Monitoring and Evaluation of Malaria Control Programs

1. Monitoring and Evaluation of Malaria Control Programs A Brief Overview

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-based indicators of the RBM strategy & recognize their strengths & limitations

3. Content Outline • Introduction and problem statement • Epidemiology of malaria • Historical & 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 • Coverage of interventions • Class activity

4. 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

5. Problem Statement: Economic Cost of Malaria Source: Global Malaria Action Plan (2008) USD 12 billionper 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)

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

7. 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

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

9. Risk Stratification

10. History of Malaria Control • 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

11. History of Malaria Control:Renewed Global Commitment • 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

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

13. Conceptual Framework: Malaria Control and Elimination

14. 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

15. 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

16. 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)

17. 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

18. Logic Model: Malaria Control Programs Inputs Process Outputs Outcomes Impact • Strategies • Policies • Guidelines • Funding • Materials • Facilities • Commodities • Supplies • Staff • Training • Services • Education • Treatments • Interventions • Services • delivered • Knowledge, • skills, practice • Coverage • Use • Malaria • incidence/ • prevalence • Mortality • Socio- • economic • wellbeing Examples of Indicators • # ITNs distrib. • # HH sprayed • IPTs delivered • # antimalarials • delivered • RDTs/slides • taken • %HH ITN • possession • %ITN use • IRS coverage • %U5 treatment • U5MR • Malaria • morbidity/ • mortality • Economic • impact

19. 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 IR1.2 Improved access to IPT IR2.2 Epidemic preparedness improved IR3.2 Efficiency in service delivery improved IR1.3 IRS coverage increased in epidemic prone areas IR2.3 Surveillance system improved 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 Results Framework: Malaria Control Program

20. Logical Framework: Malaria Control Program

21. Logical Framework: Malaria Control Program

22. 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

23. Level and Function of M&E Indicators 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 Morbidity and mortality indicators Population coverage indicators

24. RBM CoreOutcome Indicators

25. RBM Core Impact Indicators

26. 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

27. 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

28. Coverage of Interventions

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

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

32. ITN Use by Pregnant Women

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

34. 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

35. Antimalarial Treatment Source: World Malaria Report 2009 and 2010 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.

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

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

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

39. 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

40. 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,,contentMDK:22897559~pagePK:64257043~piPK:437376~theSitePK: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

41. 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.