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Gaining access

Dr. Flora Kessy is a senior Social Research Scientist and ACCESS Project Manager at Ifakara Health Institute in Tanzania.

Towards the end of 2012, Dr. Kessy organised an international dissemination conference for her ACCES project. The conference which took place in Dar es Salaam attracted over 120 participants from Tanzania and Europe. Mbarwa Kivuyo of AMMREN Tanzania interviewed Dr. Kessyabout the project and the conference.

Mbarwa Kivuyo: What is the ACCESS project?
Dr. Kessy:
The ACCESS project was conceived in Tanzania in 2003. The project started as a pilot in Kilombero and Ulanga districts in Morogoro Region (2003 – 2007) and was later extended to Kilosa and Gairo districts in 2008 and to Rufiji, Iringa Municipality and Bagamoyo districts in 2012. The aims were to analyze and improve access to healthcare – using malaria as a tracer condition.

What prompted the ACCESS project?
Access to medicines and healthcare remains a challenge for the majority of people in developing countries. However, public debate has concentrated mainly on the affordability of efficacious and safe medicines as well as the patent issue. Yet in such contexts, the issue of access to healthcare is far more complex. Patients and their families may have to mobilize and convert resources into cash. In addition, the long distances can result in delayed treatment. Patients may also avoid public health facilities and rather consult traditional healers because staff are not responsive.

What approach did the ACCESS project use to fulfil its aims?
The ACCESS project intervened on both the supply and demand side of access. A framework was developed that defines access as the degree of linkage between the health system and its services on the one hand, and patients’ resources, needs and expectations on the other hand. Access can be measured along five dimensions (the 5 As): Availability, Accessibility,Affordability, Adequacy and Acceptability.

Who is involved in the ACCESS project?
Actors in this project are the Novartis Foundation for Sustainable Development (NFSD), the Ifakara Health Institute (IHI) and Swiss Tropical and Public Health Institute (Swiss TPH). The three collaborated in the development and implementation of the ACCESS project. The partners also worked closely with the district and regional health authorities in Morogoro, Iringa and Pwani regions of Tanzania.

Two of the three partners are European institutions. Why did they choose to implement the project in Tanzania?
There are two key reasons. Firstly, the long history of development co-operation with Switzerland, dating back to the 1960s, made Ifakara Health Institute a suitable partner for a project with such a scientific component. Secondly, the Health and Demographic Surveillance System (HDSS) platform available in Tanzania allows the comprehensive collection of scientifically-sound data which is necessary for the analysis of access obstacles.

You had an international dissemination conference end of last year. What are some of the information you sent out and for what purpose?
The ACCESS dissemination conference was held in Dar es Salaam in October 2012 to present the findings of the final evaluation of the ACCESS project interventions with regard to their effectiveness and impact. The conference intended toinform policy makers, funders and other important stakeholders about the achievements, challenges and necessary future actions in the respective intervention areas. Given the purpose of the event, the district, regional and national health authorities, academia, malaria community, potential donors, organizations in Tanzania, local and international journalists were the key participants. Over 120 people attended.

What key findings did you disseminate at the conference?
From 2003 to 2007 the ACCESS project sought to gather evidence that would explain the challenges to accessing healthcare, using the example of malaria treatment. Social marketing campaigns were used to inform people in the project districts on the causes, symptoms and appropriate treatment of malaria in order to spur demand for effective treatment. The rationale of the ACCESS project was to create empirical evidence on access obstacles and to design effective interventions to address the identified issues.

We know access to healthcare is also determined by geographical factors. Did the project look at this dimension?
That is true. The issue of geographical accessibility and resulting treatment delays were addressed by convincing the partners of the Accredited Drug Dispensing Outlet (ADDO) program to extend their activities to the ACCESS project districts. ADDOs represent a second delivery channel as they are licensed to sell a limited number of essential and prescription medicines, which include the first-line malaria treatment, artemether-lumefantrine (Alu orCoartem). Results from a first evaluation at the end of 2007 revealed that thanks to the ADDO program, drug shops became more available to communities and geographically more accessible. Moreover, the quality of treatment advice improved substantially in the ADDOs. However, while the recommended new anti-malarial medicine was mostly available in health facilities, it was not widespread in ADDOs. One of the recommendations made was that community-based information campaigns be conducted by women and theatre groups in order to reach more potential patients and that the campaigns be more cost-effective and self- sustaining. From 2008 to 2011 the ACCESS project intervened in both the demand and supply side to improve access.

What were the final results?
The final evaluation of ACCESS project was conducted in 2011 and results were compared to intermediary results from 2007.

Results are encouraging, as they show a substantial increase in the number of patients treated with the recommended antimalarial medicine from 36% of all fever cases in 2007 to 62% in 2011.

However there was no substantial increase in promptness of treatment and correct dosage regimen. Results also showed persisting challenges of availability of medicines in both health facilities and ADDOs.

It is encouraging to see that substantially more fever patients from households with health insurance coverage received the recommended malaria treatment within 24 hours and in correct regimen (66% against 36% of those without coverage). This finding supports the hypothesis that health insurance membership facilitates financial access even in cases of relatively affordable primary healthcare.

The enrollment rate of the biggest community health fund that the ACCESS project support increased between 2008 and 2012 from 7.5% to 22.6% of the targeted 60% of the district population of 300,000 people. Information campaigns on malaria symptoms, causes, prevention and treatment however do not seem to have had the expected effect. On the one hand, more patients (or their caretakers) who attended a community sensitization meeting received an ACT within 24 hours in correct dosage compared to those who had not taken part in such an event (48% against 27%). On the other hand however, the fact that patients (or caretakers) could recall the messages of the campaigns did also not have an influence on prompt and appropriate treatment.

What has been learnt from the dissemination conference?
Evidence shows that project interventions substantially helped improve access to the recommended anti-malarial medicine and care. There are also strong indications that health insurance members have better health outcomes in the case of malaria treatment. However, there is still room for improvement regarding increased availability of first-line medicines.

A second challenge points to a persisting low level of provider compliance with malaria treatment guidelines and possibly weak patient adherence to treatment instructions. These results suggest two conclusions: the supply chain management for malaria and possibly other medicines needs to be strengthened, and provider compliance with treatment guidelines needs to be tackled in order to improve access and ultimately health outcomes.

What is the clarion call of the ACCESS project?
The experience of the ACCESS project underlines the importance of generating scientific empirical evidence to inform and design comprehensive yet targeted interventions and to evaluate their effects.

Furthermore it demonstrates that partnerships between public (government), private (companies) and third sector players (researchers and NGOs) are indispensable for the successful implementation and the effectiveness of comprehensive interventions in addressing complex development challenges.

 

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