1. Monitoring and Evaluation of Malaria Control Programs
A Brief Overview

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-based indicators of the RBM strategy & recognize their strengths & limitations
The objectives of this presentation are first to describe why malaria is important and its conceptual framework, Roll Back Malaria technical strategies, second to build participants’ skills in designing a monitoring and evaluation framework for national-level malaria control programs, and lastly, 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 and problem statement
Epidemiology of malaria
Historical & 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
Coverage of interventions
Class activity

4. Why is Malaria Important? Problem Statement
Estimated 225 million malaria cases and 781,000 deaths in 2009
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 approximately one in five of all childhood deaths in Africa every year
Drug resistance exacerbates the malaria problem
Why is malaria important? Today approximately half of the world’s population is at risk of malaria. In tropical and subtropical countries it causes approximately 225 million acute illnesses and 781,000 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. Of those newborns born with “preventable” low birth weight, 30% are due to malaria. 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 deaths per year in Africa.
Addressing the problem of drug resistance is also a high priority, particularly in Southeast Asia, where resistance to Artemisinin on the Thai-Cambodia border has prompted an Artemisinin-resistance containment project. The first signs of chloroquine resistance emerged in this same region before spreading to the rest of the world.

5. Economic Cost of Malaria
Problem Statement:
Economic Cost of Malaria
USD 12 billion per year in direct losses
Loss of 1.3% of GDP growth per year for Africa
Around 40% of public health spending in SSA
Approximately 30-40% of out-patient visits to hospitals and 20-50% of all admissions are due to malaria
Household spending : >10% of yearly (Africa)
Malaria also has substantial economic effects in SSA. $12 billion pr 1.3% of GDP are lost each year as a result of malaria. Approximately 40% of public health in the region goes towards malaria. This covers the cost of interventions and treatment of malaria cases % of outpatient hospital visits and 20-50% of all hospital admissions are due to malaria.
At the HH level, greater than 10% of spending goes towards the treatment of malaria.
Source: Global Malaria Action Plan (2008)

6. Epidemiology: Parasite
Malaria in SSA is mainly caused by Plasmodium falciparum
P.vivax, P. malariae and P. ovale are also present
Malaria is caused by a parasite that is transmitted by mosquitos. There are four main types of malaria parasites, 3 of which are present in SSA. P. falciparum malaria accounts for the majority of cases in SSA. P. vivax is not present in the majority of SSA due to the lack of the Duffy antigen gene in population in the region. The Duffy antigen acts as a receptor on the surface of human red blood cells for the P. vivax parasite.

7. Epidemiology: Vector
Malaria is transmitted by female Anopheles mosquitoes
They mostly feed & rest indoors
Peak biting is late in the night
Anopheles populations are more pronounced after rains
Malaria parasites are transmitted by female anopheles mosquitoes. These mosquitoes mostly feed and rest indoors, but different subspecies have different habits, making it difficult to create a one size fits all vector control strategy. Generally, peak biting occurs late at night.
Anopheles populations grow after rains. This is because mosquitoes require water to develop into adults.

8. Habitat/Environment/Human Malaria Transmission Cycle
Blood meal
Vector
Parasite
Recipient
Mosquito cycle
Eggs
Larva
Pupa
Adult
Parasite cycle
In mosquito
In human
Temperature
Rainfall
Humidity
Here you can see a diagram of malaria transmission. Malaria is transmitted between humans and mosquitoes when an infected mosquito bites a human or when an infected human is bitten by a mosquito; however mosquitoes cannot infect humans immediately after contracting the parasite, which has a complex life cycle.
The parasite takes days, depending on the species of parasite, to develop to maturity inside of the mosquito to the point that it can infect a human when it is taking a blood meal. The number of days to maturity increases as temperature decreases.
In humans, symptoms of malaria usually start to appear 9-14 days after the bite of an infected mosquito.
The life cycel of the vector also affects transmission. Anopheles mosquitoes take 5-15 days to mature from eggs to adulthood. The eggs, larva and pupa stages all take place in water. The adult mosquito lives approximately three weeks.
The parasite cycle in the mosquito and the lifecycle of the mosquito are highly dependent on temperature, rainfall and humidity. The lifecycle of the parasite is shorter in warmer temperatures and longer in colder ones. Therefore, if it is cold enough, the parasite life cycle will take longer than the lifetime of the adult mosquito.
Malaria Transmission Cycle

9. Risk
Stratification
In Africa, an estimated 74% of the population lives in areas that are highly endemic and 19% lives in epidemic prone areas. You can see on this map that the areas with epidemic malaria are those that have higher humidity, rainfall and warm temperatures.

10. History of Malaria Control
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, 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.

11. History of Malaria Control: Renewed Global Commitment
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 was 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 enunciated 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 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 an effective and sustainable malaria control through 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.
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 partnership are important to bring about the current desired changes.

12. Conceptual Framework: Malaria Burden
External factors:
Environmental (ecological, climate)
Socioeconomic (economic status,
movement, occupation, housing condition,
war, population displacement, etc.)
Demographic ( age, immunity, gender)
Malaria
infection
Prevention:
LLINs, IRS, IPT
Environmental management
Health care system:
Accessibility
Affordability
Quality of care
Efficiency
Demand/utilization
Malaria
morbidity
Treatment:
Early diagnosis
And treatment
Malaria
mortality
Program factors:
Health policy
Antimalarial drug policy
Support/partnership
National MCP
Malaria knowledge:
Cause
Prevention methods
Early treatment
Cultural beliefs
Information
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 system (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 antimalarial drug 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 antimalarials, the use of personal preventive methods and participation in disease prevention.
Conceptual Framework: Malaria Burden

13. Conceptual Framework: Malaria Control and Elimination
This framework, the Bi-Regional Malaria Indicator Framework (BMIF) is for the SEARO and WPRO regions and focuses on a different malaria situation. It also utilizes a very different design.
This framework addresses the goals of malaria control and elimination in the global malaria strategy. As these goals represent two separate endpoints on a continuum of malaria reduction they are depicted as such in the framework. Measuring progress towards these goals requires quantification of reductions in disease burden, and the successful geographical containment of disease.
The BMIF outlines six major components for achieving malaria control and elimination. These include policy and management, prevention, IEC/BCC, case management, engaging vulnerable populations and strategic information. The details of each of the six elements are described in the following section. In addition, several cross-cutting themes are specified for effective implementation of these components: regional cooperation, strong public-private partnerships, and engagement of other programs and sectors. These cross-cutting elements do not have a specific set of indicators, instead various indicators throughout the framework touch upon these important issues.
Conceptual Framework: Malaria Control and Elimination

14. Key Malaria Targets and Goals
African Summit on Roll Back Malaria, Abuja, Nigeria
Halve malaria burden between 2000 and 2010
Millennium Development Goals
MDG 6: Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
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
MDGs 1, 3, 4 & 5 -- also malaria-related
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, the Abuja Declaration made 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.
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.

15. Key Malaria Targets and Goals (continued)
World Health Assembly 2005
Ensure reduction in malaria burden of ≥ 50% by 2010 and ≥ 75% by 2015
Roll Back Malaria Partnership Global Malaria Action Plan targets
By 2010: 80% coverage with interventions; by 2015: universal coverage, preventable mortality near zero & 8–10 countries achieve elimination of malaria
The World Health Assembly met in 2005 and resolve to call for the increase malaria control efforts with the purpose of reducing the malaria burden by 50% by 2010 and 75% by 2015.
Through the Global Malaria Action Plan, which was released in 2010, Roll Back Malaria iterated the goal of achieving 80% coverage of interventions by 2010 and universal coverage by Additionally, by 2015 RBM set the goal of near zero preventable deaths and elimination of malaria in 8-10 countries.

16. RBM Technical Strategies for SSA
Vector control via insecticide-treated nets (ITNs) and indoor residual spraying (IRS)
Prompt access to effective treatment
Prevention and control of malaria in pregnant women utilizing intermittent preventive treatment (IPTp)
RBM utilizes three technical strategies in SSA. These include:
vector control which is comprised of insecticide treated nets (ITNs) and more recently, Long-lasting insecticidal nets (LLINs) which maintain effectiveness for 3-5 years
Prompt access to effective treatment includes diagnosis of cases and timely treatment using antimalarials as recommended by national guidelines. Artemisinin Combination Therapies (ACTs) are the first-line antimalarial treatment in almost all countries in SSA. However a great deal of treatment occurring uses less effective monotherapies.
Prevention and control of malaria in pregnant women utilizes Intermittent Preventive Treatment which is defined as at least 2 doses of Sulfedoxine-pyrimethamine (SP) after quickening (first movements) of the fetus. These drugs are often administered in antenatal care (ANC). ITNs are also recommended for pregnant women.

17. 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 a 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.

18. Logic Model: Malaria Control Programs
Inputs
Process
Outputs
Outcomes
Impact
Strategies
Policies
Guidelines
Funding
Materials
Facilities
Commodities
Supplies
Staff
Training
Services
Education
Treatments
Interventions
delivered
Knowledge,
skills, practice
# ITNs distrib.
# HH sprayed
IPTs delivered
# antimalarials
RDTs/slides
taken
Coverage
Use
%HH ITN
possession
%ITN use
IRS coverage
%U5 treatment
Malaria
incidence/
prevalence
Mortality
Socio-
economic
wellbeing
U5MR
morbidity/
mortality
Economic
impact
Examples of Indicators
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 delivery of interventions such as artemisinin-based combination therapy (ACT), ITN, and IRS and training and behavior change communication.
Outputs are that the services have been delivered. For example, such services may include insecticides used for malaria vector control, research studies on drug efficacy and insecticide resistance; LLINs or ITNs sold or distributed; and antimalarial drugs distributed.
Outcome indicators mostly measure changed behaviors and coverage among the target populations benefiting from malaria control interventions. Such outcomes include coverage of antimalarial treatment for fevers in children under 5 years of age; household ITN/LLIN possession and usage; and IPT use by pregnant women.
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.

19. & appropriate response
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
IR1.2 Improved
access to IPT
IR2.2 Epidemic
preparedness improved
IR3.2 Efficiency in
service delivery
improved
IR1.3 IRS coverage
increased in
epidemic prone areas
IR2.3 Surveillance
system improved
IR3.3 Utilization of
care improved
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 Programs.
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); 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. Strong surveillance system with appropriate early warning system to early detect and contain epidemics 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.
IR1.4 Use of source
reduction/ larviciding
increased
IR2.4 Early warning
system strengthened
IR3.4 Access to
services improved
Results Framework:
Malaria Control Program

20. Malaria Control Program
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
The first part of this logical framework lays out the Goal, purpose and objectives of a malaria control program. It shows the indicators and data source or means of verification for each. Assumptions are also listed.
Logical Framework:
Malaria Control Program

21. Malaria Control Program
Performance indicators
Means of verification
Assumptions
Outcome: Access to and utilization of ITNs/LLINs increased
% of households with at
least one ITN/LLIN
% of individuals who slept
under an ITN/LLIN the previous
night
% of households with at least 1 ITN/LLIN for every two people
Community
surveys
Availability of ITNs
Subsidies for ITNs
High community awareness and acceptance of ITN
Output:
Distribution of mosquito net to the target population will improve
District health workers will be trained for implementation of ITN/LLIN strategy
# of ITN/LLIN distributed to the
target population
# of health workers trained
on ITN/LLIN strategy implementation
Reports
Review document
Funds available
Since there are different RBM technical strategies resulting the desired outcomes, we now focus on ITNs/LLIN 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.
Logical Framework:
Malaria Control Program

22. Class Activity
Get into your groups to create a results, logical or logic model for one aspect of a malaria control program
Insecticide-treated nets/Long lasting insecticidal nets(ITNs/LLINs)
Indoor residual spraying (IRS)
Prompt and effective treatment and use of diagnostics
Prevention and control of malaria in pregnant women

23. Level and Function of M&E Indicators
Morbidity and mortality
indicators
Input Indicators
Process Indicators
Output Indicators
Outcome Indicators
Impact Indicators
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
Population coverage
indicators
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, such as 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 above Figure provides an example schematic of the level and function of indicators typically used for M&E.
Outcome indicators are generally used to 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. Thus it is crucial that all RBM partnership countries measure the pertinent outcome and impact indicators in order for the overall success of the RBM initiative to be assessed.

24. RBM Core Outcome Indicators
RBM Intervention
Indicator Description
Insecticide- treated nets (ITNs) and indoor residual spraying (IRS) 
1. Proportion of households with at least one ITN
2. Proportion of households with at least one ITN for every two people
3, Proportion of population with access to an ITN within their household
4. Proportion of individuals who slept under an ITN the previous night
5. Proportion of children under 5 years old who slept under an ITN the previous night
6. Proportion of households with at least one ITN and/or sprayed by IRS in the last 12 months
Prompt and effective treatment and use of diagnostics
7. Proportion of children under 5 years old with fever in the last 2 weeks who had a finger or heel stick
8. Proportion of children under 5 years old with fever in the last 2 weeks which sought advice or treatment from an appropriate provider
9. Proportion of antimalarials taken by children under 5 years old to treat a fever in the last 2 weeks that were ACTs 
Prevention and control of malaria in pregnant women
10. Proportion of pregnant women who slept under an ITN the previous night
11. Proportion of women who received intermittent preventive treatment for malaria during ANC visits during their last pregnancy
There are 11 RBM core outcome indicators. Six indicators are used to measure vector control though ITNs or IRS. There are quite a number of indicators regarding ITNs. This helps asses coverage of special populations and the population as a whole. It also allows for better interpretation of the data. It makes it easier to assess who is using nets and whether HH have enough nets.
Prompt access to effective antimalarial treatment is measured by three indicators which reflect diagnosis (finger or heel stick is used as a proxy measure), treatment seeking from appropriate providers and the proportion of antimalarials taken which were ACTs (first line drugs). 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.
RBM Core Outcome Indicators

25. RBM Core Impact Indicators
RBM Impact Measures
Indicator Description
Mortality Indicator
1. All-cause under 5 mortality rate (5q0).
Morbidity Indicators
2. Parasitemia Prevalence: proportion of children aged 6-59 months with malaria infection.
3. Anemia Prevalence: proportion of children aged 6-59 months with a hemoglobin measurement of <8 g/dL
There are 3 RBM core impact indicators. At a minimum, the RBM partners recommend that all countries with high-intensity malaria transmission regularly monitor all-cause under 5 mortality based on data from statistically-sound national-level household surveys, such as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) [32].
Alongside data on mortality, it is recommended that countries also collect data on anemia and parasitemia to assess malaria morbidity among children under the age of five. Parasitemia prevalence is a useful morbidity indicator, as it is malaria-specific and can provide a rough measure of transmission [33]. Additionally, anemia prevalence is a reliable indicator of malaria morbidity that can reflect the impact of malaria interventions
You will notice that there is no indicator for malaria-specific mortality.

26. Challenges of Measuring Malaria-Specific 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 decides to measure malaria-specific mortality, there are a number of measurement challenges. In many high-burden countries, disease surveillance systems are inadequate. National totals often do not cover all districts and months of the year. 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 deaths occur 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 refer 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.
Vital registration systems that record causes of death are important complements to the HIS but may be of low coverage and quality.

27. M&E Challenges: Complexity of Malaria Epidemiology
Not a linear relationship between transmission (immunity) and malaria-related mortality
Severity & symptomology of malaria morbidity shifts with transmission (immunity)
High transmission = chronic infections, severe anemia
Low transmission = higher life-threatening severe malaria
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.

28. Coverage of Interventions

30. Cumulative Number of ITNs Distributed in Sub-Saharan Africa, 2000–2009
Between 2008 and 2010, ~254 million LLINs / ITNs were delivered in Africa. As you can see in this graph, there are more manufacturer deliveries than NMCP distribution, demonstrating a lag time between procurement and distribution.
Source: WHO, 2010 World Malaria Report

31. Trends in Estimated ITN Coverage, Cub-Saharan Africa 2000–2009
Based on model estimates, 42% of households in sub-Saharan African countries have at least one ITN and 35% of all children slept under these nets.
Source: WHO, 2010 World Malaria Report

32. ITN Use by Pregnant Women
Surveys have found large variations between countries in regards to the percentage of pregant women sleeping under ITNs. It is clear that at the time of these surveys, no countries reached the RBM target of greater than 80%. 32

33. Proportion of Population at Risk Protected by IRS
Africa now covers a larger proportion of it’s at risk population than any other region. Until 2007, this was not the case.
32 countries in SSA use IRS, 24 use it for prevention and control of epidemics
In 2009, about 73 million people, or 10% of the population at risk, were protected with IRS in SSA
Source: WHO, 2010 World Malaria Report

34. Source: WHO, 2010 World Malaria Report
Diagnostic Testing
Proportion of suspected malaria cases attending public health facilities that receive a parasitological test by microscopy or RDT
Diagnostic testing is an important component of malaria control programs. In 2010, WHO recommended that all malaria treatment be given on the basis of parisitological confirmation except where no such confirmation is available in which case treatment should be given presumptively.
Sub-Saharan Africa confirms a much smaller proportion of cases (less than 40% in 2009) than the other regions of the world. With the increasing focus on parasitological confirmation of malaria cases before treatment, there is hope that this will change. By confirming cases before treatment, use on highly effective Artemisin Combination Therapies (ACTs) will reduce and potential for drug resistance will decrease.
Source: WHO, 2010 World Malaria Report

35. Antimalarial Treatment
In 2003, 2 sub-Saharan African countries had adopted ACTs, by 2010, all sub-Saharan African countries except one had adopted an ACT as a first line drug.
Measuring the percentage of malaria cases which receive appropriate antimalarial treatment has challenges.
In 2003, 2 sub-Saharan African countries had adopted ACTs, by 2010, all sub-Saharan African countries except one had adopted ACT policy .
Measuring the percentage of malaria cases which receive appropriate antimalarial treatment has challenges and the RBM MERG is currently revising its recommendations for doing so.. HMIS data is often incomplete and many malaria cases are never seen in facilities. Fever has been used as a proxy measure for malaria in surveys in the past, as most cases were treated presumptively. The scale-up of diagnostics presents an M&E challenge for measuring treatment through surveys as many patients will not know or remember their diagnosis and fevers which are known to be non-malarious should be excluded from measurement.
Source: World Malaria Report 2009 and 2010

36. Intermittent Preventative Treatment
Proportion of all pregnant women receiving the second dose of IPT
IPTp has been adopted as policy in all 35 SSA countries with stable malaria transmission
According to survey data from 2007–2009, the percentage of women who received two doses of treatment during pregnancy ranged from 2.4% in Angola to 62% in Zambia.
Source: WHO, 2010 World Malaria Report

37. Reduction of >50% in Cases: 11 African countries
Eritrea
Rwanda
Zambia
Sao Tome and Principe
Over the past decade, 11 African countries have reduced confirmed malaria cases or malaria admissions and deaths by more than 50%. In all of them—Algeria, Botswana, Cape Verde, Eritrea, Madagascar, Namibia, Rwanda, Sao Tome and Principe, South Africa, Swaziland, and Zambia—these decreases are linked with intense malaria control interventions.
Reduction of >50% in Cases: 11 African countries

38. Highlight: Rwanda
Describe trends in malaria admissions and deaths over the past 10 years.
What could be causing this increase in admissions and deaths between 2008 and 2009?
How should the Rwanda NMCP respond to this evidence of an increase in admissions and deaths?
What does this case demonstrate about malaria control efforts?
Question for Class 1) Describe trends in malaria admissions and deaths over the past 10 years
Possible answer: Malaria admissions and deaths declined with some fluctuation. Between 2008 and 2009 there has been an increase in both admissions and deaths.
Facilitator: While we can see the overall trend, some extra details are needed to interpret how to address this recent uptick in cases. According to the 2010 World Malaria Report “The entire population of Rwanda is at risk of malaria, but transmission is most intense in the eastern and southwest parts of the country. Diagnostic capacity has progressively improved in recent years and the annual examination rate reached 14% in A nationwide seasonal resurgence of malaria cases occurred during both the 2008–2009 and 2009–2010 malaria seasons, which was 2–3 years after the nationwide campaign to provide LLINs for children <5 years of age in 2006.
Question for class 2) What could be causing this increase in admissions and deaths between 2008 and 2009?
Possible answer: This could be a reflection of increased confirmation of cases (The number of cases tested doubled between 2008 and 2009) or it could be evidence of failure of one or more aspects of the malaria control strategy.
Question for class 3) How should Rwanda respond to this evidence of an increase in admissions and deaths?
Possible answer: Since it had been 2-3 years since the scale-up of LLINs, the nets in place may be losing some of their effectiveness and need to be replaced. However, from the information that we know that is not completely clear. The program should redistribute nets and also research other possible reasons for this increase. They should continue monitoring this trend at a district level on a timely basis so that they can focus efforts where they are most needed and be able to respond to any resurgence of malaria in a timely manner.
Question for class 4) What does this case demonstrate about malaria control efforts?
Possible answer: This case shows that even programs that have shown considerable progress need to be vigilant about monitoring trends in cases and deaths of malaria and continuing interventions even after they have shown success. While this increase may seem small, Rwanda still has vectors and with neglect, malaria could easily increase to pre-intervention levels and cause more severe cases than before, because with sustained malaria control, individuals loose their immunity to malaria. It may be difficult to convince policy makers to sustain malaria control efforts when there are few malaria cases, but not doing so could have dire consquences.
Source: World Malaria Report 2010

39. Class Activity Malaria in Nigeria (Pop. 152 million)-
Among all age groups, malaria is the cause of 60% of all out-patient visits and 30% of hospitalizations
Nigeria has more reported cases of malaria and deaths due to malaria than any other country in the world
PMI will work with Nigeria starting this year to:
Distribute 2 million long lasting insecticidal nets (LLIN)
Support malaria case management in five initial focus states so that 90% of children diagnosed with malaria receive an appropriate antimalarial
Increase 2 doses of IPTp to 15% and one dose to 25% of pregnant women using ANC services in five initial focus states
Strengthen the capacity of the IRS unit at the NMCP and in selected states
1. Describe the various components of the program that need to be monitored and evaluated?
2. Define key output and outcome indicators and identify a data source for each
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 a malaria prevention program implemented by the NMCP in Nigeria. Further details are provided in the handout.

40. References
Africa Malaria Report. Geneva, World Health Organization, Global Malaria Action Plan. Geneva, Roll Back Malaria Partnership, 2008 Households that have at least one ITN, Malaria and children: Progress in intervention coverage. New York, UNICEF, Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region, WHO-AFRO, Malaria Campaign: Millions Receive Treated Mosquito Nets. Washington, D.C., World Bank Available at: heSitePK:4607,00.html Malaria and children: Progress in intervention coverage. New York, UNICEF, The President's Malaria Initiative Progress through Partnerships: saving lives in Africa Second Annual Report. Washington, D.C., PMI, World Malaria Report. Geneva, World Health Organization, 2008 World Malaria Report. Geneva, World Health Organization, 2009 World Malaria Report. Geneva, World Health Organization, 2010

41. MEASURE Evaluation is funded by the U.S. Agency for
International Development (USAID) and implemented by the
Carolina Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF Macro, John
Snow, Inc., Management Sciences for Health, and Tulane
University. Views expressed in this presentation do not necessarily
reflect the views of USAID or the U.S. government. MEASURE
Evaluation is the USAID Global Health Bureau's primary vehicle for
supporting improvements in monitoring and evaluation in
population, health and nutrition worldwide.