Measuring progress and impact

Monitoring and evaluation

National malaria elimination programmes should be evaluated at regular intervals for compliance with the targets and objectives to be achieved. Parameters should be established to monitor and evaluate all programme areas, with a focus o­n four key issues:

·    monitoring the operational aspects of the programme, and measuring impact or process indicators to ensure that the activities are yielding desired results and moving the programme towards achieving its operational targets and objectives;

·     monitoring changes in epidemiological indicators resulting from the activities implemented;

·     appropriately interpreting results and informing revisions in policies or strategies, when needed, to help ensure progress; and

·      documenting progress towards malaria elimination.

Information o­n coverage and quality of interventions, mapping out residual and new active foci of malaria, relevant eco-epidemiological data and first-line treatment efficacy are particularly important.

For the elimination phase, each country will need to establish a malaria elimination database. This will serve as the national repository of all information related to malaria elimination, and should include the following.

·     National malaria case register: a single database of all individual case information from identified sources in the entire country, allowing detailed analysis and synthesis of epidemiological information and trends, which can help to guide the elimination programme over time.

·      Malaria patient register: a central repository of all malaria patient records.

·      Laboratory register: a single database, linked to the patient register, which contains all pertinent information regarding malaria diagnosis of the patient. Comparison of the laboratory and malaria patient registers allows cross-checking for completeness of case data.

·     Entomological monitoring and vector-control records: a central repository of information related to entomological monitoring and application of chosen vector-control interventions.

Ideally, the oversight of the malaria elimination database should be the responsibility of a national committee that is independent of the malaria programme (22).

Progress o­n the path to malaria elimination within the GMS will be based o­n countries' surveillance efforts. Progress will be measured using multiple data sources, including routine information systems, household and health facility surveys, and longitudinal studies. Progress should be monitored through a minimal set of outcome and impact indicators (see Annex 3 & 4) drawn from a larger set of indicators recommended by WHO and routinely tracked by malaria programmes.

Essential steps in strengthening monitoring and reporting

A number of essential activities will need to be implemented to develop and strengthen the surveillance, monitoring and reporting systems required for the effective implementation of the GMS malaria elimination strategy.

At national level, strengthening of surveillance, monitoring and evaluation (SME) will need to include:

·     establishment of country SME technical working groups;

·     updating of the national SME plan;

·     SME capacity-building;

·     establishment of a national malaria elimination database;

·     regular external or joint malaria programme reviews; and

·     annual national malaria reporting.

At subregional level, strengthening SME will need to include:

·     establishment of intercountry SME technical working groups;

·     development of a GMS surveillance and monitoring and evaluation (M&E) framework;

·     harmonization and standardization of SME tools;

·     monthly reporting against a GMS scorecard;

·     establishment of a web-based data sharing platform; and

·     joint external monitoring and evaluation.

M&E framework

A draft M&E framework has been developed by the WHO ERAR Regional Hub, in consultation with GMS countries and partners. The framework, which was reviewed by the ERAR SME Regional Technical Working Group, will be adjusted to suit the Strategy for malaria elimination in the Greater Mekong Subregion (2015-2030). In further refining the framework, the following principles and assumptions will be taken into account.

·     Malaria surveillance is the central component in M&E in the elimination phase. Programmes are assumed to be capable of rapidly transferring funds to ensure coverage and quality.

·     Operationally, the main information requirement is to indicate which areas are in the elimination phase at a given point in time. Based o­n the criteria for the elimination phase, it is possible to distil a shortlist of criteria that can be verified for each first level administrative area. From the perspective of coordinated GMS elimination, it is then important to report exactly which administrative units have reached this operational status.

·      Indicators o­n surveillance coverage are central to verification of elimination and to its sustainability. o­ne indicator can be collected from surveys asking people what kind of provider they will go to or went to last time, in case of fever. The other should cover all kinds of health service provider, and the questions should address how the provider would manage a case of fever and how it would be reported, if the provider manages malaria. In countries that have eliminated malaria, health services are usually reasonably well developed. Setbacks o­n the pathway to malaria-free status or reintroduction of malaria are often related to lack of awareness o­n the part of physicians and other kinds of service providers.

Cost of implementing the strategy

In 2015, a costing exercise of malaria elimination will be carried out in collaboration with the national malaria programmes in each GMS country and then consolidated at regional level.

A cost estimate for P. falciparum elimination was prepared as part of an elimination feasibility study done in 2014. This cost estimate was based o­n the funding gap analysis developed by WHO to mobilize resources for resistance containment. This analysis was expanded to cover the period until 2030 and to include a new set of activities for elimination. The projection is made for the 15-year period from 2015 to 2030 (see Table 4).

Table 4. Total costs and distribution of costs by category for two scenarios for elimination of P. falciparum malaria in the GMS, 2015-2030

Scenario 1 Scenario 2 Assumptions Relatively difficult to reduce P. falciparum malaria; continued need for high coverage with LLINs in all high- and low-transmission areas. Faster decline of P. falciparum; high coverage of LLINs o­nly in high-transmission areas and 40% of low-transmission areas; gradual cost-sharing for community health workers. Costs     Total cost 2015?2030, US$ 3.9 billion Vector control 27% 22% Case management 26% 23% Surveillance 17% 22% Private sector 7% 9% Supporting activities 23% 24%

Based o­n the specific assumptions included in these estimates, the total cost of eliminating P. falciparum malaria in the GMS would range from US$ 3.2 to 3.9 billion over 15 years; that is, it would be an average of US$ 1.8-2.2 per capita for the population at risk of malaria per year. Although the total cost is significant it should not be out of reach. These costs should be weighed against the epidemiological and economic costs of inaction.

Governance and coordination

There is a general consensus that governance and coordination of malaria activities across the GMS is essential, and must be improved at both the regional and country level.

Countries need to establish strong and proactive national malaria elimination committees responsible for monitoring progress and coordination. Efforts to strengthen coordination will need to focus o­n strategic planning, research, data sharing, resource mobilization, review mechanisms, communications and advocacy, oversight of implementation, division of labour and private sector engagement.

At regional level, a governance and coordination structure would comprise three components: a political component with strong country representation; a technical component led by WHO; and a financial component responsible for fund-raising and fund management.

The final regional governance and coordination structure for malaria elimination in the GMS will be determined by countries in consultation with partners. In proposing options for a future governance structure for malaria elimination in the GMS, several principles need to be taken into account, as outlined below.

Strong country ownership and representation

National governments are key to the success of the elimination effort and need to take the lead role in governance.

Building o­n existing structures

If o­ne of the reasons to strive for better coordination is to improve efficiency, this is unlikely to benefit from yet another separate mechanism. With this in mind, and to guard against duplication of mechanisms in the future, the structure adopted needs to be acceptable to a range of partners, including those that are currently funding, or may in future be funding, malaria elimination in the region.

Key stakeholders and constituencies adequately represented

This does not mean that every stakeholder can participate directly in the mechanism, because this would result in an unmanageably large group. Constituencies (e.g. civil society organizations, NGOs, private sector, academia and military) should be asked to agree o­n a regional representative to participate in meetings of the governance mechanism.

Strong engagement and accountability of members

It is critical that members of the governance mechanism are actively engaged. This is more likely if they are selected for their interest in malaria elimination, if the mechanism gives them authority to influence the use of resources and they are provided with appropriate and up-to-date information.

Ability to challenge

Effective governance mechanisms need to be able to question the information being provided to them and, where necessary, call for its verification. Whatever the governance mechanism decided for malaria elimination in the GMS, it is likely to benefit from being reported to by an independent monitoring group that can provide an objective assessment of how malaria elimination activities are progressing across the region.

Flexibility to respond to changing circumstances

The governance mechanism should not be bound by institutional limitations that make decision-making a lengthy process. The mechanism must be empowered to make decisions.

Accepting of risk

Elimination of malaria will require innovation, which almost always involves risk. The governance mechanism should not be set up under the auspices of an organization that is highly risk averse.

Stability

Funding and the institutional base for the governance mechanism and its secretariat need to be predictable for a reasonable duration.

Annex 1.The WHO Global technical strategy for malaria 2016?2030 at a glance

Vision - A World Free Of Malaria Goals Milestones Targets 2020 2025 2030 1. Reduce malaria mortality rates globally compared with 2015 > 40% > 75% > 90% 2. Reduce malaria case incidence globally compared with 2015 > 40% > 75% > 90% 3. Eliminate malaria from countries in which malaria was transmitted in 2015 At least 10 countries At least 20 countries At least 35 countries 4. Prevent re-establishment of malaria in all countries that are malaria-free Re-establishment prevented Re-establishment prevented Re-establishment prevented Principles All countries can accelerate efforts towards elimination through combinations of interventions tailored to local contexts. Country ownership and leadership, with involvement and participation of communities, are essential to accelerating progress through a multisectoral approach. Improved surveillance, monitoring and evaluation, as well as stratification by malaria disease burden, are required to optimize the implementation of malaria interventions. Equity in access to services especially for the most vulnerable and hard-to-reach populations is essential. Innovation in tools and implementation approaches will enable countries to maximize their progression along the path to elimination. Strategic framework Comprising three major pillars, with two supporting elements: (1) innovation and research and (2) a strong enabling environment Maximize impact of today?s life-saving tools Pillar 1. Ensure universal access to malaria prevention, diagnosis and treatment Pillar 2. Accelerate efforts towards elimination and attainment of malaria-free status Pillar 3. Transform malaria surveillance into a core intervention Supporting element 1. Harnessing innovation and expanding research Basic research to foster innovation and the development of new and improved tools Implementation research to optimize impact and cost-effectiveness of existing tools and strategies Action to facilitate rapid uptake of new tools, interventions and strategies Supporting element 2. Strengthening the enabling environment Strong political and financial commitments Multisectoral approaches, and cross-border and regional collaborations Stewardship of entire heath system including the private sector, with strong regulatory support Capacity development for both effective programme management and research Source: The WHO Global technical strategy for malaria 2016-2030

The Greater Mekong Subregion malaria elimination strategy is based o­n the principles, strategies and support elements described in the GTS. The WHO Global technical strategy for malaria 2016-2030 elimination strategy roll-out will be guided by the three pillars and supporting elements, adapted in response to local epidemiological settings.

Annex 2. The malaria situation in the Greater Mekong Subregion

Historical aspects and lessons learnt

Malaria control in the GMS began in the 1930s. In the 1950s, WHO promoted mass drug administration with chloroquine as an additive to household salt, and by 1960, chloroquine-resistant P. falciparum had emerged o­n the Cambodia-Thailand border. Genetic studies indicate that chloroquine resistance then spread from South-East Asia to India and later to Africa. About 20 years later, resistance to sulfadoxine-pyrimethamine emerged in Thailand, and soon after some of the causative polymorphisms spread from Thailand to Africa (23).

As with other endemic regions, during the late 1950s and 1960s the GMS participated in the WHO-coordinated Global Malaria Eradication Programme. While the programme was successful in eliminating malaria from most temperate countries, it failed to achieve its goal and was abandoned in 1969 (24). It was recognized that the weapons used had been inadequate against two challenges: the high vectorial capacity in African savannah areas and the convergence of resilient vectors and population movement in the forests and forest fringes of South-East Asia and South America.

After termination of the Global Malaria Eradication Programme, China, Thailand and Viet Nam maintained strong control programmes and saw gradually reducing malaria burdens. Viet Nam experienced a resurgence in 1990-1991, but from 1992 the situation o­nce more improved, thanks to increased investments and the adoption of insecticide-treated mosquito nets (ITNs) and artemisinin-based antimalarials. From the mid-1990s, Cambodia and then the Lao People's Democratic Republic began to attract international support and were able to introduce new tools and start to reduce their malaria burdens.

Progress accelerated around 2003 thanks to the adoption of ACTs, RDTs and high levels of coverage of interventions, which became possible with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

However, Myanmar was neglected and, because of the continued high burden there, the disease has persisted in western Thailand and in Yunnan Province, China. From around 2011, increased international support for Myanmar has allowed increased coverage with malaria control interventions with the result that the country is now catching up with others in the subregion.

Recent history and current trends

Estimates of malaria morbidity and mortality show a 35% reduction in cases between 2000 and 2012, and a 30% reduction in the annual number of malaria deaths. The estimates are derived from routine surveillance data adjusted for factors such as health-seeking behaviour. In 2012, Myanmar accounted for 77% of the estimated cases and 79% of estimated malaria deaths in the GMS, and the regional trends in incidence in the last few years have been dominated by the significant reductions there. Population at risk, reported cases and deaths and trends since 2000 are shown in table A2.1. In Cambodia, reported malaria cases have also been falling, but in the Lao People's Democratic Republic, malaria resurgence has led to an increase in the number of reported cases (Fig. A2.1). Increases in numbers of reported cases in recent years have occurred because of more inclusive reporting in Cambodia, Myanmar and Thailand.

Table A2.1 2013 Malaria situation in Greater Mekong Subregion countries

Figure A2.1 Changes in key malaria indicators in the GMS, 2000-2013, WHO World malaria report 2014(25)

Confirmed malaria cases and ABER (%)

Malaria admissions and deaths

                 

The malaria drug resistance situation and efforts to contain it

In 2006-2007, WHO alerted the international malaria community to the emergence of artemisinin tolerant P. falciparum parasites at the Cambodia-Thailand border. Because artemisinin compounds are a key component of ACTs, the mainstay for the treatment of P. falciparum malaria, this was highlighted as a potential threat to malaria control worldwide. Continuous weakening of artemisinins could mean that any partner drug is being used as a virtual monotherapy. Ultimately, this could select for P. falciparum strains resistant to the partner drug as well, undermining the efficacy of ACTs.

A containment project was then initiated in Cambodia and Thailand with support from the Bill & Melinda Gates Foundation, based o­n the Strategy for the containment of artemisinin tolerant malaria parasites in South-East Asia, 2009-2011 (ARCE), which established defined zonation associated with artemisinin tolerance in P. falciparum.

In 2009-2010 emergence of artemisinin resistance was recognized in Myanmar and Viet Nam. In 2010, WHO launched the Global action plan o­n artemisinin resistance (GPARC), which delineated the roles and responsibilities of different actors. The definition of artemisinin resistance was further defined, and a tier-wise geographical prioritization based o­n status of artemisinin resistance was devised. Areas in countries were then classified as follows:

• Tier I: Areas for which there is credible evidence of artemisinin resistance, where an immediate, multifaceted response is recommended;
• Tier II: Areas with significant inflows of mobile and migrant populations from Tier I areas, with intensified malaria control to reduce transmission; and
• Tier III: P. falciparum-endemic areas that have no evidence of artemisinin resistance, where prevention and preparedness should focus o­n increasing coverage with standard malaria control.

The intensified activities in Tier I under ARCE led to a decline in the number of cases, but unsurprisingly, the level of artemisinin resistance increased (26). Following the assessment of the response to artemisinin resistance in the GMS in late 2011 and early 2012, the Emergency response to artemisinin resistance (ERAR) in the Greater Mekong Subregion was initiated, and a regional framework for action was launched in April 2013 (27). The framework highlighted areas where urgent action is needed to preserve ACTs as an effective treatment for P. falciparum, and ultimately eliminate malaria from the GMS. Fifteen essential actions, which constitute the basis for the current response to artemisinin resistance, were then defined in the following four areas:

• full coverage with high-quality interventions in priority areas;
• tighter coordination and management of field operations;
• better information for artemisinin resistance containment; and
• regional oversight and support.

WHO has received funding from the Australian Government and Bill & Melinda Gates Foundation to strengthen coordination and technical support for related activities. A dedicated office, the 'ERAR Regional Hub', has been established in Phnom Penh. The Global Fund has allocated US$ 100 million to activities over three years (2014-2016) to fund containment and elimination operations and ultimately eliminate artemisinin resistance in the GMS. This funding supports activities both at country and regional levels. All GMS countries, with the exception of China, are now implementing an artemisinin resistance containment plan.

There has been dramatic progress over the last few years in research o­n artemisinin resistance. The discovery of molecular markers for artemisinin resistance (mutation in the propeller domain of the Plasmodium falciparum Kelch 13 protein) has greatly impacted o­n definitions of resistance and surveillance methods and has allowed greater efficiency, precision and differentiation in the surveillance of artemisinin resistance.

According to the latest report from the Drug Resistance Containment - Technical Expert Group: "Genetic analysis has identified multiple genetic lineages of artemisinin resistance, suggesting that it is not o­nly spreading but also emerging de novo, thus raising concerns about the effectiveness of a 'firewall approach' (delaying or preventing spread from a focus) and giving further support to the advisability of eliminating P. falciparum malaria transmission in all areas of confirmed artemisinin resistance. Prevention of spread of resistance from GMS, however, remains crucial because P. falciparum malaria has become increasingly resistant to the main new partner drugs (lumefantrine, mefloquine, piperaquine)." In consequence of this strategic reorientation, DRC-TEG also recommended that the category of Tier III be abandoned: within GMS, any P. falciparum-endemic area that is not Tier I should be considered as Tier II (28).

The recent emergence of significant resistance to partner drugs, especially piperaquine, in western Cambodia, raises the spectre of untreatable malaria in the GMS.

Epidemiological characteristics

Vectors, climate and ecology

Due to interactions between bio-geography and ecology malaria transmission in the GMS is largely restricted to forest-like environments below 800-1500 m, foothills and coastal areas. It depends o­n, among other factors, vector behaviour and ecology, and the degree of contact between humans and the Anopheles mosquitoes. The primary inland malaria vectors are: Anopheles dirus, which o­nly survives in shaded and humid areas; An. minimus, which can survive in light forest and in foothills after deforestation; and various less efficient vectors, which are associated with rice fields. In coastal areas with stagnant brackish water, members of the An. sundaicus complex are important; higher population density with better developed health services has made it easier to control malaria in such areas. All of the vectors exhibit tendencies to exophily (outdoor resting), exophagy (outdoor biting) and early biting, but such habits are especially pronounced for An. dirus; this to some extent constrains the effectiveness of IRS, and LLINs in forest-like environments (29).

In most areas of the GMS, transmission is perennial with seasonal peaks. North of 20-25°N, transmission is interrupted in the cold season. GIS mapping of malaria incidence rates confirms that malaria is concentrated in forested areas, but the burden can vary dramatically over short distances. Outbreaks in the GMS are mostly related to population movements and rarely to climatic factors, except in some instances like in the central 'dry zone' in Myanmar where outbreaks have been associated with increased rains. Over 2011-2012, there were outbreaks in six southern provinces of the Lao People's Democratic Republic accounting for 95% of the cases reported in the country for 2012. These were attributed to a number of factors including unregulated logging and development projects attracting migrant workers. In late 2013, there was a tenfold increase of malaria cases in Ubon Ratchathani Province, Thailand, as loggers returned from the Lao People?s Democratic Republic.

Risk groups and mobility

The main risk groups in forested and foothill areas are:

• ethnic minority groups living in or near forested areas, who are typically engaged in swidden (slash and burn) agriculture;
• villagers and farmers living in forest fringes, including new settlers and planters;
• plantation workers, especially in rubber plantations with night-time work; these workers are often seasonal and often migrants;
• people who have been displaced to forest or forest-fringe areas as refugees or because of development projects such as dams;
• other persons who temporarily enter forests, such as security forces, loggers, miners, tourists and many others;
• military and police forces deployed at border areas; and
• people living or working in coastal areas involved in farming, aquaculture, fishing or smuggling.

These different groups can be distinguished by different degrees and types of mobility, as well as by their legal status or lack thereof. They may overlap: persons belonging to ethnic minority groups may, for example, be forest-fringe farmers or plantation workers.

In the recent past, ethnic minority groups practising swidden agriculture were the largest and most important populations in the GMS in terms of malaria burden. Among them, whole families but especially adult males spend days or weeks away from their villages, tending forest plots, gathering forest products or hunting (30). As a result, the cycle of transmission may continue in these communities, even if it is interrupted within the village (31). Swidden farming communities are gradually disappearing (though in Myanmar they may still number more than 2 million [5,6] (32, 33)) and most of those that remain are now relatively well served by LLIN provision and community-based case management services.

Migrants are not necessarily in very remote areas, nor excluded (4, 34). 'Recognizing mobility as a system involving multiple demographic groups, localities and intersecting socio-economic processes' is proving increasingly important (35). When malaria elimination in the GMS approaches the final stage, the main concern will be the risk of importation from other countries, especially malaria-endemic areas in Bangladesh and north-east India bordering Myanmar. Compared to flows within the GMS, movements across Myanmar's borders with these two countries appear relatively small. Malaria control there is making progress; the determinants of risk are the same as in the GMS. Good progress in elimination in the GMS will likely inspire similar efforts in Bangladesh and north-east India, reducing the vulnerability of Myanmar.

Increased global air travel may increase the risk of malaria importation. For example, China is experiencing frequent importation of P. falciparum from Africa, and travel between Africa and the capital cities of South-East Asia is also increasing (36). In a containment perspective, two problems at present are: migrants from western Myanmar, who are moving to other countries including Bangladesh, possibly to malaria risk areas; and soldiers visiting Africa either as a result of deployment as members of peacekeeping forces or for military training visits and exchanges.

Other determinants

The reduction in the malaria burden in the GMS during the last decade is a result of not o­nly investments in malaria control but also contextual changes such as deforestation and poverty reduction (37). Although economic growth should be expected to reduce migration-related malaria risk, such factors as inequity, demand for forest products and infrastructure projects near to or in forested areas will maintain migration-related malaria risk, possibly facilitated by the development of transport networks and opening up of borders. In the short term, o­ne of the most important interventions, which could be undertaken by governments, would be to improve regulation and enforcement, to completely prevent such activities as illegal logging and to mandate companies that are licensed to operate in or near forested areas to seek the advice and collaboration of the health sector.

Insecurity and political instability remain the most serious potential risks. The situation in the GMS is improving in this respect, but a reversal could jeopardize the chances of malaria elimination and reverse many of the recent gains of malaria control.

Annex 3. Proposed indicators to measure progress and impact in the elimination phase

Source: WHO Disease surveillance for malaria elimination: an operational manual.

Annex 4.Proposed surveillance indicators in the transmission-reduction phase

Indicator Definition / calculation Purpose Confirmed malaria cases (number and rate per month or per year) Number of confirmed malaria cases x 1000/Population at risk of malaria To measure trends in malaria morbidity and to identify locations of o­ngoing malaria transmission. This indicator is the most important measure of progress and management in low-incidence areas. Inpatient malaria cases (number and rate per month or per year) Number of inpatient malaria cases x 10 000/Population at risk of malaria To monitor the impact of programs o­n severe disease. This indicator may reflect the impact of treatment, as treatment attenuates clinical progression from uncomplicated to severe disease. Inpatient malaria deaths (number and rate per month or per year) Number of inpatient malaria deaths x 100 000/Population at risk of malaria To monitor the impact of programs o­n the number of malaria deaths Malaria test positivity rate (RDT and/or blood slide) Number of confirmed malaria cases x 1000/Number of patients receiving a parasitological test To reflect trends in malaria morbidity and identify areas with the most intense malaria transmission. Partially 'corrects' for incompleteness of reporting and RDT stock-outs because the numerator is derived from the same source as the denominator. Percentage of cases disaggregated by species Number of confirmed malaria cases by species x 100/Number of confirmed malaria cases To reflect the proportion of cases due to various species and provide information o­n the likelihood of observing severe cases Percentage of inpatient cases with a discharge diagnosis of malaria Number of inpatient cases with a discharge diagnosis of malaria x 100/Total number of inpatients To monitor the impact of programs o­n severe disease. Partially 'corrects' for incompleteness of reporting because the numerator is derived from the same source as the denominator Percentage of inpatient deaths due to malaria Number of inpatient deaths due to ma-laria x 100/Total number of inpatient deaths To monitor the impact of programs o­n the number of malaria deaths. Partially 'corrects' for incompleteness of reporting because the numerator is derived from the same source as the denominator. Annual blood examination rate Number of patients receiving a parasitological test x 100/Population at risk of malaria To reflect the extent of diagnostic testingn a population; aids interpretation of other surveillance indicators. Percentage of suspected malaria cases that have had a diagnostic test Number of patients receiving a parasitological test x 100/Number of suspected cases of malaria WHO recommends that all suspected malaria cases should receive a diagnostic test by microscopy or RDT, regardless of age. The indicator reflects the extent to which malaria programs are able to achieve this goal and where further effort may be required. Completeness of health facility reporting Number of health facilities reports received x 100/Number of health facilities expected Regular monitoring and follow-up can improve the completeness of reporting until all health facilities are consistently reporting everyonth. Aids interpretation of other surveillance indicators. Source: WHO Disease surveillance for malaria control: an operational manual.

 

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