Microplanning: the key to success for MDA
Microplanning is the stabilising structure within which all elements of an MDA campaign are organised, planned, and managed at the district level.
By the end of this presentation you should be able to: Describe the procurement process for antibiotics. Understand how dosage is calculated at district level. And discuss how teams implementing the distribution of antibiotics are coordinated and supported. Once the decision to employ antibiotics for trachoma elimination has been taken, the national trachoma task force should calculate the amount of antibiotics needed.
Typically, in a target population: About 83.3% of people need azithromycin tablets, 14.7% of people (children age six months to 5 years) need azithromycin paediatric oral suspension, 2% of people (infants up to six months old) need tetracycline eye ointment. Azithromycin - which has a trade name of Zithromax - is donated by Pfizer for trachoma elimination as part of the SAFE strategy. Health ministries and national trachoma task forces work together with the International Trachoma Initiative (ITI) to obtain the antibiotic. Applications are sent to ITI by April for MDA distributions planned for the following year. ITI will always try to fulfil requests for azithromycin outside the normal annual cycle, but this depends on enough drugs being available.
The Zithromax application form provided by ITI calculates the quantities of each drug required, once you type in the district population figures. The national trachoma task force works with ITI to ensure that applications meet the criteria for a donation from Pfizer. Firstly, trachoma must be a public health problem. That is a prevalence of active trachoma (TF) greater than or equal to 5% in children aged 1-9 years. Donated azithromycin must be used as part of the SAFE strategy to eliminate trachoma. Funds are available to carry out MDA, and finally mechanisms are in place for the safe storage and management of the medicine. This is to restrict its use to the trachoma elimination programme.
It can take up to 18 months for a country to receive donated drugs after contacting ITI for the first time.
Planning the MDA requirements for each district includes: 1. Calculating the required number of drug doses for the azithromycin tablets, paediatric oral suspension and tetracycline eye ointment. 2. Determining the necessary number of distribution teams. 3. Creating a system to supervise the distribution teams. And 4. Creating a system for recording and reporting the MDA data. The number of distribution teams needed varies from district to district. It depends on the total population, the population density (that is, how many people live in each square kilometre), and the geographical terrain. On average, one team of three people (two volunteers and a health worker or drug distributor) can reach between 300 and 500 people per day, or around 2000 people in a week.
Let’s look at an example. District X has a population of 100 000 and a population density of 2000 people per square kilometre, as the terrain is variable and the population is widely scattered. This population density is about average so we can calculate that 50 distributor teams are required. Each team will have a target of reaching and delivering drugs for 2000 people during the MDA week. It’s possible for one supervisor to manage up to six teams, although this varies across districts and programmes. So in District X, the number of supervisors required is eight - the total number of teams (50) divided by six. Each distributor team needs to be very familiar with the area they work in.
It is best if at least one member of the team knows, and is known by, the target population.
Typically, the supplies required by each distribution team are: Sufficient quantities of azithromycin tablets and paediatric oral suspension. Allow 166 doses per bottle of 500 tablets and four doses per bottle of oral suspension. Sufficient tetracycline eye ointment. Allow two tubes per person treated; record books and tally sheets; pens, pencils, and a marker. a dosing pole; and health education materials; cartons or bags to carry everything; a whistle, trumpet or other device to attract attention; and promotional materials such as caps, aprons or t-shirts, and any other items.
Budgets are set to support the teams and their supervisors: Per diem rates per person - both for training and MDA delivery. Number of vehicles needed to transport the required materials to the distribution nodes. The amount of fuel and oil needed to manage transportation needs per district. And the quantities of supplies needed per team per community. Each team records the treatments they provide in their record books. The target for MDA is to achieve 100% coverage with antibiotics. An important role of supervisors is to monitor coverage during the MDA period. This is to ensure targets are being achieved and that teams are appropriately supported. For each team, the supervisor should obtain progress information on the team’s coverage.
Coverage equals the number of people treated by the team, divided by the target for the team. This multiplied by 100 to get a percentage. Teams can monitor progress as they work and report the figures to their supervisors using mobile phones. Each distribution team needs a clear plan for the distribution and the health education messages to be delivered as part of the MDA. Distribution team leaders should consult with the village leadership in their target areas. This is to ensure that each neighbourhood knows on which day they will have access to the MDA. It is not courteous to expect busy farmers to wait for the team and it should be possible to give them an appointment time of a half day block.
For example, the people living in neighbourhood A will be treated on Monday morning, those in neighbourhoods B and C on Monday afternoon, those in neighbourhood D on Tuesday morning and so on. Since we know the population of the neighbourhoods being targeted, the distribution team can take the correct amount of azithromycin tablets, paediatric oral suspension and tetracycline ointment each day. Along with MDA information, health education messages
can include: What trachoma is, what it causes, and how blindness from trachoma can be prevented. Why antibiotics are being distributed and their safety. Who is eligible to take the different antibiotics. And that the antibiotics are being given free. And also, the importance of the facial cleanliness and environmental improvement components of the SAFE strategy. Distributors must be trained and given clear roles and responsibilities.
Training should cover: The key elements of the SAFE strategy, especially antibiotic distribution How to manage distribution sites efficiently - minimising crowding and maximising the flow of people. How to manage azithromycin in the field - ensuring that only one bottle of tablets is open at a time and that empty bottles are not mixed with full ones. How to mix and dispense oral suspension. For example, the parent or guardian should give the cup of oral suspension as this is more comfortable for the child. That children should never be forced to take azithromycin and how to manage children and their parents when a child is distressed.
How to measure height and use the height-dosing stick How to keep records on the daily tally sheets and complete the registers. How to deface empty azithromycin bottles by scribbling on the label with a black marker pen, and what to do with the empty bottles - whether to give them to community residents, or keep them for disposal or recycling. And who to contact in the very unlikely event that a recipient should die or be hospitalised after taking azithromycin. Drug distributors should also be given guidance on how to return both unopened and opened bottles of azithromycin. At the end of each round of treatment, a review meeting should be held to learn from the experience.
Any adjustments which are necessary should be then made for the next MDA round.
In summary, you should now understand: The point at which a country makes a request for azithromycin. How annual treatment requirements are calculated. The need to prepare logistics ahead of time, with the aim of achieving a treatment coverage of greater than or equal to 80%. And the need for proper team training and clear role designation.
Microplanning is the mechanism through which all elements of an MDA campaign are organised, planned, and managed at the district level. Microplans are detailed enough to outline how an MDA can be completed within a timeframe.
A microplan starts by identifying a date for the MDA distribution and then works backwards, identifying which key activities should be completed ahead of this date:
- Ordering supplies
- Training distributors
- Distributing materials
- Mobilising the community
- Deploying the distribution teams.
Some of these activities need to begin 10 – 12 months ahead of the MDA campaign.
Identifying the MDA distribution date should be done in consultation with community leaders and key stakeholders. They can advise when villagers will be available to participate as this depends on seasonal activities, religious observance, holidays, and so on. They also know the best distribution locations and can respond to villagers’ questions about the MDA.
When planning MDA, it’s also important to consider the local health services and whether there might be any competing health activities in the targeted area.
As you watch this presentation, think about why planning for, and reporting on, gender-specific MDA coverage may be an important in microplanning.
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