmatory testing – a third of which were diagnosed as tuberculosis and enrolled into treatment programs.

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The shortage of skilled health workers is widely acknowledged as a significant barrier to achieving Universal Health Coverage. To address this challenge, PSI supported ministries of health to develop a digital ecosystem that brings together stewardship, learning, and performance management (SLPM). The ecosystem enhances training, data-driven decision-making, and the efficiency of healthcare delivery.

Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities. The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

A new initiative will deliver enhanced malaria prevention to children under two across Africa through a WHO-recommended but under-implemented intervention

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Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

Building community health worker capacity to deliver malaria care

Taking a market-based approach to scale sanitation in Ethiopia

Promoting self-managed care like Self-testing and Self-Sampling

Using peer coaches to counter HIV stigma in South Africa

simplifying consumers’ journey to care in Vietnam

Engaging the private sector for disease surveillance in Myanmar

Training health workers in Angola

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