This document discusses challenges with pharmaceutical management of malaria in pregnancy in several African countries. It notes that while policies for intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) and distribution of insecticide-treated nets (ITNs) have been widely adopted, implementation faces several hurdles. These include frequent stockouts of SP, ITNs, and antimalarial treatments at health facilities. Other challenges include weak quantification and procurement planning, poor inventory management and distribution systems, and inadequate training of healthcare workers. Addressing these health systems issues through improved governance, financing, supply chain management and information systems is needed to better realize policies aimed at controlling malaria in pregnancy.

1. Pharmaceutical
Management for the
Control of Malaria in
Pregnancy
Rima Shretta
May 2, 2012
CORE meeting, Wilmington, Delaware

2. Background: IPTp
• By 2010, 37 countries had adopted IPTp (WMR, 2011)
• SP for IPTp is free for pregnant women and available at health
facilities during ANC
• Household survey data from 13 African countries 2008–2010
indicated that women who received two doses of IPTp during
pregnancy in ranged from 4% in Namibia to 68% in Zambia
(average: 24%)
• Data on IPTp coverage from national surveys remains limited

3. Background: Insecticide Treated Nets
• A total of 82 countries, of which 38 are in the African Region,
distribute ITNs free of charge to for all persons at risk for
malaria in accordance with WHO recommendations
• Mass distribution was the primary channel of distribution in
followed by distribution through antenatal clinics
• Proportion of households owning at least one ITN in sub-
Saharan Africa has risen from 3% in 2000 to 50% in 2011
• Despite the investment in LLIN distribution, global coverage
still below the 80% target set by RBM and 85% by PMI

4. Background: Treatment
• 11 of 13 countries surveyed in 2007-8, fewer than 15% of
children received an ACT. WMR (2011) estimates that about
65% of treatment needs are fulfilled for patients attending
public health facilities (children)
• Limited data available for pregnant women for ACTs and
quinine
• Coverage still below the 80% target set by RBM and 85% by
PMI
• Anectdotal data: high percentage of quinine use for
uncomplicated malaria in children and non-pregnant adults

5. Challenges
• Availability of SP: 0-100% (PMI)
• Frequent and long stock-outs of SP. Data from PMI:
• Stock outs greater than 3 days: SP: 0-37.5% facilities
ITNs: upto 47%
RDTs: upto 46%
• Number of days of stock outs of SP vary from a 16 days (data
from PMI countries) to four months (MCHIP, 2011)
• Availability of LLINs: inadequate distribution of LLINs
particularly at ANC level
• Use of SP for treatment: 1-25% health facilities (PMI)

6. Challenges
• PMI (2009-2011)
• ACT stock outs: Up to 90% in some countries
• Quinine stock outs: > 60% (tabs); Up to 63% (inj)
• Poor inventory management
• Facilities with up to date stock cards: 27-78%
• Training
• Providers with in-service training in IPTp: 36-96%
• Providers with in-service training in SM: 36-100%
• Poor distribution
• Difference between products ordered vs. received: 64%

7. Countries Reporting Stock Outs of SP at Central Level
25
20
20 19 19
17
Number of Countries
15 14
13
SP Stockout
10
10
8
7 Total Countries
6 6 Reporting SP Products
5
5
0
Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4
Source: USAID|DELIVER Project. 2012. Procurement Planning &
Monitoring Report – Malaria.
Note: Quarters 2, 3, and 4 of 2011 include 6, 8, and 7 Nigerian
states, respectively, reporting independently.

8. Countries Reporting Stockouts of
Artemether/Lumefantrine Products at Central Level
18
16
14 A/L 6x1 Stockout
12
Number of Countries
A/L 6X2 Stockout
10
8 A/L 6x3 Stockout
6
A/L 6x4 Stockout
4
Total Countries Reporting A/L
2
Products
0
Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2
2008 2009 2010 2011
Source: USAID|DELIVER Project. 2011. Procurement Planning &
Monitoring Report – Malaria.

9. Percent of Facilities Stocked Out of SP on Day of Visit:
One Country Example
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1
2009 2010 2011 2012
Source: USAID|DELIVER Project. 2012. PMI End Use Verification
Activity. Data provide a snapshot of commodity availability and
are not nationally representative.

10. Zambia: Case Study
• In 2008, 50.3% of pregnant women reported sleeping
under a mosquito net the previous night and 43.2%
reported sleeping under a treated net
• SP is stocked out much of the time in health facilities
and at the central level and ITNs are available in
health facilities only periodically
• Misuse of SP for case management
• Procurement and distribution not efficient
• Responsibilities of the NMCC and Pharmacy Unit in
addressing stockouts not clearly defined
Source: MCHIP, 2010

11. Zambia: Case Study
• A 2008 assessment by HSSP in Central and Eastern
provinces found that of 54 facilities surveyed, 95%
had experienced a stock-out of SP in the period of
July 2007 to July 2008
• No procurement plan in place-procurement
according to funding level available
• Lack of accurate consumption data from health
facilities challenging quantification
• Delays in the receipt of donor funds
Source: MCHIP, 2010

12. Improving access to Malaria in Pregnancy Strategies by
Pharmaceutical Management and Health Systems
Strengthening
• Long lasting • Safe motherhood
insecticide- and f-ANC
treated nets strategies
(LLINs) including
Governance detection and
treatment of
anemia
Quantification and
Selection and Policy
Procurement
Service Delivery Human
Resources
Access
Storage, Distribution
Prescribing, Dispensing
and Inventory
and Patient Adherence
Management
Financing Information
• Intermittent • Diagnosis and
preventive treatment with
treatment of ACTs/quinine
pregnant women
(IPTp)

13. Selection and Policy
Selection and
Policy
• Lack of clarity in policy guidelines causing uncertainty
among health workers including timing of doses
• Suspicion in promoting SP for IPTp, but using ACTs for
treatment
• Free vs. payment for products

14. Quantification and Procurement
Quantification
and
Procurement
• Poor quantification
• Lack of procurement plan – uncoordinated
procurement
• Lack of consumption and burden data
• Problems with management of stocks at all levels

15. Storage and Distribution
Storage, Distri
bution and
Inventory
Management
• Poor storage capacity: LLINs
• Poor distribution to peripheral areas
• Transport
• Poor reporting systems and inventory management

16. Prescribing, Dispensing and Use
Prescribing, Di
spensing and
Patient
Adherence
• Use of SP for treatment – stock outs and resistance
development
• Lack of water and cups for administering DOT
• Concerns about administering SP late in pregnancy
• In-service training and supervision

17. Recommended Pharmaceutical Management
Intereventions
• Clear guidelines emphasizing efficacy (even in areas with 25%
SP treatment failures, IPTp with SP provides benefits to
pregnant women)
• Financing
• Procurement planning
• Forecasting
• Distribution plans/microplanning
• IEC/BCC
• Training in case and supply chain management and IPTp
• Strengthen routine distribution of nets through ANC
• Strengthen monitoring and data reporting on IPTp as well as
treatments given during pregnancy