1. Monitoring and Evaluation: Malaria-Control Programs

2. 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
The objectives of this presentation are: 1) to describe the importance of malaria and its conceptual framework, Roll Back Malaria technical strategies, including the prevention and case management of malaria illness in children under five years old. 2) to build participants’ skills in designing a monitoring and evaluation framework for national-level malaria-control programs, and 3) to identify core population coverage indicators of the Roll Back Malaria strategy and recognize their strengths and limitations. We will deal according to the following content outline and proceed with a discussion of the global burden of malaria and key targets that have been established at the global level.

3. Content Outline Introduction Current situation of malaria control
Conceptual framework for malaria control
RBM-control strategies
International and regional targets
Results and logical frameworks for malaria
Level and function of M&E indicators
M&E indicators for malaria
Strengths and limitations of indicators
The presentation will be done according to this content outline, starting from introduction to the practical case study dealing with the development and assessment of M&E indicators.

4. Why is Malaria Important? Problem Statement
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
Why is malaria important? Today approximately 40% of the world’s population is at risk of malaria. In tropical and subtropical countries it causes more than 300 million acute illnesses and at least one million deaths annually. Ninety percent of the deaths due to malaria occur in SSA, mostly among children under the age of five. Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas. In these areas, malaria accounts for significant morbidity in pregnant women, which also affects the health of newborns. For example, malaria accounts for 2–15% of maternal anemia and 5–14% of low birth-weight births. Malaria causes 30% of with “preventable” low birth-weight births. Malaria also accounts for between 3–5% of all newborn deaths. Malaria accounts for one in five of all childhood deaths in Africa every year. Children who survive an episode of severe malaria may suffer from learning impairments or brain damage. Malaria epidemics also result in up to 12 million malaria episodes and up to 310,000 deaths per year in Africa. Addressing the problem of drug resistance is also a high priority, particularly in Africa.

5. 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
During the mid of the 20th century, malaria control played an important role in opening up many tropical areas to economic developments. In the 1950s, the World Health Assembly mandated WHO to initiate a global malaria-eradication program. The campaign was based on large-scale spraying with DDT supplemented by treatment with chloroquine. As a result, malaria was eliminated from Europe, the Soviet Union, and some countries in the Middle East, Asia and the Americas. By 1969 the global eradication program was cancelled, mainly due to problems related to insecticide resistance, drug resistance, poor infrastructure, and logistic and financial constraints. The eradication program was eventually converted to a control program, and little attention was given to malaria control, particularly in the 1970s and 1980s.

6. 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
There is a growing realization among the world community about the threat posed by malaria during the 1990s. In 1992, the Ministerial Conference on Malaria in Amsterdam announced a Global Malaria Control Strategy. The four fundamental elements of this strategy are: early diagnosis and prompt treatment; selective use of preventive measures such as ITNs and other vector-control measures; prevention and timely control of epidemics; and strengthening local capacities in basic and applied research. The World Health Assembly passed a resolution on controlling malaria in Africa in May 1996, and the Organization of African Unity made declarations on malaria in Harare, Zimbabwe in 1997 and in Ouagadougou, Burkina Faso in In 1996, the African Regional Office of the WHO became increasingly attentive to malaria and launched the African Initiative for Malaria Control (AIM). AIM contributed $9 million in 1997 and 1998 for accelerated implementation of malaria control activities in 10 countries in the region, and provided the foundation for the eventual launch of Roll Back Malaria in The heads of African States conference was held in April 2000 in Abuja, Nigeria, which declared the goal of reducing malaria deaths by half by the year The diverse array of meetings, programs, and activities are testimony to the growing recognition of the regional and global nature of the threat posed by malaria. Strong political commitment, financial support and partnerships are important to bring about the current desired changes.

7. 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
Prevention:
ITNs, IRS, IPT
Environmental mgt
Health care system:
Accessibility
Affordability
Quality of care
Efficiency
Demand/utilization
Malaria
morbidity
Treatment:
Early diagnosis
& treatment
Malaria
mortality
Depending on the epidemiology of malaria, people are at risk of acquiring infection due to factors related to environment, demographic and socio-economic status. Strong health-care systems (and malaria control program (MCP)) with adequate global and national support, prevention and control of malaria using early diagnosis & prompt treatment, and vector-control strategies have a significant impact on reducing malaria morbidity and mortality. Prevention methods inhibit the establishment of infection or suppress the progression of the parasite after infection. Access to early diagnosis and prompt treatment with effective anti-malarial drugs significantly reduce the severity of the illness, which will ultimately affect malaria mortality. A related factor is the perception of people about what causes malaria, their understanding of early treatment with appropriate anti-malarials, and the use of personal prevention methods and participation in disease prevention.
Program factors:
Health policy
Anti-malarial drug policy
Support/partnership
National MCP
Malaria knowledge:
Cause
Prevention methods
Early treatment
Cultural beliefs
Information

8. 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
The Roll Back Malaria (RBM) partnership was launched in 1998 by WHO, UNICEF, UNDP, and the World Bank. RBM made a clear aim to cut the burden of malaria-related illnesses and deaths in half by 2010 by a means of promoting effective and sustainable malaria control through a partnership approach. Since the commencement of RBM, substantial funds from multilateral, bilateral, non-governmental, and private organization have been allocated for malaria control. RMB mainly focuses on Africa. At country levels, RBM maintains sustained local capacity to address malaria (and other priority health problems) depending on the local situations.

9. 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
Other targets have been set globally to augment the RMB initiative. Goal 6 of the Millennium Development Goals (MDGs) is to combat HIV/AIDS, malaria, and other diseases and target 8 is to have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. Two of the indicators for measuring progress towards the achievement of the MDGs are malaria related. Indicator 21 is the prevalence and death rates associated with malaria. Indicator 22 is the proportion of the population in malaria-risk areas using effective malaria prevention and treatment measures.

10. 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
The goal of RBM is to halve the world's malaria burden by Heads of State or senior representatives from 44 malaria-afflicted countries in Africa endorsed the goal of RBM at a summit in Abuja, Nigeria, in April This endorsement was vital because 90% of the one million deaths from malaria are in Africa, mostly in young children and pregnant women. The Heads of State at the Africa Summit on RBM, made the Abuja Declaration, a commitment to halve the burden of malaria by The African summit on RBM reflected high political commitment and technical consensus on methods for dealing with the prevention and control of malaria. Since the Abuja summit, many African governments have demonstrated their commitment to anti-malarial intervention efforts by allocating human and financial resources and removing taxes and tariffs on mosquito nets.

11. 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
The Abuja summit set a series of interim targets for specific intervention strategies to be attained by 2005, by achieving a 60% coverage of all at-risk populations with suitable preventive and curative measures. The commitment was to ensure that 60% of children suffering from malaria receive prompt and effective treatment, that 60% of pregnant women, especially those in their first pregnancies, receive intermittent preventive treatment, and that 60% of children and pregnant women sleep under ITNs. Though not addressed here, the Abuja targets also include malaria epidemics and emergency response, which stated that 60% of epidemics should be detected within two weeks of onset and responded to within two weeks of detection. However, few countries are likely to reach these targets, because until very recently, control efforts were fragmented and major international investments came too late. For example, the population-weighted coverage of ITN usage in African children under 5 years of age reported in the Africa Malaria Report 2003 for the year 2000 was 2% from 29 surveys. However, the Abuja targets are attainable: Eritrea has attained these targets.

12. RBM Strategies
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
The RBM strategy is four-pronged. The first prong focuses on prevention: children and pregnant women must be protected from the mosquitoes that transmit malaria. The best way to do this is to ensure that they sleep under insecticide-treated nets (ITNs) and use other locally approved means of vector control. Studies in Africa have shown that ITNs can reduce deaths among under-fives by up to one-third. Indoor residual spraying (IRS), for example, is a highly effective method of malaria vector control and is particularly useful for achieving a rapid reduction in transmission during epidemics. The second strategy focuses on prompt recognition and effective treatment of malaria cases. Nevertheless, it is a major challenge in countries with poor health-care service coverage, because treatment must begin very early, generally within 24 hours of the onset of illness, near the home. There is an urgent need to ensure that effective and affordable antimalarial drugs or drug combinations are widely available to all individuals living in malaria-endemic areas. Since many Africans first go to their local store for antimalarial drugs, shopkeepers are now being trained to supply appropriate treatment doses and durations. Increasing parasite resistance to chloroquine and sulfadoxine-pyrimethamine drugs are requiring artemisinin-combination therapy, which is far more expensive than traditional monotherapy. The third strategy focuses on the prevention and control of malaria in pregnancy and associated malaria-related low birth-weight: pregnant mothers must be encouraged to take advantage of Intermittent Preventive Treatment (IPT) and use ITNs. This has been shown to increase birth-weight, a major determinant of child survival. The fourth strategy is the early detection of and response to malaria epidemics.This requires early detection through weekly disease surveillance, malaria early warning systems, and adequate preparedness plans of action to make sure that drugs, IRS and ITNs can be rapidly deployed when needed.

13. 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
Extensive and systematic M&E is relatively new to malaria-control programs. RBM has set up a monitoring and evaluation reference group, known as MERG, to address monitoring-and-evaluation issues associated with national-level malaria-control programs. In general, the goal of a national RBM M&E system is to provide reliable information on progress in controlling malaria that can be used at local, national, regional and global levels. The specific objectives of a national RBM M&E system is to collect, process, analyze and report on malaria-relevant information; to verify whether activities have been implemented as planned and address problems that have emerged in a timely manner; to provide feedback to relevant authorities to improve future planning, and to document periodically whether planned strategies have achieved expected outcomes and impact.

14. 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.)
This slide presents a basic monitoring and evaluation framework for malaria-control programs. It highlights the key areas that should be tracked in a good monitoring and evaluation system. For example, measurement of inputs should involve a review of the policies, guidelines and strategies for malaria control that have been put in place at the national level, as well as human and financial resources allocated to malaria control programs. Processes typically involve artemisinin-based combination therapy (ACT), ITN, net/ and insecticide commodities. They may also involve training and behavior change communication. Outputs are the services delivered. For example, such services may include insecticides used for malaria vector control, research studies on drug efficacy and insecticide resistance; nets or ITNs sold or distributed; nets retreated; and anti-malarial drugs distributed. Outcome indicators mostly measure changed behaviors and coverage among the target populations benefiting from malaria control interventions. Such outcomes include coverage of anti-malarial treatment for fevers in children under 5 years of age; household ITN possession and usage; IPT use by pregnant women; and malaria epidemics detected and properly controlled. Impact indicators focus on health status, biology, and the quality of life. Information to measure malaria impact include malaria case and death reports; proportional outpatient visits, hospital admissions and hospital deaths due to malaria; all-cause under-five mortality; and prevalence of childhood anemia.

15. 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
However, in limited resource settings, it may not be possible for national malaria-control programs to monitor all these aspects. In such settings, priorities must be established. The highest priorities include tracking the human and financial inputs; malaria-control services delivered to those at risk of malaria; coverage of interventions; and malaria-associated morbidity and mortality.
Class activity:
The facilitator should lead a brainstorming session about these issues and list the answers on a flipchart: What do you think might be some methods for monitoring indoor residual spaying? What are some tools you have used (if any)? What has been your experience using those tools (if any)?

16. Results Frameworks (MCP)
SO1: Reduced
Malaria Burden
IR1: Improved
malaria prevention
IR2: Improved malaria
epidemic prevention
& management
IR3: Increased access
to early diagnosis &
prompt treatment of
malaria
IR1.1 Access to &
coverage by ITNs
increased
IR2.1 Early detection
& appropriate response
improved
IR3.1 Quality of
care improved
IR2.2 Epidemic
preparedness improved
IR1.2 Improved
access to IPT
The above framework shows the main critical areas for monitoring and evaluation of RBM control interventions. The ultimate objective of RBM is to reduce the burden of malaria (i.e. mortality, morbidity, and economic losses). The reduction in burden will be achieved through control interventions undertaken by the National Malaria Control Program. The actual interventions, according to malaria epidemiology, will include the critical areas of: prevention (e.g., use of ITNs, indoor residual spraying, prevention of malaria during pregnancy); and early diagnosis and effective treatment of the disease, and prevention and control of epidemics in epidemic-prone areas. Utilization of ITNs, application of indoor residual spraying (IRS), environmental management and improved access to Intermittent Presumptive Treatment (IPT) will improve malaria prevention. A strong surveillance system with appropriate early warning systems to early detect and contain epidemics will alleviate mortality and morbidity associated with malaria epidemics. Quality of adequate care (technical and perceived quality), efficiency in providing services, utilization of adequate care (prompt access and early treatment seeking) and access to health care services are the critical areas that should be given attention with regard to malaria treatment.
IR3.2 Efficiency in
service delivery
improved
IR2.3 Surveillance
system improved
IR1.3 IRS coverage
increased in
Epidemic-prone areas
IR3.3 Utilization of
care improved
IR1.4 Use of source
reduction/ larviciding
increased
IR2.4 Early warning
system strengthened
IR3.4 Access to
services improved

17. 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
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
Health facility
surveys
Community
Strong HIS
Availability and use
of DSS
Effective and
affordable drugs
available
Sustainable funding
and partnership

18. 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
Since there are different RBM technical strategies resulting the desired outcomes, we now focus on ITNs to illustrate the importance of logical framework in order to demonstrate the performance indicators, means of verification and related assumptions. The components of this logical framework are also illustrated using the following figure.

19. Level and function of M&E indicators
Input
Indicators
Process
Output
Outcome Indicators
Impact
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
Indicators of inputs, processes, and outputs are typically used for monitoring purposes at the program level. Input indicators are generally used to measure the level of resources available for use by the program or intervention, such as the funding obtained to purchase ITNs. Process indicators are generally used to verify that a program or intervention has been implemented as planned. One example would be verifying that ITNs have been purchased and are ready for distribution. It is expected that inputs and desired processes will lead to desired changes in output indicators, which are generally used to measure benchmarks of program-level performance, such as the number of ITNs distributed to a particular target population. The figure above provides an example schematic of the level and function of indicators typically used for M&E.
Outcome indicators generally measure medium-term population-level results, such as the level of ITN coverage among a particular target population that can be attributed to an ITN program or intervention. It is expected that desired changes in outcomes will lead to a desired impact, which generally refers to the overall, long-term goals of a program or initiative, such as the RBM goal of halving malaria-related morbidity and mortality by 2010.
Please note that population-level changes for impact indicators are most often challenging to measure and are very difficult to attribute to a particular program or intervention without the use of a rigorous experimental design. For this reason, all of the core RBM indicators for population coverage are intended to measure national-level changes at the outcome level. However, it is expected that desired changes in outcome indicators will yield desired reductions in malaria-related morbidity and mortality. Thus it is crucial that all RBM partnership countries measure the pertinent outcome indicators for population coverage in order for the overall success of the RBM initiative to be assessed.

20. RBM Core Coverage Indicators
RBM Technical Strategies
RBM outcome indicators of
population coverage
Vector control- ITNs
% of households with at least one ITN
% of children <5 who slept under an ITN the previous night
Prompt access to effective treatment
% 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
% of pregnant women who slept under an ITN the previous night
% of women who received IPT for malaria during their last pregnancy
There are five RBM core-coverage indicators. Two indicators are used to measure vector control. The first indicator is the percentage of households with at least one ITN and the second indicator is the percentage of children under five years of age who slept under an ITN the previous night. Prompt access to effective anti-malarial treatment is measured by the percentage of children under 5 years of age with fever in the last two weeks who received anti-malarial treatment within 24 hours of the onset of symptoms. Prevention and control of malaria in pregnant women is measured by two indicators. The first is the percentage of pregnant women who slept under an ITN the previous night, and the second is the percentage of pregnant women who received IPT during their last pregnancy. Coverage of indoor residual spraying is not included here due to lack of a standardized measure and operational definition of IRS coverage. Countries and regions vary in whether they define IRS coverage in terms of geographical areas, number of houses or household structures sprayed, or number of people living in sprayed houses. They also vary in whether populations at no or low risk are included in the denominator. The World Malaria Report 2005 has recommended that WHO develop standardized definitions of IRS coverage and its denominator, which is the population at risk of malaria. Note that IRS is not recommended everywhere, and that it is better to get coverage data from programs rather than individuals or households.

21. 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
Let us now talk about the challenges of M&E of national malaria-control programs. First, it is often argued that impact measurements are not needed. According to this argument, technical strategies have already proven efficacious – otherwise, they would not be scaled up; hence coverage measures should suffice. This is highly debatable and we will not go into a discussion of this issue. The most important consideration regarding the measurement of impact is that it requires a rigorous experimental design that compares outcomes in intervention areas with outcomes in non-intervention areas. However, most national malaria-control programs are full-coverage programs. In areas where malaria is endemic, these programs are intended to reach the entire population. Hence it would be impossible to find a control or comparison group. Another consideration is that the measurement of impact at the national level is costly. Using existing health-system level data has limitations as 80% of malaria cases are treated at home. Therefore, malaria surveillance has to be active not passive.

22. 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
Even if one decided to measure malaria-specific morbidity and mortality, there are a number of measurement challenges. In many high-burden countries, disease surveillance systems are inadequate. National totals do not cover all districts and months of the year. In addition, it is difficult to define a case. In the absence of laboratory diagnosis in areas where malaria is most prevalent, most diagnoses and treatments occur presumptively. Even if clinical diagnosis are confirmed by laboratory tests, asymptomatic parasitaemia is common so that a fever accompanied by parasitaemia does not necessarily indicate that the fever is caused by malaria. Variations in the completeness of reporting over time and regions make comparisons difficult. In addition, the malaria burden in health facilities frequently does not cover the total burden in the population where access to health care is low and where the majority of cases are treated at home. In high-endemic countries, population-based surveys are therefore critical for measuring mortality, but there are special considerations in their use. Because under-five mortality measured in cross-sectional surveys refers to the mortality rate over the 5 years preceding a survey, it reflects the situation an average of 2.5 years ago, delaying the detection of intervention impact. Conducting surveys at shorter intervals, say every two years, would be too costly. Furthermore, using all-cause under-five mortality (available from the DHS and MICS) as a measure of impact is not ideal as this indicator is not specific to malaria. In countries where access to health care is high and malaria diagnoses are generally laboratory confirmed, malaria cases and deaths reported through HIS are important burden and impact indicators. However, it is important to ensure that the completeness of reporting is high and that the HIS covers malaria cases that are treated in the public as well as the private sector. Vital registration systems that record causes of death are important complements to the HIS but may be of low coverage and quality.

23. 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
The complexity of malaria epidemiology also introduces measurement challenges. First the relationship between transmission and malaria mortality is not linear. The intensity of malaria transmission in an area determines the effect of malaria on health status. In areas of stable transmission, malaria is frequently transmitted by mosquitoes from one person to another resulting in high levels of acquired immunity. Therefore, in areas of stable transmission, people at increased risk of chronic infections and severe anemia but are less likely to suffer from complicated malaria (which may present as renal failure, cerebral malaria, and hypoglycemia). On the other hand, in areas of unstable transmission, the lack of frequent exposure to malaria infection early in life delays the acquisition of clinical immunity. Thus, the risk of mortality from malaria is higher among people living in areas of unstable malaria transmission. Note that this relationship is still being studied. Recent research from Burkina Faso and Ghana show no evidence in rebound of malaria due to ITNs. In the meantime, coverage is used as a primary outcome indicator for evaluating national-level MCPs.

24. 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?
{This slide is modified to cut on time. Participants may be divided into groups to work on this exercise.}
This concludes the lecture component of this session. We will now move on to the case study. The case study provides participants with the opportunity to develop a monitoring and evaluation framework for a malaria control program and to select output and outcome indicators for measuring the program’s success. This case study is based on the malaria prevention program implemented by Population Services International in Malawi. Further details are provided in the handout.

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