Monitoring and Evaluation: Malaria-Control Programs

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

Content Outline
1. Introduction 2. Current situation of malaria control 3. Conceptual framework for malaria control

4. RBM-control strategies
5. International and regional targets 6. Results and logical frameworks for malaria 7. Level and function of M&E indicators 8. M&E indicators for malaria 9. Strengths and limitations of indicators

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

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

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

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

Health care system:

Accessibility Affordability Quality of care Efficiency Demand/utilization

Prevention: ITNs, IRS, IPT Environmental mgt Treatment: Early diagnosis & treatment Malaria knowledge: Cause
Prevention methods Early treatment Cultural beliefs Information

Malaria morbidity Malaria mortality

Program factors: Health policy

Anti-malarial drug policy Support/partnership National MCP

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

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

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

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

RBM Strategies
1. 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

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 malariarelevant information Verify whether activities implemented as planned Provide feedback to relevant authorities Document periodically whether planned strategies have achieved expected outcomes & impact

Basic Malaria M&E Framework

Inputs Policies, guidelines, strategies for malaria control at national level; human resources; financing & disbursements Malaria-related commodity procurement (ACT, ITN); training; BCC Services delivered (insecticides; drug-efficacy studies; ITNs sold, distributed; nets retreated; anti-malarial drugs distributed, etc.) Changed behaviors and coverage (anti-malarial treatment of children < 5; HH ITN possession & usage; IPT use by pregnant women; malaria epidemics detected & controlled

Processes Outputs

Outcomes

Impact

Malaria-associated morbidity and mortality (childhood anemia; proportional outpatient; health facility visits, admissions, deaths due to malaria, etc.)

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

Results Frameworks (MCP) SO1: Reduced Malaria Burden IR2: Improved malaria epidemic prevention & management IR2.1 Early detection
& appropriate response improved

IR1: Improved malaria prevention IR1.1 Access to & coverage by ITNs increased IR1.2 Improved access to IPT

IR3: Increased access to early diagnosis & prompt treatment of malaria IR3.1 Quality of care improved

IR2.2 Epidemic preparedness improved IR2.3 Surveillance system improved

IR1.3 IRS coverage increased in Epidemic-prone areas IR1.4 Use of source reduction/ larviciding increased

IR3.2 Efficiency in service delivery improved

IR3.3 Utilization of care improved IR3.4 Access to services improved

IR2.4 Early warning system strengthened

Logical Framework (MCP)

Performance indicators Goal: Reduced malaria morbidity and mortality. Malaria incidence and prevalence rates Means of verification Annual reports Surveys DSS (INDEPTH) DHS Annual reports Surveys Record reviews Assumptions Strong financial support Malaria control capacity increased Problem of drug resistance will be reduced through effective and affordable drugs

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

Coverage of control interventions

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

Logical Framework (MCP)

Performance indicators Outcome: Access to and utilization of ITNs increased % of households with at least one ITN % of under-5 who slept under ITN the previous night % of pregnant women slept under ITN the previous night # of ITNs distributed to the target population # of health workers trained on ITNs # of CHWs trained Means of verification Assumptions

Community surveys

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

Output: Distribution of mosquito nets to the target population will be improved District health workers will be trained for implementation of ITNs strategy Social marketing strengthened

Reports Review document

Fund available

Level and function of M&E indicators

Core population coverage indicators for RBM

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

RBM Core Coverage Indicators

RBM Technical Strategies
1. Vector control- ITNs 2.

RBM outcome indicators of population coverage

% of households with at least one ITN % of children <5 who slept under an ITN the previous night

3.
Prompt access to effective treatment 4. Prevention and control of malaria in pregnant women 5.

% of children <5 with fever in last 2 weeks who received antimalarial treatment according to national policy within 24 hours of onset of fever
% of pregnant women who slept under an ITN the previous night % of women who received IPT for malaria during their last pregnancy

M&E Challenges of National MCPs: Measuring Impact

Not routinely requiredtechnical strategies already proven efficacious for these indicators of impact, so coverage should suffice
debatable

Requires rigorous experimental design Technical strategies intended to be fullcoverage programs

Costly

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

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

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?

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