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Monitoring and Evaluation:Malaria-Control Programs

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Learning ObjectivesBy 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 ofthe RBM strategy & recognize their strengths &

limitations

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Content Outline1. 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

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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 to310,000 deaths in Africa annually

Drug resistance exacerbates the malaria problem

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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

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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

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Malaria

mortality

Treatment:

Early diagnosis

& treatment

Health care system:Accessibility

AffordabilityQuality of care

Efficiency

Demand/utilization

Program factors:

Health policyAnti-malarial drug policy

Support/partnership

National MCP

Malaria knowledge:CausePrevention 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)

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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

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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 effectivemalaria prevention and treatment

measures

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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

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Abuja Targets: By 2005

At least 60% of those suffering from malariashould be able to access and use correct,affordable, and appropriate treatment within 24hours of the onset of symptoms

At least 60% of those at risk of malaria,particularly pregnant women and childrenunder five years of age, should benefit fromsuitable personal and community protective

measures such as ITNs

At least 60% of all pregnant women who are atrisk of malaria, especially those in their first

pregnancies should receive IPT

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RBM Strategies1. Use of ITNs and other locally approved

means of vector control

Children

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Roll Back Malaria M E

Extensive & systematic M&E relatively newfor 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 asplanned

Provide feedback to relevant authorities

Document periodically whether plannedstrategies have achieved expected outcomes &impact

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Basic Malaria M&E Framework

Inputs Polic ies, guid el ines, strategies for malaria control atnat ional level; human resourc es; f inancing &

disbursements

Processes Malaria-related commod ity pr ocurement (ACT, ITN);training; BCC

Outputs Services d el ivered (insect ic ides; dru g-eff icacy stud ies;ITNs sold , distr ibuted; nets retreated; ant i-malaria l drug s

dis trib uted, etc.)

Outcomes Changed b ehaviors and coverage (ant i-malaria l treatmentof ch i ldren < 5; HH ITN possession & u sage; IPT use by

pregnant women; malaria epidemics detected &contro l led

Impact Malaria-associated morb idi ty and mo rtal i ty (chi ldh oodanemia; propo rt ional outp at ient; health faci l i ty vis i ts,

adm issio ns, deaths due to malaria, etc.)

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M E Priorities in LimitedResource Settings Human & financial inputs

Malaria control services delivered to those at

risk of malaria

Coverage of interventions

Malaria-associated morbidity & mortality

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SO1: ReducedMalaria Burden

IR1: Improved

malaria prevention

IR2: Improved malaria

epidemic prevention

& management

IR3: Increased access

to 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 ITNsincreased

IR1.2 Improved

access to IPT

IR1.3 IRS coverage

increased in

Epidemic-prone areas

IR1.4 Use of source

reduction/ larviciding

increased

IR2.1Early detection

& appropriate responseimproved

IR2.3 Surveillancesystem improved

IR2.2 Epidemic

preparedness improved

IR2.4 Early warning

system strengthened

Results Frameworks (MCP)

IR3.4 Access to

services improved

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Logical Framework (MCP)

Performanceindicators Means ofverification Assumptions

Goal: Reduced malariamorbidity and mortality.Malaria incidence and

prevalence rates

Annual reportsSurveys

DSS (INDEPTH)

DHS

Strong financialsupport

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

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Logical Framework (MCP)

Performance indicators Means of

verification

Assumptions

Outcome: Access to andutilization of ITNs increased

% of households with atleast 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 strategySocial marketing strengthened

# of ITNs distributed to the

target population

# of health workers trained

on ITNs

# of CHWs trained

Reports

Review

document

Fund available

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Input

Indicators

Process

Indicators

Output

Indicators

Outcome

Indicators

Impact

Indicators

Ind icators for moni tor ing the performance

of malaria programs / interventions ,

measured at the program level

Indicators for evaluating results of

malaria programs / interventions,

measured at the popu lation level

Core populat ion

coverage indicators

for RBM

Level and function of M E indicators

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RBM Core Coverage IndicatorsRBM Technical Strategies RBM outcome indicators of

population coverage

Vector control- ITNs

1. % of households with at least one ITN

2. % of children

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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 full-coverage programs

Costly

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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

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M&E Challenges: Complexity of

Malaria Epidemiology

Not a linear relationship between

transmission (immunity) and malaria-related

mortality

Severity and symptomology of malariamorbidity 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

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Class Activity

Malaria is the most frequent cause of morbidityand 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 increasingownership and appropriate use of ITNs.

Q. Describe the various components of the PSI program

that need to be monitored?

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References

World Health Organization and UNICEF. 2005.

World Malaria Report 2005. Geneva: WHO.