Throughout the Western Pacific Region, many countries are making significant progress towards the elimination of lymphatic filariasis as a public health problem. WHO has validated Cambodia, Cook Islands, Niue and Vanuatu in 2016 and Marshall Islands in 2017 for having eliminated lymphatic filariasis as a public health problem, together with two countries in the Southeast Asia Region, joining China and the Republic of Korea as the only countries in the world to eliminate lymphatic filariasis as a public health problem since the launch of the Global Programme to Eliminate Lymphatic Filariasis.
Achieving elimination of the disease as a public health problem is not the end of the story. Stopping the spread of infection through preventive chemotherapy will prevent new cases of the disease. However, morbidities caused by lymphatic filariasis, such as lymphoedema and elephantiasis, are incurable and often overlooked. Provision of a minimum package of care is essential for people affected by residual morbidity and sustained within the health system.
To assist programmes in implementing Morbidity Management and Disability Prevention (MMDP) services, WHO is developing the MMDP Toolkit in collaboration with partner institutions. The purpose of the toolkit is to describe national MMDP situations, as well as each country’s capacity to measure the burden and distribution of lymphoedema and hydrocele patients. The toolkit should also help identify the best platforms and models to improve access to surgery and self-help training.
A component of the toolkit is the Direct Inspection Protocol (DIP), which is a survey protocol to assess the quality of lymphoedema management services in health facilities and to provide recommendations on actions needed to strengthen MMDP provision.
Viet Nam is one of the countries reportedly achieving the criteria for elimination of lymphatic filariasis as a public health problem, so the DIP was piloted in April 2016 by the National Institute of Malariology, Entomology and Parasitology (NIMPE), Viet Nam, with technical support from the World Health Organization, the United States Centers for Disease Control and Prevention, the Research Triangle Institute International and Helen Keller International, through USAID's MMDP project.
First, the number and geographic distribution of lymphoedema and hydrocele patients was estimated and the list of all facilities serving such patients was created through a questionnaire and communications with all provincial authorities. Of these facilities, 10% were selected and visited with standardized questionnaires given to staff members. The questionnaire included information such as the availability of services, staff knowledge, patient knowledge and demonstration of leg washing. The health service quality of each selected facility was also inspected and scored to identify strengths and weaknesses.
The DIP provided an assessment of lymphoedema services by quality indicator, such as trained staff, medications and water, and by health facility, thereby enabling the identification of well-performing areas and those needing improvement. In the pilot, areas most in need of improvement were availability of trained staff (none within the last two years), and equipment such as buckets, gauze and soap. There was also a need to teach patients proper leg washing and provide them information, education and communication materials. In addition, only one facility had recorded lymphoedema patients in the previous year. However, water source and medication availability were found to be well-managed.
DIP was useful in Viet Nam, not only to assess the quality of MMDP services, but also to externally evaluate the national lymphatic filariasis elimination programme. Through interviews with relevant health staff members and observations at provincial, district and communal levels, a discussion about the way forward emerged, to ensure that MMDP services remain active after validation of lymphatic filariasis elimination as a public health problem and outcomes of the DIP will be incorporated in the dossier for validation.