CNTD has supported the NTD programme in Mozambique for the control and elimination of LF since 2010. From 2011, as part of our plans towards integration of NTD support, we have also managed the programmes for schistosomiasis and soil-transmitted helminths on behalf of the Schistosomiasis Control Initiative (SCI) at the Imperial College London.
The integrated MDA consists of the annual or twice yearly administration of medication (Ivermectin and Albendazole for LF and STH and Praziquantel for SCH) to the population in endemic areas to eliminate the parasites and reduce the possibility of transmission of the disease from the infected to the non-infected.
The MDA requires the transportation of 46m pills of Ivermectin, 18m pills of Albendazole and 16m pills of Praziquantel to administer to 20 million people per their age and endemicity of the district in which they live. More than 5,000 health workers and activists are mobilized to inform the population, establish distribution points and provide the drugs in one week.
In line with global best practice, Mozambique started in 2013 to provide all three medication at once to the target population. This approach allows for economies of scale and reduction in the cost per person treated from £0.13 to £0.09. The combined treatment facilitates the country’s progress towards achieving the goal of having one integrated MDA per year followed by a ‘mop-up’ for province or districts with very high endemicity (such as Nampula or Zambezia).
Advantages of integration
Mozambique is successfully progressing towards the elimination of NTDs and has gathered unique experience on the implementation of MDA.
- Reduction of impact on other health services. Each campaign means considerable disruption to districts and health service operations which virtually come to a standstill to allow for the campaign to take place in their premises and for their staff to participate and contribute. By limiting this to a single integrated campaign, such disruption is minimised.
- Reduction of administrative costs. Whilst an integrated campaign costs more than each individual campaign, economies of scale allow for a 60% reduction of costs overall. For example, four people at a drug distribution post can administer an MDA for two diseases, whereas increasing this to five people allows treatment for all 3 diseases. Integrating social mobilization, training and post-MDA coverage surveys reduces costs in a similar fashion.
- Increase in compliance. To participate in an MDA, individuals may have to travel up to 15km to reach the distribution points, take time out of their work or otherwise be significantly inconvenienced. A single integrated MDA reduces this inconvenience significantly, thereby increasing the likelihood that individuals will participate.
- Integrated Programme Management: The implementation of STH and STH programmes on behalf of SCI allows for a better coordination of the control and elimination activities for these infections and LF.
Challenges of integration
- Planning and management. A single integrated campaign is larger and more complicated. This requires very careful planning and management. CNTD works closely with the Ministry of Health to ensure that the MDA is a success.
- Distribution. Praziquantel for Schistosomiasis is given to school-aged children only (5-14 years of age) whereas the other drugs are also given to adults. This can be quite challenging for the drug distributors, due to difficulties in assessing the age of children and sometimes confusing for the population being treated as they are not always sure of why some of the family are receiving some drugs and others are not.
- Training. Health staff and volunteers require training. Usually, the same volunteers participate in several MDAs, which allows them to gather knowledge and experience that facilitates the next campaign. With an integrated campaign, there is only a single training event and less opportunity to practice skills. Moreover, the integrated campaign is far more complicated to administer. This necessitates very careful and thorough training and supervision by the district officers with an emphasis on continuous improvement and checking that lessons learnt have been acted on.