Prof. Eric Sompwe Mukomena tells us about some of the challenges of severe malaria case management in his country.
Could you tell us about your national strategy for improving the case management of severe malaria in DRC?
DRC has a high burden of malaria, with over 95% of the population living in areas of high transmission. Following on from its 2013–2015 strategy, the NMCP developed a new National Malaria Control Strategic Plan (NSP) for 2016 to 2020. The overall objective of this new strategy is to reduce malaria morbidity and mortality in the DRC by 40% compared with 2015; we are, however, unlikely to reach this ambitious target. For the treatment of severe malaria, the NSP recommends injectable artesunate or, if unavailable, intramuscular artemether or intravenous quinine. Prereferral intervention with artesunate rectal capsules at a peripheral level1 is national policy, although roll-out of training for health workers2 and commodities is still ongoing.
What are some of the challenges for case management of severe malaria, especially in rural settings?
Despite improved coverage of malaria interventions in recent years, access to medicines, lack of funding and infrastructure challenges continue to be major obstacles for the case management of severe malaria in rural settings. As quinine is cheaper and has been the treatment of choice for many decades, it is still being used to treat severe malaria in certain parts of the country – even though it is less effective than injectable artesunate. For artesunate rectal capsules, there are knowledge gaps that prevent effective administration of the intervention, and sometimes there is just not enough supply of medicines. In some areas, patients aged 6 years and above are receiving artesunate rectal capsules, although WHO and national guidelines do not recommend them for this age group. Lastly, seeking treatment in the private sector is common in the DRC, and we cannot always ensure that private facilities are adhering to our national policies and prescribing quality assured medicines.
What more can be done to improve case management of severe malaria in DRC?
We need to advocate for more funding to ensure an adequate supply of quality-assured treatments for severe malaria (between 2016 and 2018, financial contributions from DRC’s three biggest donors fell by 27%).3 Our current priorities are training and supervision of health workers, especially in regard to pre-referral intervention, and expanding referral centres and community care sites. Alongside donor funding, we also need to mobilize government funding for severe malaria care, especially for people that currently don’t have access, and improve the integration of public–private health services to streamline care aligned to national and international guidelines. In particular, we need to do much more to improve malaria outcomes in pregnancy.
What is your experience of working with MMV?
MMV-supported products have made a major contribution in terms of reducing the burden of severe malaria in DRC, and we welcome the diversified supply base of both injectable and rectal artesunate. Through the CARAMAL project, we are currently benefiting from the introduction of artesunate rectal capsules, made available by MMV-supported manufacturers, as well as community training on their correct use. We expect to identify the key gaps in our current system of integrated community case management,4 which in turn will help us ensure that artesunate rectal capsules are an effective part of a continuum of care – right from the community level up to a referral healthcare facility.
1. The health system in DRC has three levels: central, intermediate, and peripheral. The peripheral level is comprised of communities, health facilities, general referral hospitals and health zones.
2. Health workers in DRC work at the community level and carry out health promotion and community mobilization, and they also provide diagnosis, treatment and referral services for selected conditions, which includes administration of artesunate rectal capsules.
3. WHO World Malaria Report 2019: https://www.who.int/publicationsdetail/world-malaria-report-2019
4. Integrated Community Case Management (iCCM) aims to provide timely and effective treatment of malaria, pneumonia and diarrhoea to populations with limited access to facility-based healthcare providers, and especially to children under 5. Source: WHO (2016) ‘Integrated community case management of malaria’: https://www.who.int/ malaria/areas/community_case_ management/overview/en/