Monitoring and Evaluation: Malaria-Control Programs

1. Monitoring and Evaluation:Malaria-Control Programs

2. 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 coverage indicators of the RBM strategy & recognize their strengths & limitations

3. Content Outline • Introduction • Current situation of malaria control • Conceptual framework for malaria control • RBM-control strategies • International and regional targets • Results and logical frameworks for malaria • Level and function of M&E indicators • M&E indicators for malaria • Strengths and limitations of indicators

4. Why is Malaria Important?Problem Statement • 300-500 million cases and >1 million deaths annually • 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 one in five of all childhood deaths in Africa every year. • Malaria epidemic causes >12 million malaria episodes & up to 310,000 deaths in Africa annually • Drug resistance exacerbates the malaria problem

5. Introduction to MCP (1) • Historical • 1950s Global malaria-eradication program • As a result, malaria was eradicated from many countries • 1960s global eradication stopped • Insecticide resistance • Drug resistance • Poor infrastructure, particularly in Africa • Eradication program changed to malaria control • During 1970s and 1980s malaria received little attention

6. Introduction to MCP (2) • Current situation • Malaria reemerged as a major international health issue in the 1990s • Global malaria control strategy adopted in 1992 • Roll Back Malaria 1998 • Abuja Declaration 2000 • Strong political commitment and partnership

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

8. Roll Back Malaria • Partnership launched in 1998 to fight malaria • WHO, UNDP, UNICEF and WB • Mainly focuses on Africa • Goal: • Halve the burden of malaria by 2010

9. Millennium Development Goals • Target 8: Have halted and begun to reverse the incidence of malaria and other major diseases by 2015 • 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

10. African Summit on RBM • Abuja summit 2000 • 44 heads of state or senior representatives from malaria-afflicted countries in Africa • Endorsed the goal of RBM • Reflected high political commitment

11. Abuja Targets: By 2005 • At least 60% of those suffering from malaria should be able to access and use correct, affordable, and appropriate treatment within 24 hours of the onset of symptoms • At least 60% of those at risk of malaria, particularly pregnant women and children under five years of age, should benefit from suitable personal and community protective measures such as ITNs • At least 60% of all pregnant women who are at risk of malaria, especially those in their first pregnancies should receive IPT

12. RBM Strategies • Use of ITNs and other locally approved means of vector control • Children <5 (and pregnant women) 2. Prompt access to effective treatment • Children <5 3. Prevention and control of malaria in pregnancy • Intermittent preventive treatment (IPT) & ITNs 4. Early detection of and response to malaria epidemics

13. 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

14. Basic Malaria M&E Framework

15. M&E Priorities in Limited Resource Settings • Human & financial inputs • Malaria control services delivered to those at risk of malaria • Coverage of interventions • Malaria-associated morbidity & mortality

16. Results Frameworks (MCP) SO1: Reduced Malaria Burden IR2: Improved malaria epidemic prevention & management IR1: Improved malaria prevention IR3: Increased access to early diagnosis & prompt treatment of malaria IR1.1 Access to & coverage by ITNs increased IR2.1 Early detection & appropriate response improved IR3.1 Quality of care improved IR2.2 Epidemic preparedness improved IR1.2 Improved access to IPT IR3.2 Efficiency in service delivery improved IR2.3 Surveillance system improved IR1.3 IRS coverage increased in Epidemic-prone areas IR3.3 Utilization of care improved IR1.4 Use of source reduction/ larviciding increased IR2.4 Early warning system strengthened IR3.4 Access to services improved

17. Logical Framework (MCP)

18. Logical Framework (MCP)

19. Core population coverage indicators for RBM Input Indicators Process Indicators Outcome Indicators Output Indicators Impact Indicators Indicators for monitoring the performance of malaria programs / interventions, measured at the program level Indicators for evaluating results of malaria programs / interventions, measured at the population level Level and function of M&E indicators

20. RBM Core Coverage Indicators

21. M&E Challenges of National MCPs: Measuring Impact • Not routinely required…technical strategies already proven efficacious for these indicators of impact, so coverage should suffice • debatable • Requires rigorous experimental design • Technical strategies intended to be full-coverage programs • Costly

22. M&E Challenges of National MCPs • Measuring malaria-specific morbidity & mortality • Case definitions • Variations in completeness of reporting over time and space • Selectivity • Time frame of survey estimates • Low coverage & quality of vital registration

23. M&E Challenges: Complexity of Malaria Epidemiology • Not a linear relationship between transmission (immunity) and malaria-related mortality • Severity and symptomology of malaria morbidity shifts with transmission (immunity) • High transmission = chronic infections, severe anemia • Low transmission = higher life-threatening severe malaria • Coverage is primary outcome indicator for national- level MCP

24. Class Activity Malaria is the most frequent cause of morbidity and mortality in Malawian children under five years of age, and is the cause of over 40% of deaths in children under two. Children under five suffer on average 9.7 malaria episodes per year, while adults suffer 6.1 such episodes (Ettling et al., 1994a). The cost of malaria to the average Malawian household has been estimated to be 7.2% of average household income. PSI/Malawi is reducing malarial disease and death by increasing ownership and appropriate use of ITNs. Q. Describe the various components of the PSI program that need to be monitored?

25. References • World Health Organization and UNICEF. 2005. World Malaria Report 2005. Geneva: WHO.