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

Malaria mortality

Treatment:Early diagnosis& treatment

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

Program factors:• Health policy• Anti-malarial drug policy• Support/partnership• National MCP

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

Prevention:• ITNs, IRS, IPT• Environmental mgt

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

Malaria infection

Malaria morbidity

Conceptual Framework (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 malaria-relevant 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

Processes Malaria-related commodity procurement (ACT, ITN); training; BCC

Outputs Services delivered (insecticides; drug-efficacy studies; ITNs sold, distributed; nets retreated; anti-malarial drugs distributed, etc.)

Outcomes Changed behaviors and coverage (anti-malarial treatment of children < 5; HH ITN possession & usage; IPT use by pregnant women; malaria epidemics detected & controlled

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

SO1: Reduced Malaria Burden

IR1: Improved malaria prevention

IR2: Improved malariaepidemic prevention & management

IR3: Increased accessto early diagnosis & prompt treatment of malaria

IR3.1 Quality ofcare improved

IR3.2 Efficiency in service delivery improved

IR3.3 Utilization of care improved

IR1.1 Access to & coverage by ITNs increased

IR1.2 Improved access to IPT

IR1.3 IRS coverage increased in Epidemic-prone areas

IR1.4 Use of source reduction/ larvicidingincreased

IR2.1 Early detection & appropriate response

improved

IR2.3 Surveillance system improved

IR2.2 Epidemic preparedness improved

IR2.4 Early warning system strengthened

Results Frameworks (MCP)

IR3.4 Access to services improved

Logical Framework (MCP)

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

Logical Framework (MCP)

Performance indicators Means of verification

Assumptions

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

•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

• # of ITNs distributed to the

target population• # of health workers trained

on ITNs• # of CHWs trained

• Reports• Review document

• Fund available

InputIndicators

ProcessIndicators

OutputIndicators

Outcome Indicators

ImpactIndicators

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

Core population coverage indicators for RBM

Level and function of M&E indicators

RBM Core Coverage Indicators

RBM Technical StrategiesRBM outcome indicators of

population coverage

Vector control- ITNs

1. % of households with at least one ITN

2. % of children <5 who slept under an ITN the previous night

Prompt access to effective treatment

3. % of children <5 with fever in last 2 weeks who received antimalarial treatment according to national policy within 24 hours of onset of fever

Prevention and control of malaria in pregnant women

4. % of pregnant women who slept under an ITN the previous night

5. % of women who received IPT for malaria during their last pregnancy

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

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.