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 Outline1. 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

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)

Problem Statement: Economic Cost of Malaria

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

Malaria Transmission Cycle

RecipientVector

Parasite

Blood meal

Habitat/Environment/Human

Mosquito cycle

Eggs

Larva

Pupa

Adult

Parasite cycleIn mosquito

In human

Temperature

Rainfall

Humidity

Risk Stratification

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

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

Conceptual Framework:Malaria Burden

Malaria mortality

Malaria infection

Malaria morbidity

Treatment:Early diagnosisAnd treatment

Health care system: Accessibility Affordability Quality of care Efficiency Demand/utilization

Prevention:• LLINs, IRS, IPT• Environmental management

Malaria knowledge:• Cause• Prevention methods• Early treatment• Cultural beliefs• Information

Program factors:• Health policy• Antimalarial drug policy• Support/partnership• National MCP

External factors:• Environmental (ecological, climate)• Socioeconomic (economic status, movement, occupation, housing condition, war, population displacement, etc.)• Demographic ( age, immunity, gender)

Conceptual Framework: Malaria Control and Elimination

Key Malaria Targets and GoalsAfrican 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 Outputs Outcomes Impact•Strategies•Policies•Guidelines•Funding•Materials•Facilities•Commodities•Supplies•Staff

•Training•Services•Education•Treatments•Interventions

•Services delivered•Knowledge, skills, practice

•# ITNs distrib.•# HH sprayed•IPTs delivered•# antimalarials delivered•RDTs/slides taken

•Coverage•Use

•%HH ITN possession•%ITN use•IRS coverage•%U5 treatment

•Malaria incidence/ prevalence•Mortality•Socio- economic wellbeing

•U5MR•Malaria morbidity/ mortality•Economic impact

Examples of Indicators

SO1: Reduced Malaria BurdenSO1: Reduced

Malaria Burden

IR2: Improved malariaepidemic prevention & management

IR2: Improved malariaepidemic prevention & management

IR3: Increased accessto early diagnosis & prompt treatment of malaria

IR3: Increased accessto early diagnosis & prompt treatment of malaria

IR1.1 Access to & coverage by ITNs increased

IR1.1 Access to & coverage by ITNs increased

IR1.2 Improved access to IPTIR1.2 Improved access to IPT

IR1.3 IRS coverage increased in epidemic prone areas

IR1.3 IRS coverage increased in epidemic prone areas

IR1.4 Use of source reduction/ larvicidingincreased

IR1.4 Use of source reduction/ larvicidingincreased

IR3.4 Access to services improved IR3.4 Access to services improved

IR1: Improved malaria preventionIR1: Improved malaria prevention

IR2.1 Early detection & appropriate response

improved

IR2.1 Early detection & appropriate response

improved

IR2.2 Epidemic preparedness improvedIR2.2 Epidemic preparedness improved

IR2.3 Surveillance system improvedIR2.3 Surveillance system improved

IR2.4 Early warning system strengthenedIR2.4 Early warning system strengthened

IR3.1 Quality ofcare improved IR3.1 Quality ofcare improved

IR3.2 Efficiency in service delivery improved

IR3.2 Efficiency in service delivery improved

IR3.3 Utilization of care improved IR3.3 Utilization of care improved

Results Framework: Malaria Control Program

Logical Framework:Malaria Control Program

Performance indicators Means of verification

Assumptions

Goal: Reduced malaria morbidity and mortality. • Malaria incidence and

prevalence rates

• Annual reports• Surveys• DSS (INDEPTH)• DHS

• Strong financial

support• Malaria control

capacity increased

Purpose: Strong and sustainable malaria prevention and control strategies to reduce morbidity and mortality will be implemented

• Coverage of control

interventions

• Annual reports• Surveys• Record reviews

• Problem of drug resistance will be reduced through effective and affordable drugs

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

• 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

Performance indicators Means of verification

Assumptions

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

•Community

surveys

• Availability of ITNs• Subsidies for ITNs• High community awareness and acceptance of ITN

Output: •Distribution of mosquito net to the target population will improve

• District health workers will be trained for implementation of ITN/LLIN strategy

• # of ITN/LLIN distributed to the

target population• # of health workers trained

on ITN/LLIN strategy implementation

• Reports• Review document

• Funds available

Logical Framework:Malaria Control Program

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

Input Indicators

Process Indicators

Output Indicators

Outcome 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

RBM CoreOutcome Indicators

RBM Intervention

Indicator Description

Insecticide-treated nets (ITNs) and indoor residual spraying (IRS) 

1. Proportion of households with at least one ITN2. Proportion of households with at least one ITN for every two people

3, Proportion of population with access to an ITN within their household

4. Proportion of individuals who slept under an ITN the previous night

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

Prompt and effective treatment and use of diagnostics

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 control of malaria in pregnant women

10. Proportion of pregnant women who slept under an ITN the previous night

11. Proportion of women who received intermittent preventive treatment for malaria during ANC visits during their last pregnancy

RBM Core Impact Indicators

RBM Impact Measures Indicator Description

Mortality Indicator 1. All-cause under 5 mortality rate (5q0).

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/dL

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 TestingProportion 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

Source: WHO, 2010 World Malaria Report

Proportion of all pregnant women receiving the second dose of IPT

Reduction of >50% in Cases: 11 African countries

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Eritrea Rwanda

ZambiaSao Tome and Principe

Highlight: Rwanda

Source: World Malaria Report 2010

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?

Class ActivityMalaria 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

ReferencesAfrica 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

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.