Monitoring and Evaluation of Malaria Control Programs A

Monitoring and Evaluation of Malaria Control Programs A Brief Overview

Learning Objectives By the end of this session, participants will be able to: § Realize why malaria is important § Describe a conceptual framework for malaria § Describe Roll Back Malaria technical strategies § Design an M&E framework for national-level malaria control programs § Identify core population-based indicators of the RBM strategy & recognize their strengths & limitations

Content Outline 1. Introduction and problem statement 2. Epidemiology of malaria 3. Historical & current situation of malaria control 4. Conceptual framework for malaria control 5. RBM control strategies 6. International and regional targets 7. Results and logical frameworks for malaria 8. Level and function of M&E indicators 9. M&E indicators for malaria 10. Strengths and limitations of indicators 11. Coverage of interventions 12. Class activity

Why is Malaria Important? Problem Statement § Estimated 225 million malaria cases and 781, 000 deaths in 2009 § Malaria during pregnancy in malaria-endemic settings may account for: § 2– 15% of maternal anemia § 5– 14% of low birth weight newborns § 30% of “preventable” low birth weight newborns § 3– 5% of newborn deaths § Malaria accounts for approximately one in five of all childhood deaths in Africa every year § Drug resistance exacerbates the malaria problem

Problem Statement: Economic Cost of Malaria § USD 12 billion per year in direct losses § Loss of 1. 3% of GDP growth per year for Africa § Around 40% of public health spending in SSA § Approximately 30 -40% of out-patient visits to hospitals and 20 -50% of all admissions are due to malaria § Household spending : >10% of yearly (Africa) Source: Global Malaria Action Plan (2008)

Epidemiology: Parasite § Malaria in SSA is mainly caused by Plasmodium falciparum § P. vivax, P. malariae and P. ovale are also present

Epidemiology: Vector § Malaria is transmitted by female Anopheles mosquitoes § They mostly feed & rest indoors § Peak biting is late in the night § Anopheles populations are more pronounced after rains

Habitat/Environment/Human Blood meal Vect or Parasite Recipient Parasite cycle In mosquito Mosquito cycle Adult Temperature Rainfall Eggs Pupa Humidity In human Malaria Transmission Cycle Larva

Risk Stratification

History of Malaria Control § 1950 s Global malaria eradication program § As a result, malaria was eradicated from many countries § 1960 s global eradication stopped § Insecticide resistance § Drug resistance § Poor infrastructure particularly in Africa § Eradication program changed to malaria control § During 1970 s and 1980 s malaria received little attention

History of Malaria Control: Renewed Global Commitment § Malaria reemerged as a major international health issue in the 1990 s § Global malaria control strategy adopted in 1992 § Roll Back Malaria 1998 § Abuja Declaration 2000 § Strong political commitment and partnership

External factors: • Environmental (ecological, climate) • Socioeconomic (economic status, movement, occupation, housing condition, war, population displacement, etc. ) • Demographic ( age, immunity, gender) Health care system: § Accessibility § Affordability § Quality of care § Efficiency § Demand/utilization Program factors: • Health policy • Antimalarial drug policy • Support/partnership • National MCP Malaria infection Prevention: • LLINs, IRS, IPT • Environmental management Treatment: Early diagnosis And treatment Malaria knowledge: • Cause • Prevention methods • Early treatment • Cultural beliefs • Information Conceptual Framework: Malaria Burden Malaria morbidity Malaria mortality

Conceptual Framework: Malaria Control and Elimination

Key Malaria Targets and Goals African Summit on Roll Back Malaria, Abuja, Nigeria § Halve malaria burden between 2000 and 2010 Millennium Development Goals § § MDG 6: Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases § Indicator 21. Prevalence and death rates associated with malaria § Indicator 22. Proportion of population in malaria-risk areas using effective malaria prevention and treatment measures MDGs 1, 3, 4 & 5 -- also malaria-related

Key Malaria Targets and Goals (continued) World Health Assembly 2005 § Ensure reduction in malaria burden of ≥ 50% by 2010 and ≥ 75% by 2015 Roll Back Malaria Partnership Global Malaria Action Plan targets § By 2010: 80% coverage with interventions; by 2015: universal coverage, preventable mortality near zero & 8 – 10 countries achieve elimination of malaria

RBM Technical Strategies for SSA § Vector control via insecticide-treated nets (ITNs) and indoor residual spraying (IRS) § Prompt access to effective treatment § Prevention and control of malaria in pregnant women utilizing intermittent preventive treatment (IPTp)

Roll Back Malaria M&E § Extensive & systematic M&E relatively new for national malaria control programs § M&E reference group (MERG) established § Objectives of national RBM M&E system § Collect, process, analyze and report malaria-relevant information § Verify whether activities implemented as planned § Provide feedback to relevant authorities § Document periodically whether planned strategies have achieved expected outcomes & impact

Logic Model: Malaria Control Programs Inputs Process • Strategies • Policies • Guidelines • Funding • Materials • Facilities • Commodities • Supplies • Staff • Training • Services • Education • Treatments • Interventions Outputs • Services delivered • Knowledge, skills, practice Outcomes • Coverage • Use Examples of Indicators • # ITNs distrib. • # HH sprayed • IPTs delivered • # antimalarials delivered • RDTs/slides taken • %HH ITN possession • %ITN use • IRS coverage • %U 5 treatment Impact • Malaria incidence/ prevalence • Mortality • Socioeconomic wellbeing • U 5 MR • Malaria morbidity/ mortality • Economic impact

SO 1: Reduced Malaria Burden IR 1: Improved malaria prevention IR 1. 1 Access to & coverage by ITNs increased IR 2: Improved malaria epidemic prevention & management IR 2. 1 Early detection & appropriate response improved IR 1. 2 Improved access to IPT IR 2. 2 Epidemic preparedness improved IR 1. 3 IRS coverage increased in epidemic prone areas IR 2. 3 Surveillance system improved IR 1. 4 Use of source reduction/ larviciding increased IR 2. 4 Early warning system strengthened Results Framework: Malaria Control Program IR 3: Increased access to early diagnosis & prompt treatment of malaria IR 3. 1 Quality of care improved IR 3. 2 Efficiency in service delivery improved IR 3. 3 Utilization of care improved IR 3. 4 Access to services improved

Performance indicators Goal: Reduced malaria morbidity and mortality. • Malaria incidence and prevalence rates Purpose: Strong and sustainable malaria prevention and control strategies to reduce morbidity and mortality will be implemented • Coverage of control interventions Objectives: 1. Reduce malaria mortality by 50% by the year 2010 2. Reduce malaria morbidity by 50% by 2010 3. Reduce mortality due to malaria epidemics by 50% by 2010 • Malaria case fatality rate • General crude death rate • Annual parasite incidence • # of cases of severe malaria among target groups • Malaria specific death rate Means of verification Assumptions • Annual reports • Surveys • DSS (INDEPTH) • DHS • Strong financial support • Malaria control capacity increased • Annual reports • Surveys • Record reviews • Problem of drug resistance will be reduced through effective and affordable drugs • Routine HIS • DSS • DHS • Health facility surveys • Community surveys • Strong HIS • Availability and use of DSS • Effective and affordable drugs available • Sustainable funding and partnership Logical Framework: Malaria Control Program

Performance indicators Outcome: Access to and utilization of ITNs/LLINs increased • % of households with at least one ITN/LLIN • % of individuals who slept under an ITN/LLIN the previous night • % of households with at least 1 ITN/LLIN for every two people Output: • Distribution of mosquito net to the target population will improve • # of ITN/LLIN distributed to the target population • # of health workers trained on ITN/LLIN strategy implementation • District health workers will be trained for implementation of ITN/LLIN strategy Logical Framework: Malaria Control Program Means of verification Assumptions • Community surveys • Availability of ITNs • Subsidies for ITNs • High community awareness and acceptance of ITN • Reports • Review document • Funds available

Class Activity Get into your groups to create a results, logical or logic model for one aspect of a malaria control program § Insecticide-treated nets/Long lasting insecticidal nets(ITNs/LLINs) § Indoor residual spraying (IRS) § Prompt and effective treatment and use of diagnostics § Prevention and control of malaria in pregnant women

Level and Function of M&E Indicators Population coverage indicators Input Indicators Process Indicators Output Indicators for monitoring the performance of malaria programs/interventions, measured at the program level Outcome Indicators Morbidity and mortality indicators Impact Indicators for evaluating results of malaria programs/interventions, measured at the population level

RBM Intervention Indicator Description Insecticide 1. Proportion of households with at least one ITN treated nets 2. Proportion of households with at least one ITN for every two people (ITNs) and indoor residual spraying 3, Proportion of population with access to an ITN within their household (IRS) 4. Proportion of individuals who slept under an ITN the previous night Prompt and effective treatment and use of diagnostics 5. Proportion of children under 5 years old who slept under an ITN the previous night 6. Proportion of households with at least one ITN and/or sprayed by IRS in the last 12 months 7. Proportion of children under 5 years old with fever in the last 2 weeks who had a finger or heel stick 8. Proportion of children under 5 years old with fever in the last 2 weeks which sought advice or treatment from an appropriate provider 9. Proportion of antimalarials taken by children under 5 years old to treat a fever in the last 2 weeks that were ACTs Prevention and 10. Proportion of pregnant women who slept under an ITN the previous night control of malaria 11. Proportion of women who received intermittent preventive treatment for in pregnant malaria during ANC visits during their last pregnancy women RBM Core Outcome Indicators

RBM Core Impact Indicators RBM Impact Measures Indicator Description Mortality Indicator 1. All-cause under 5 mortality rate (5 q 0). Morbidity Indicators 2. Parasitemia Prevalence: proportion of children aged 6 -59 months with malaria infection. 3. Anemia Prevalence: proportion of children aged 6 -59 months with a hemoglobin measurement of <8 g/d. L

Challenges of Measuring Malaria. Specific Mortality § Case definitions § Variations in completeness of reporting over time and space § Selectivity § Time frame of survey estimates § Low coverage & quality of vital registration

M&E Challenges: Complexity of Malaria Epidemiology § Not a linear relationship between transmission (immunity) and malaria-related mortality § Severity & symptomology of malaria morbidity shifts with transmission (immunity) § High transmission = chronic infections, severe anemia § Low transmission = higher life-threatening severe malaria

Coverage of Interventions

Cumulative Number of ITNs Distributed in Sub-Saharan Africa, 2000– 2009 Source: WHO, 2010 World Malaria Report

Trends in Estimated ITN Coverage, Cub-Saharan Africa 2000– 2009 Source: WHO, 2010 World Malaria Report

ITN Use by Pregnant Women

Proportion of Population at Risk Protected by IRS Source: WHO, 2010 World Malaria Report

Diagnostic Testing Proportion of suspected malaria cases attending public health facilities that receive a parasitological test by microscopy or RDT Source: WHO, 2010 World Malaria Report

Antimalarial Treatment § In 2003, 2 sub-Saharan African countries had adopted ACTs, by 2010, all sub-Saharan African countries except one had adopted an ACT as a first line drug. § Measuring the percentage of malaria cases which receive appropriate antimalarial treatment has challenges. Source: World Malaria Report 2009 and 2010

Intermittent Preventative Treatment Proportion of all pregnant women receiving the second dose of IPT Source: WHO, 2010 World Malaria Report

Eritrea Sao Tome and Principe Rwanda Zambia Reduction of >50% in Cases: 11 African countries

Highlight: Rwanda 1. Describe trends in malaria admissions and deaths over the past 10 years. 2. What could be causing this increase in admissions and deaths between 2008 and 2009? 3. How should the Rwanda NMCP respond to this evidence of an increase in admissions and deaths? 4. What does this case demonstrate about malaria control efforts? Source: World Malaria Report 2010

Class Activity Malaria in Nigeria (Pop. 152 million) • Among all age groups, malaria is the cause of 60% of all out-patient visits and 30% of hospitalizations • Nigeria has more reported cases of malaria and deaths due to malaria than any other country in the world PMI will work with Nigeria starting this year to: • Distribute 2 million long lasting insecticidal nets (LLIN) • Support malaria case management in five initial focus states so that 90% of children diagnosed with malaria receive an appropriate antimalarial • Increase 2 doses of IPTp to 15% and one dose to 25% of pregnant women using ANC services in five initial focus states • Strengthen the capacity of the IRS unit at the NMCP and in selected states 1. Describe the various components of the program that need to be monitored and evaluated? 2. Define key output and outcome indicators and identify a data source for each

References Africa Malaria Report. Geneva, World Health Organization, 2006. Global Malaria Action Plan. Geneva, Roll Back Malaria Partnership, 2008 Households that have at least one ITN, Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007. Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region, WHO-AFRO, 2007. Malaria Campaign: Millions Receive Treated Mosquito Nets. Washington, D. C. , World Bank 2011. Available at: http: //web. worldbank. org/WBSITE/EXTERNAL/NEWS/0, , content. MDK: 22897559~page. PK: 64257043~pi. PK: 437376~t he. Site. PK: 4607, 00. html Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007. The President's Malaria Initiative Progress through Partnerships: saving lives in Africa Second Annual Report. Washington, D. C. , PMI, 2008. World Malaria Report. Geneva, World Health Organization, 2008 World Malaria Report. Geneva, World Health Organization, 2009 World Malaria Report. Geneva, World Health Organization, 2010

MEASURE Evaluation is funded by the U. S. Agency for International Development (USAID) and implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill in partnership with Futures Group, ICF Macro, John Snow, Inc. , Management Sciences for Health, and Tulane University. Views expressed in this presentation do not necessarily reflect the views of USAID or the U. S. government. MEASURE Evaluation is the USAID Global Health Bureau's primary vehicle for supporting improvements in monitoring and evaluation in population, health and nutrition worldwide.