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)
Health care system:
 Accessibility
 Affordability
 Quality of care
 Efficiency
 Demand/utilization
Program factors:
• Health policy
• Anti-malarial drug policy
• Support/partnership
• National MCP
Malaria
infection
Prevention:
• ITNs, IRS, IPT
• Environmental mgt
Treatment:
Early diagnosis
& treatment
Malaria knowledge:
• Cause
• Prevention methods
• Early treatment
• Cultural beliefs
• Information
Malaria
morbidity
Malaria
mortality
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
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
Results Frameworks (MCP)
SO1: Reduced
Malaria Burden
IR2: Improved malaria
epidemic prevention
& management
IR1: Improved
malaria prevention
IR1.1 Access to &
coverage by ITNs
increased
IR1.2 Improved
access to IPT
IR2.1 Early detection
& appropriate response
improved
IR2.2 Epidemic
preparedness improved
IR1.3 IRS coverage
increased in
Epidemic-prone areas
IR1.4 Use of source
reduction/ larviciding
increased
IR2.3 Surveillance
system improved
IR2.4 Early warning
system strengthened
IR3: Increased access
to early diagnosis &
prompt treatment of
malaria
IR3.1 Quality of
care improved
IR3.2 Efficiency in
service delivery
improved
IR3.3 Utilization of
care improved
IR3.4 Access to
services improved
Logical Framework (MCP)
Goal: Reduced malaria
morbidity and mortality.
Performance
indicators
Means of
verification
Assumptions
• Malaria incidence and
prevalence rates
• Annual reports
• Surveys
• DSS (INDEPTH)
• DHS
• Strong financial
support
• Malaria control
capacity increased
• Annual reports
• Surveys
• Record reviews
• Problem of drug
resistance will be
reduced through effective
and affordable drugs
• 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
Purpose: Strong and
sustainable malaria prevention
and control strategies to reduce
morbidity and mortality will be
implemented
• Coverage of control
interventions
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
Logical Framework (MCP)
Performance indicators
Outcome: Access to and
utilization of ITNs increased
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 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
• Reports
• Review
document
• Fund available
Level and function of M&E indicators
Core population
coverage indicators
for RBM
Input
Indicators
Process
Indicators
Output
Indicators
Indicators for monitoring the performance
of malaria programs / interventions,
measured at the program level
Outcome
Indicators
Impact
Indicators
Indicators for evaluating results of
malaria programs / interventions,
measured at the population level
RBM Core Coverage Indicators
RBM outcome indicators of
population coverage
RBM Technical Strategies
Vector control- ITNs
1.
% of households with at least one ITN
2.
% of children <5 who slept under an ITN
the previous night
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
4.
% of pregnant women who slept under
an ITN the previous night
5.
% of women who received IPT for
malaria during their last pregnancy
Prompt access to effective
treatment
Prevention and control of
malaria in pregnant women
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 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.