Achieving Equitable and Feasible Campaign Integration through SMC and Vitamin A Collaboration

Research Project

Achieving Equitable and Feasible Campaign Integration through SMC and Vitamin A Collaboration

Findings from Bauchi State Nigeria

Summary

Malaria Consortium conducted a study of the integration of vitamin A supplementation with seasonal malaria chemoprevention (SMC) campaigns.

Nigeria

Giade (rural) and Katagum (urban) in Bauchi state

Malaria and Vitamin A

Promising Practices

Engage stakeholders early to ensure consensus on the integrated campaign implementation strategy.
Identify existing coordination platforms comprising key decision makers to provide campaign oversight and coordination.
Use quality data from the microplans for commodity supply management.
See more.

Key Messages

Malaria Consortium carried out a study to test the integration of vitamin A supplementation (VAS) with seasonal malaria chemoprevention (SMC) campaigns in Giade (rural) and Katagum (urban) LGA in Bauchi state between May and December 2021. The purpose was to provide a body of evidence to support policy makers’ decision-making regarding full integration of VAS with SMC campaigns at scale and in diverse settings

The study was co-designed with key stakeholders including the National Malaria Elimination Programme (NMEP), the National Agency for Food and Drug Administration and Control; the Department of Planning Research and Statistics; the Bauchi State Malaria Elimination Programme and the State Primary Health Care Development Agency.

High-dose vitamin A supplementation (VAS) delivered twice annually is a proven low-cost intervention that has been shown to reduce all-cause mortality in children.
Integrating community interventions for multiple diseases increases coverage, improves health outcomes and is cost-effective.
Integrating VAS with the seasonal malaria chemoprevention (SMC) platform resulted in increased coverage of VAS, without compromising the quality of SMC or its coverage.
Stakeholder and caregiver engagement at all levels on behavioural expectation was critical to success.
Integrating VAS with SMC is safe, feasible, acceptable to community members and implementers, and can be achieved at minimal additional cost.
Integration of VAS with SMC can strengthen the health system for more equitable service delivery and provide a template for deployment in other health interventions.

Background

Context

190 million children under five are affected by vitamin A deficiency (VAD) globally. Prevalence is 30% in Nigeria.
Vitamin A deficiency is a major risk factor for child survival, children with clinical signs of vitamin A deficiency are 3-12 times more likely to die than those who are non-deficient.
High-dose vitamin A supplementation (VAS) delivered twice per year is a proven low-cost intervention which can reduce all-cause mortality in children by 24%.
WHO recommends bi-annual high-dose VAS given every 4-6 months to children aged 6-59 months who are at risk of vitamin A deficiency.

Problems and Opportunities

Vitamin A supplementation (VAS) campaigns in place in Nigeria have largely been ineffective due to poor implementation of the MNCH Week strategy.
In 2018, VAS coverage in Nigeria was 45% with wide variations sub-nationally, ranging from 6 to 86% inequity.
The number of states meeting the effective coverage threshold of 70% has been on the decline since 2014.
Addressing the poor coverage of VAS is key for child survival in Nigeria and critical for universal health coverage.
Based on WHO’s recommendation to integrate community interventions, SMC provides an existing viable and promising platform within which VAS could be fully integrated to achieve higher coverage.
A pilot study was conducted earlier in Sokoto with promising results but outstanding research questions.

Research Objectives

Design and implement in collaboration with key stakeholders, an integrated SMC plus VAS campaign at scale and in diverse settings (rural and urban) in Bauchi state as part of the existing SMC program.
Assess the feasibility (including effectiveness, equity, safety and cost) and acceptability of integrating VAS with SMC among caregivers, CDDs and health workers as well as policy makers.
Develop and implement a research uptake plan
Provide policy makers and stakeholders with a body of evidence to inform decision about integrated SMC and VAS in Nigeria.

Image to right: Study locations were Giade (rural) and Katagum (urban) LGAs of Bauchi State, North East, Nigeria.

View the slides and research brief for details on the study’s methods.

Results

Summary

VAS coverage increased from 1.2% at baseline to 82.3% at endline (with SMC integration), while SMC coverage stayed high at 90%. SMC quality was maintained and the integration was safe, and equitable.

The total cost per child receiving only SMC at baseline was $0.94, while total cost per child receiving both Vitamin A and SMC at endline was $1.18.

Scroll down for more key findings.

Dr. Olusola Oresanya, Senior Country Technical Coordinator, Malaria Consortiumm, shared the results of the study during an HCE Test & Learn session.

Key Findings

Overall, 170,681 children received both SMC and VAS during the integrated campaign, whereas 157,876 received VAS only after the campaign.
VAS coverage increased from 1.2 percent at baseline (without SMC integration) to 82.3 percent at endline (with SMC integration), in both project LGAs.
Integration did not adversely affect the coverage of the SMC campaign (the proportion of children who received SMC medicines on day 1 of the course). There was no marked difference in coverage between baseline and endline, which was 91.9 and 89.4 percent, respectively.
The quality of SMC delivery was maintained: the proportion of children who received the first dose of SMC increased from 77.1 percent at baseline to 85.9 percent at endline.
Integrating VAS with SMC is safe in children 3–59 months. Also, adverse drug reactions were reported in only 1.6 percent of children who received VAS and SMC, and 4.1 percent of children who received SMC only.
Integration was equitable. There was no difference between wealth indices, education level of caregivers, or age or sex of children who received SMC only, VAS only or SMC with VAS. However, more children received SMC and VAS in rural versus urban areas.
The total economic and financial cost per child that received SMC during the baseline cycle was $0.94, while the cost per child receiving both VAS and SMC during the endline cycle was $1.18. Integrating VAS into the usual SMC cycle introduced an additional minimal cost of $0.24 per child.
From focus group discussions and key informant interviews with the caregivers, implementers and government stakeholders showed that integration is feasible and acceptable.

"We feel like lifting her up because of happiness... We have four children in the house that have eye problem[s]...we were happy that it will cure the eye problem even before she gave us [VAS]”. -Caregiver, Katagum

The following points are also considered implications for policy research. See the research brief for specific practices for this project.

Conduct early and all-inclusive stakeholder engagement to ensure consensus on the integrated campaign implementation strategy before the start of campaign.
Identify existing coordination platforms comprising key decision makers to provide oversight and coordination, sign off on the implementation strategy and help resolve bottlenecks.
Use quality data from the microplans for commodity supply management. Factor in lead time for supply of commodities.
Consider increased workload of the additional intervention in determining daily targets for community distributors to ensure protocol adherence, without compromising the quality of delivery.
Use existing government-owned platforms to capture campaign data.
Train and properly equip all staff in pharmacovigilance.
Pay personnel remunerations promptly, through appropriate institutional structures, to encourage optimal staff performance.
Carry out a budget impact analysis and explore funding options for an integrated campaign to scale up the intervention.

Research Project