PAKISTAN MALARIA PROGRAMME REVIEW (MPR)
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Contents Executive summary ...... 4 1. Introduction ...... 17 1.1 Background ...... 17 1.2 Objectives of the MPR ...... 17 1.3 Methodology of the MPR ...... 18 1.4 Outline of the document...... Error! Bookmark not defined. 2. Context of malaria control ...... 20 2.1 Historical milestones in malaria control ...... Error! Bookmark not defined. 2.2 Malaria control within the national development agenda .... Error! Bookmark not defined. 2.3 National health policy ...... Error! Bookmark not defined. 2.4 National health sector strategic plan ...... Error! Bookmark not defined. 2.5National development plan ...... Error! Bookmark not defined. 2.6 Organizational structure for malaria control ...... 25 2.7 Key strategies for malaria control ...... 26 2.8 Key players in malaria control ...... 27 2.9 Linkages and coordination ...... 28 2.10 Conclusions and Recommendations ...... 28 3. Epidemiology of malaria ...... 28 3.1 Geographical distribution of malaria ...... Error! Bookmark not defined. 3.2 Population at risk ...... Error! Bookmark not defined. 3.3 Stratification and risk map ...... Error! Bookmark not defined. 3.4 Malaria parasites ...... Error! Bookmark not defined. 3.5 Malaria vectors...... Error! Bookmark not defined. 3.6 Disease trends ...... Error! Bookmark not defined. 3.7 Conclusions and recommendations ...... Error! Bookmark not defined. 4. Programme performance by thematic areas ...... Error! Bookmark not defined. 4.1 Programme management ...... Error! Bookmark not defined. 4.2 Procurement and supply chain management ...... 91 4.3 Malaria vector control ...... Error! Bookmark not defined. 4.4 Malaria diagnosis and case management ...... 213
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4. 5 Advocacy, BCC, IEC and social mobilization...... Error! Bookmark not defined. Error! Bookmark not defined. 4.7 Surveillance, Monitoring and Evaluation ...... 168 Conclusions ...... Error! Bookmark not defined. Key recommendations ...... Error! Bookmark not defined. Annexes...... Error! Bookmark not defined. Annex 1: Agenda for all the phases of the MPR ...... Error! Bookmark not defined. Annex 2: People involved in MPR ...... Error! Bookmark not defined. References ...... Error! Bookmark not defined.
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Executive summary
The specific objectives of the MPR were:
• To review the epidemiological outlook of malaria disease in each province of Pakistan with particular reference to disease trends, Slide positivity rate, Species wise distribution, Blood exam rate BER, Severe Malaria and Outcome of the managed cases at health facility with particular reference on disease specific mortality. • To review the Malaria program structure, capacity and management in each province and at national level (DOMC), in view of its new roles after devolution and identify issues and challenges arising post devolution. • To assess the current programme performance by intervention thematic areas and review progress, challenges and towards achievement of targets in each province and progress towards achieving national and regional goals. • To identify way forward, priority needs and gaps for improving programme performance and coordination at provincial and federal level. • To define steps to improve programme performance and redefine the strategic direction and focus, including revision of policies and strategic plans at provincial levels which can help tapping the available funds from various sources including the public sector and donors e.g. Global Fund from R10 malaria grant phase II and from the new funding model. • To assess the effectiveness of Global Fund grants supported projects in highly endemic regions of the country and to suggest ways and means for quality assured interventions following the principals of transparency, accountability and value for money. • To develop the post MDG strategic plan at provincial and national level for Pakistan for 2015 2020, based on the results of PRM, which will help mobilize resources based on new funding model.
Key Findings
Pakistan was one of the high endemic countries who launched Malaria eradication program in the 1960’s, with the support of WHO, UNICEF and USAID. As a result of this campaign there was marked reduction in malaria cases from a reported 7 million cases in 1961 to 9,500 cases in 1967 with associated slide positivity rate reduction from 15% to less than 0.01%. However there was a major resurgence and epidemics in early 1970s even in urban areas such as Karachi with reported malaria cases rising to 10 million in 1974. Some of the reasons for the resurgence were the onset of vector resistance to Organochlorines (DDT & Dieldrin/BHC), under estimation of A. stephensi in maintenance of urban malaria, inadequate planning for malaria control within irrigation and water development projects together with financial and administrative constraints, inadequate administration of programs, inadequate research, training, and supplies of chemicals and drugs, inadequate health services infrastructure with premature withdrawal of donor support. The Malaria Program switched from Eradication to Control Program during 1975 1985 and implementation handed over to provincial government and district health offices and malaria control program was integrated with general health services in 1985.
In 2003 as part of the global Roll Back Malaria Movement, Pakistan launched its Roll Back Malaria program with support of government planning commission Roll Back Malaria plan 2008/2009 2012/2013 with support of GF Round 7 and Round 10 malaria grant. This started accelerated malaria control activities in 38 priority high malaria transmission districts out of the 136 districts in the country. 4
Today Pakistan has an estimated population of 173.5 million people, out of which, according to the 2012 national malaria disease surveillance annual report, 9% are living in high transmission districts (34) with an annual parasitic index (API) ranging from 5 to 28, 20% are living in moderately endemic districts (41 districts) with API ranging from 1 to 5, and 71% living in low endemic districts with an API below 1/1000 population. The national API for the entire country is averaging 1.69, which classifies Pakistan as a moderate malaria endemic country. Malaria mappings show clearly that the highly endemic districts are located mainly in the provinces of Baluchistan, FATA, Sindh, and KPK. The lowest malaria incidence was reported in two provinces – Punjab and AJK with combined population of more than 56% of total population of the country.
The primary malaria vectors are A.culicifacies and A.stephensi. A number of secondary vectors have been reported and their contribution to malaria transmission is being investigated. The last nationwide vector surveillance was in 2009 and a new one has been completed in 2013 and data is being analysed and report under preparation
The primary malaria parasite is P. Vivax with P. falciparum being the secondary parasite. In 2012, Annual Blood Examination Rate (ABER) varied between 1.78% in Punjab to 7.09% in Baluchistan. Out of the 289,759 malaria cases confirmed positive in 2012, 249,504 were identified by microscopy (86.1 %), while 40,255(13.89%) by rapid diagnostic test. Majority of cases were considered as P. vivax (74.39 %) and 23.95 % as P. falciparum and 1.65 % as mixed infections. Highest P.falciparum malaria proportion is reported in Baluchistan (44%) followed by Sindh (27%).
Malaria indicator survey of 2009 showed malaria prevalence rates in Baluchistan 6.2% (Pf 2.4% Pv 3.8% ), FATA 13.9% (Pf 0.6%:Pv13.3%),Khyber Pakhtunkhwa 3.8% (Pf0.9%:Pv2.9%) and Sind 0.7% (Pf 0.7%: Pv0.4%).
The provincial prevalence is consistent with the reported incidence from the malaria surveillance system. The 2013 prevalence survey is being analysed and report should be available in early 2014.
The historical malaria trends in Pakistan from the malaria surveillance system between 1973 and 2012 shows clearly: 1)That the Annual parasitic index dropped drastically from 1973 ( API 13.18) to below 1/1000 in 1977 ( API 0.93) with a sharp decline in the slide positivity rate from 14% to 0.62% with malaria eradication campaigns in less than 5 years; 2)A tremendous increase of positive cases was observed between the years 2005 2009 with around 130.000 cases /year (malaria strategic plan) to almost 300.000 positive cases in 2012 ( National malaria disease surveillance report 2012)., The annual parasitic incidence went up from 0.74 in 2009 to 1.46 in 2010 and 1.88 in 2011. Similar trends were observed in low transmission areas of Punjab province which also suffered from the floods, the malaria cases went up from 3,432 cases in 2009 to around 30,000 cases in 2010; 3) It is important to note during this long period ,that the blood examination rate ( indicator for malaria surveillance ) dropped from 9.36 in 1973 to 5.46 in 1980 and remains quasi stable around 2 3 / 1000 inhabitants between 1983 and 2013 , indicating a poor case detection during almost 30 years.;4)Given the variety of ecotypes in the country (valleys with rivers at various altitudes, agriculture related malaria, peri urban type, migrant malaria,…) the epidemiology of malaria varies considerably between provinces / districts and union councils. More detailed spatial analysis with micro stratification by districts is critical for malaria control/elimination monitoring.
Transmission of malaria in most parts of the country is highly seasonal and unstable with peaks of transmission in the summer (June Sept) for P. vivax and late summer and winter months (August November) for falciparum malaria. Because P.vivax relapses, there is a peak of relapse episodes seen in the early summer (April June) resulting from transmission in the previous year.
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Malaria epidemics frequently occur in Pakistan which has a history of unstable transmission. Between 2010 and 2013, Disease Early Warning System (DEWS) reported maximum number of malaria alerts and outbreaks from Baluchistan followed by Sindh, These alerts and outbreaks peaked in 2011 and 2012 which might be explained by the fact that during those years, both provinces had major emergency due to floods and secondly during the same period almost every district had a DEWS surveillance officer in the provinces thus detecting alerts and outbreaks was quite efficient. Predictably, 7 out of 15 districts reporting the highest number of alerts and outbreaks during 2010 13 belonged to Baluchistan province with highest numbers reported from Jaffarabad with 44 alerts and 32 outbreaks.
The new malaria information system launched in 2009 in 19 priority districts managed by the DOMC shows an increase of API from 7.13 in 2009 to 10.13 in 2012 associated with increased malaria risk with major flood emergency and increased access to RDT and Microscopy, followed by a decrease to 7.82 in 2012 following the control measures especially with increased access to Primaquine and ACT. It is noted that in 2010, out of 122,350 positive slides, 20,051 were taken in IDP camps. Age distribution of cases indicates the confinement of malaria to the age group above 15 years with only 17.82% of confirmed cases among children below 5 years.
The District Health Information System (DHIS) data from primary/clinic health centre health care facilities suggests that proportion of suspected/clinical malaria cases presenting to OPD is highest in Baluchistan with 8.9% and 8.6% of total OPD consultations followed by Sindh with 8.50% and 7.36%, KPK with 3.7% and 2.3% and Punjab with 1.5% and 1.5% for 2011 and 2012 respectively.
Similar proportions can also observed in DHIS secondary/ hospital health care facilities data with 2.6% and 5.54% malaria OPD consultations for Baluchistan followed by Sindh with 7.8 % and 5%, KPK with 3.1 % and 2.3% and Punjab 0.6% and 0.6% respectively in 2011 and 2012.
Punjab tested the highest proportion of suspected Malaria cases with 83% and 86% of total suspected malaria cases followed by low testing rates In KPK with 28.4% and 36.3%, and Baluchistan with 19% and 23% and very low testing rate in Sind with 18% and 18% respectively in 2011 and 2012.
In 2011 and 2012, Baluchistan had the highest proportion of malaria cases admitted in the primary health care facilities where as in the secondary health care facilities, Sindh province had the highest proportion of malaria admission during the same time period. Taking admissions as proxy indicator for severe malaria, proportion of inpatient admissions in secondary hospitals was highest in Sind with 6% and 8% followed by Baluchistan with 1.8 and 2.7%, KPK 2% and 2.2 % and Punjab with 0.2 and 0.3% respectively in 2011 and 2012. The hospital fatality rate among the severe malaria cases was highest in Punjab 2% with 67 deaths in 2011 and in 2012 Sindh had a case fatality rate of 1.73% with 155 deaths. However inpatient admission from primary health care facilities was highest in Baluchistan with 52% in 2011 and 43% in 2012.indicating the continued challenges of PF transmission and different level of access to primary and secondary facilities in Baluchistan and Sind.
The nationwide epidemiological data shows clearly that Pakistan is a low to moderate endemic country with an important diversity within and between the provinces and districts. The mapping of Malaria situation (2012 data) shows clearly that the highly endemic districts are located gradually in Baluchistan (API 7.68), FATA (6.83), Sindh (2.92), and KPK (2.76), Punjab (0.19) and AJK (0.10).
The MPR showed the existence of a fragmented malaria and health information system, with very limited capacities of analysis. The geographical information system necessary for the strategic orientation of malaria control interventions is absent at all levels. There is a need to understand much better the epidemiology of malaria in all provinces.
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Key best practices, success stories and facilitating factors
Access and coverage to malaria control interventions
Malaria control program and all malaria partners supporting delivery of malaria control services have not adequately focused on the needs and demands of the malaria risk populations and have not tracked trends in universal access and coverage to malaria control services. An estimated 20 % of the population have access to public health facilities, from which the number of reported cases by per year is approximately 300,000 resulting in the total number of malaria cases to be an estimated 1.5 million per year.
The demographic health survey conducted in 2012 13, with a representative sample of 12,943 households, recorded 38% of children under age 5 had fever symptoms in the 2 weeks preceding the survey. Children under 5 who sought treatment from health facilities/providers was estimated to be 58.2% in Sindh, 50.1 % in Punjab and 39.1% in Baluchistan. A higher percentage of children under the age of fiver were detected with fever (38%) than diagnosed as confirmed malaria (20%) highlighting the need for further investigation on the origin of fever cases and more efforts needed to confirm all suspected/ clinical malaria cases in Pakistan.
Similarly data collected from DEWS on suspected malaria indicates many fever cases of fever are diagnosed as malaria cases, for example in Jamal Kot ( Okara district, Punjab) BHU and rural dispensary,717 suspected malaria cases were reported in 2013 ( up to October 2013), 99 slides taken and 0 malaria cases confirmed. Lack of diagnostic facilities in BHUs and non availability of trained staff weakens the coverage and access to malaria control activities.
To date, the programme has distributed 2.4 million LLINs since 2009, initially targeting pregnant women and children under the age of five in high risk areas. The current National Malaria Strategy targets 85% (6.9 million) of the 8 million populations living in high risk areas with Long Lasting Insecticidal Nets (LLINs) and the remaining 15% (1.2 million) of the population living in epidemic prone areas are targeted with Indoor Residual Spraying (IRS). The overall LLIN operational coverage in targeted districts (38) is 41%, ranging from 25% to 65% at district level. The overall IRS operational coverage at union council level in the 38 districts targeted by Global Fund is 99%, ranging from 25% to over 100% in targeted union councils. The programme has based their estimations for IRS on the census data taken from 2010 which consequently has resulted in districts over achieving their original targets. Furthermore, given that only targeted union councils are subjected to both interventions undermines the whole concept of “universal coverage” as denoted by WHO guidelines, especially in the case of IRS where the total population at risk, the distribution of malaria cases in all union councils and geographical reconnaissance have been overlooked.
There are 24 reported anopheline species in Pakistan. The predominant vectors vary according to ecological niches in the Country: An. culcifacies ( sibling species A and B ), An.stephensi (urban and mysorensis ). Insecticide resistance has been reported in Pakistan since 1980s to organochlorine and organophosphate used in past Indoor Residual Spraying (IRS) campaigns. To date, the programme has distributed 2.4 million LLINs since 2009, initially targeting pregnant women and children under the age of five in high risk areas. The current National Malaria Strategy targets 85% (6.9 million) of the 8 million populations living in high risk areas with Long Lasting Insecticidal Nets (LLINs) and the remaining 15%
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(1.2 million) of the population living in epidemic prone areas are targeted with Indoor Residual Spraying (IRS). The National LLIN operational coverage is approximately 39% and for IRS it is 15%.
There is a LLIN distribution strategy with an accountable voucher system (among Global Fund (GF) supported districts), which utilizes a continuous distribution channel i.e. routine immunization campaigns for registration and collection from Basic Health Units. A basic monitoring system exists for IRS and larviciding in selective provinces
Disease early warning system (DEWS) supported by WHO includes malaria outbreak detection and alert and rapid response.
Coverage of health facilities with microscopy and RDTs, particularly in 38 target districts supported by GFATM, has expanded. Malaria diagnostic centers are available in district hospitals, Rural Health Centers (RHC) and District Health Offices (DHO). Diagnostic support is provided by CDC labs in DHOs to all Basic Health Units (BHUs), though there is a significant delay in providing feedback to health facilities in the periphery. Malaria treatment in the public sector is being provided free of charge. A registration system for medicines exist, procurement of anti malarial drugs (with unknown quality) from local market is common at the district level. Monitoring of drug efficacy of first line drugs is conducted regularly and so far is efficacious.
Key malaria indicators mostly available at central, provincial and district levels are the API, SPR, BER and Parasites species proportion. Multiple malaria information systems are in place such as the old malaria surveillance system, new malaria information system (MIS), DHIS and DEWS generating different malaria indicators. New malaria information system (MIS) s being rolled out to cover 38 targets districts and plans in place to roll out in non GF supported districts. Malaria indicator surveys conducted in 2009 and in 2013. The results of MIS 2013 are being analysed and report under preparation. Excellent federal annual malaria surveillance reports and malaria reports prepared as part of Ministry of Health year book. In some provinces such as Punjab active case detection and case investigation surveys are conducted by CDC officers. M&E capacity is being developed with M&E officers in districts and provinces.
Malaria provincial and federal financing was started under Roll Back Malaria initiative though the provincial and federal planning system till 2012/2013 and new cycles are being initiated as integrated vector disease control management. Plans are underway to increase health and malaria financing in 2013 in all provinces. The Federal Malaria strategic framework 2011 2015 has been developed to support the transition of provincial and federal PC1 2013 2018 plans. Malaria control activities are being successfully piloted in some union councils with, supply of commodities, capacity building and M&E in 38 high malaria burden districts supported by Global Fund and contracting malaria partners.
There is a PSM plan to support the procurement in Global Fund supported 38 districts. There are estimates prepared for malaria commodities as part of the PC I by the FMCP and PMCP. WHO specifications are being used for procurement of LLIN, IRS insecticides, RDT and ACT. There is a standardized procedure for procurement Public Procurement Regulatory Authority PEPRA. There is a good malaria storage system in provinces with partners such as Merlin and SCF. ACT and RDT stock control and reporting system is part of new MIS. There are drug quality control laboratories at federal and provincial level with drug regulatory officers at district level. There are insecticide quality control centers in Kharachi and Faisalabad
Main problems and challenges
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Advocacy for prioritizing malaria control with high level policy makers and political leaders needs to be strengthened to ensure adequate funding for BCC activities. A Malaria BCC strategy has been developed at the Federal level but needs to be approved and made available to the provinces and districts. There is limited capacity and insufficient staff in advocacy, information, education, communication at the provincial level. Complex socio cultural settings exist in different provinces and districts, further highlighted by the low literacy rate in provinces such as Baluchistan and FATA and limited access to households, specifically women and children has resulted in the lack of broad based community involvement. Hence the need to develop community based malaria control, design context specific IEC messages and ensure the judicious use of communication channels (mass media, interpersonal and printed materials). The capacity of lady health workers has been overlooked as a potential for expanding and strengthening community based malaria control interventions.
No systematic approach towards LLIN replacement has been initiated. Universal coverage for IRS and LLINs is not being met in all the targeted districts and union councils and universal equity for LLINs is not being met within all targeted households. There has been observed instances of “wear and tear” of recently distributed LLINs. The timing of IRS campaigns does not always coincide prior to the rainy season and peak transmission period (on religious grounds) in all the targeted union councils/localities. Some provincial programmes conduct larviciding which is not done consistently throughout the transmission season and dosages and quantities may not be applied appropriately according to the type of breeding sites.
There is a functioning vector control program in some provinces and districts with few trained and experienced staff; this includes an entomologist and insect collector. Vector control strategies (malaria, dengue, LLIN distribution), guidelines (IRS, community mobilisation for LLINs, Crimean Congo Haemorrhagic Fever) , training manuals (IRS, LLINs) have been developed by the federal programme but with restricted circulation to the provincial programmes, while vector control guidelines (2007) are utilised in some provincial programmes but this needs updating. Furthermore, IRS guidelines are not widely available at provincial and district level nor in local languages making it difficult for field use. The Federal programme has established a basic IRS and LLIN database yet lacks tracking of operational coverage of interventions by province and district. Evidence based need assessment and M&E tools developed at the federal level have yet to be disseminated to provincial programmes.
At the provincial level, there is a lack of adequate equipment, supplies, inappropriate use, maintenance and storage of available ones. The provincial programmes are at times incapacitated by poor logistical support which impacts on the quality of service delivery.
Despite Pakistan’s long history of malaria operational research, which documents the change in vector composition in different ecological surroundings, vector sampling surveys, entomology and susceptibility surveys. There are no updated vector maps with information on vector species, distribution, breeding sites, resting and biting habits and insecticide susceptibility. This is partly attributed to a lack of adequate resources (entomology lab and insectaries) and skills (by newly recruited and existing staff) to conduct routine monitoring on key entomological indicators at established sentinel sites. The programme has yet to develop an integrated vector management strategy, which addresses the increasing demands of dengue and irrational use of public health pesticides. There is no collaboration with provincial universities for vector surveillance and research.
Malaria transmission is unstable with high risk of epidemics but there are no maps of districts with high epidemic potential and those with reported malaria outbreaks over the last 5 or more years. Malaria emergency risk is high due to political and security challenges in some districts and provinces and past 9
risk of floods and earthquakes. There are no malaria epidemic emergency focal points in the federal and provincial malaria programs supported by a technical working group. Malaria epidemic threshold for detection of malaria outbreaks being used by the DEWS system but no thresholds are in use in by the malaria information (MIS) system and the DHIS system.
There is a lack of trained malaria program teams on malaria epidemic emergency preparedness and response at all level. There are numerous partners such as WHO provincial sub offices and emergency programs such as OCHA, UNHCR, UNICEF working in health emergency but inadequate partnership by malaria program to address universal access and coverage of malaria control interventions in emergency affected districts and provinces.
Parasitologicaly confirmed cases count for around 20% of all reported cases over the last few years. A systematic approach for quality control/assurance for lab services is missing. There are no reference labs at the provincial and federal levels. There is limited number of trained and qualified microscopists and on average one third of their positions remain vacant. Shortage of trained staff, supplies, refresher training and poor practice is more evident in districts outside GFATM support. The treatment chart based on national treatment guideline is present in some of the health facilities, yet the adherence to guidelines is poor. The guideline was not distributed widely and the health staffs are in need of refresher trainings on malaria case management. Second line ACT, and in some health facilities SP, is used for the treatment of PV and suspected cases. The radical treatment by Primaquine for P. vivax is still not available in all health facilities. There is no designated focal person for case management in provincial and federal levels. Regular supportive supervision for case management activities and standard supervisory checklist are lacking. Treatment of malaria during pregnancy is part of national treatment guidelines, though adherence to it is poor. The reporting of inpatient and severe malaria cases and deaths from health facilities appears incomplete and not accessed consistently by the malaria program. There is inadequate focus on severe malaria case management in the program and in general are not managed in secondary district hospitals but referred for ICU care at tertiary hospitals. Measures to control and assure the quality of anti malaria drugs needs to be further strengthened. The supply management system is weak, improper estimation and distribution of anti malarial drugs leading to stock outs in health facilities. The estimated utilization of public health facilities remains low (20 30% in different districts), private sector plays a key role in malaria case management. However, a systematic approach for involving private sector in malaria case management is missing.
Different malaria case definitions used by DEWES and DHIS, new and old malaria surveillance and information systems. Lack off comprehensive compilation of access and outcome coverage Indicators of the program complied by, district, province and federal levels. Impact indicators such as % of malaria admissions and deaths among hospital admissions and % of severe malaria cases are poorly collected, with few exceptions. There is no comprehensive ONE malaria data base at district, provincial and federal level to bring together malaria information from different sources and systems. Questions are being raised regards the accuracy and completeness of the malaria information from public sector and it is also estimated that 70% of malaria cases are seen in the private sector.
There is not enough mapping of malaria data due to limited malaria program GIS capacity but excellent mapping capacity in other program such as EPI, Polio, DEWS and WHO malaria atlas that could be used. Malaria Epidemiological orientation capacity is inadequate at all levels with many vacant provincial posts of malaria epidemiologists.
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There are serious delays and gaps between funds allocated, released and actual expenditure. International financing is mainly though Global Fund and the contracted local malaria partners. Despite this, malaria control is not seen as a priority by policy makers and politicians at the district, provincial and federal levels with more implementation efforts being placed on the millennium development goals 4 and 5 as well as many other competing health priorities such as dengue, expanded programme for immunization, polio, hepatitis, emergencies and health reform.
There is inadequate sharing of information and coordination and alignment between the district, provincial and federal malaria control programs with lack of clarity with regards to their roles and responsibilities. Inadequate partnership exists at all levels (Federal, provincial and district) of the Malaria Control Programme as well as with other programs such as, Primary Health Care and Lady Health worker program, District Health Information system, DEWES, etc. There is inadequate coordination and alignment between the malaria program at federal and provincial levels and the various malaria control partners.
Different components of malaria control policies have been integrated with the strategic and PC 1 plans and federal guidelines although they are generally in line with WHO recommended policies. The annual malaria operational plans are only being used in Global Fund supported districts and partially in others and not holistically within the overall district and provincial malaria programs. Federal malaria control guidelines and wall charts are available in certain Global Fund supported districts but appear to be complex to use and not widely available in all provinces and district, especially in local languages.
There is inadequate partnership between malaria program with provincial and federal universities and health institutes to support operational research and training malaria control and elimination. Malaria control program is oriented towards neither supply based on output and neither on need nor demand based on access, equity and coverage towards rapidly achieving and sustaining universal access and coverage. There is a fragmented district, provincial and federal public health system which is unable to provide adequate support to the devolution transition, emergency, health reform and is overshadowed by a dominant private sector. The formal and informal private sector provides a large part of the fever/malaria control services especially in urban areas and in some rural areas. Federal cross border meetings (Pakistan Iran Afghanistan) have been held with inadequate practical follow up in border districts and provinces.
The unstable political and security situation in some districts and provinces has created challenges for access and M&E of the malaria program but also presents opportunity for developing a malaria emergency support. There are multiple malaria control activities being implemented at all levels of the health system, resulting in a desynchronized malaria control program at the district, provincial and federal level that fails to achieve systematic coverage and impact that can be sustained. Provincial malaria managers/ coordinators are at times not senior to support district health coordinators such as EDOS/DHO. There is a lack of functioning district malaria focal points/coordinators to be able to comprehensively follow up implementation in all malaria thematic areas. There are lack of malaria epidemiologists, entomologists, case management coordinators at federal and provincial levels of the program and malaria supervisors/technicians and malaria microscopists at district and BHU levels.
Malaria PSM is a push system based on supply and not a pull system based on need and demand. There are multiple malaria procurement and supply systems within the DOMC, PMCP, district health offices and hospitals and the various implementing malaria partners. There is no quality assurance system in place for RDT
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Key action points
Advocacy, Information Education Communication/ Behavior Change and Social and Community mobilization
1. To develop a strategy for increasing malaria advocacy and prioritization for community, district, provincial and federal government action.
2. To build partnership with LHW program and PPHI for social mobilization and community based malaria control program delivery.
3. Update malaria messages to target the local situation and adopt a local strategy which identifies appropriate inter personal channels for reaching the local communities and families
4. Harness the capacity of lady health workers for improving community BCC and scaling up malaria control activities;
5. Prioritize the use and develop tools for inter personal malaria communication for BCC using schools, madrasas, local traditional and political leaders.
6. Introduce qualitative monitoring tools, which assess how well the elements of the COMBI strategy are being carried out.
Malaria Prevention: Entomology and Vector control
1. LLIN gap analysis towards accelerated coverage of 80% in target high transmission districts through mass campaigns supported by routine continuous distribution mechanisms (outreach, routine, schools, community, commercial sector, social marketing) for hard to reach areas and three yearly replacement.
2. Revise the LLIN distribution strategy to ensure there is universal equity at the household level.
3. Develop a simple stratification and mapping method using reported incidence, topography and local experts’ opinion to focus evidence based vector control on high transmission districts and union councils.
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4. Reserve IRS (80%) to target high PF transmission districts to control and eliminate PF as well as to prevent epidemics and eliminate malaria foci in pre elimination phase and prevent re introduction
5. LSM to be targeted to support urban malaria control & elimination and can be used in general nuisance mosquito control. LSM to be targeted to eliminate malaria foci in districts for pre elimination and elimination of PF and PV
6. Establish vector sentinel surveillance sites in different eco epidemiological settings with standard guidelines by PMCP in collaboration with HSA and provincial universities and research institutes
7. Update vector distribution maps stratified at district level which reflects the seasonal distribution (vivax and falciparum) as well as vector binomics and susceptibility status of the predominant malaria vectors.
8. Establish an integrated vector borne disease control program (Malaria, Dengue, Leishmania) with adequate focus on each disease control and elimination as appropriate.
9. Develop a integrated vector management strategy, which addresses insecticide resistance management and identifies innovative approaches for inter sectoral collaboration
10. Entomological spot surveillance to be conducted by insect collectors and malaria supervisors supported by districts and provincial entomologists with provincial entomological reference laboratories.
11. Conduct LLIN hole index proportion study
12. Revive the vector control technical committee with updated TOR
13. Update and simplify the national vector control guidelines and supporting training materials
Malaria Prevention: Epidemic-Emergency Preparedness and Response
1. Update risk maps and tables on malaria epidemics and emergencies
2. Provincial quarterly malaria emergency update on needs and gaps in emergency affected populations and districts for follow up with provincial health emergency cluster
3. Malaria program and DEWS, DHIS to jointly review and update malaria case definitions and malaria outbreak and emergency thresholds and guidance for malaria outbreak control
4. To develop specific malaria emergency strategies such as simple community based malaria control to access and deliver malaria control to emergency affected areas.
5. To build malaria partnership with other organizations such as OCHA, WHO, UNICEF, UNIHCR, IOM, JICA, etc to move to universal coverage with malaria interventions by MDG 2015 in emergency affected districts
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Parasite Control: Malaria diagnosis and treatment
1. Strengthening lab capacity: all suspected/clinical malaria cases should be tested with RDT or microscopy before anti malaria treatment is administered. RDT to be rapidly scaled up to all BHUs in partnership with PPHI, IMNCI and PPNCP programs in malaria high risk districts.
2. Introduction of a systematic quality assurance system: strengthen quality control by establishing provincial and district reference labs with adequate infrastructure, competent lab technicians with support for annual cascade training and supervision, and continuous availability of consumables.
3. Training and development: after thorough need assessment at the central, provincial and district levels, a comprehensive training plan (refresher, pre service and in service training) for strengthening diagnostic capacity should be developed.
4. Recruitment of new staff: deployment of lab technicians in all relevant vacant positions, particularly in malaria high risk districts is needed.
5. Competent officers should be assigned as focal points for malaria case management at federal and provincial levels.
6. Update the federal and provincial essential drug list for health facilities and follow up the de regulation and ban on all malaria mono therapy in public and private sector
7 Radical treatment for PV with Primaquine with DOTS for 15 days to reduce relapse and transmission, supported by regular supply of Primaquine to all health facilities in malaria high risk districts.
8 Provision of new malaria treatment policy, guidelines and wall charts to all public and private health facilities by April 2014 supported by a ban on mono therapy and standardized training for all clinical staff
9 Establish community based malaria control with RDT and ACT with LHS LHW and community based organizations.
10 Case based reporting system be established for severe malaria cases followed by supportive clinical investigation and audit.
11 Engagement and scale up public private partnership in malaria control through professional association and sharing guidelines and wall charts and orientation sessions
12 Supervision by PPHI and DHO supported medical officer for implementation of high standard of malaria case management.
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13 DoMC and PRs should ensure efficient drug supply management system with monthly stock situation update especially for RDTs and ACTs.
Surveillance, Monitoring and Evaluation
1. Production of monthly, quarterly and annual district, provincial and federal malaria program reports based on strategic information at district and provincial level such as outcome/impact and mortality data 2. Update information on needs and gaps on RDT, ACT, Primaquine, LLINs and IRS to achieve universal coverage. 3. Establish one standard malaria case definition for diagnosis and treatment and , MIS, DHIS, DWES . 4. Review and update the old malaria surveillance system in place in districts targeting elimination of Malaria 5. Move to one malaria information system with data collection tool for an integrated malaria M&E system in all malaria risk districts by first quarter 2014.(Harmonize the M&E system among the PRs and SRs) 6. Malaria program to collect data on malaria inpatients and mortality from secondary and tertiary hospital DHIS reporting. 7. To establish GIS and malaria mapping capacity within the provincial and federal malaria program using WHO country office EPI and malaria atlas programs to guide malaria epidemiological analysis and target interventions at districts level. 8. DEWS to be sustained and transferred to the DHIS provincial and district departments to support malaria epidemics detection and response and in the future district malaria elimination. 9. MDC/PMRC/WHO/MEDVC HSA to propose an agenda for operational research to support malaria control efforts 10. Use the available GF funds to extend the M/E system to all district under malaria control strategy and adjust the M&E system for the districts targeted for elimination
Program Leadership and Management
1. Development of a new joint provincial and federal vision for malaria control and elimination in Pakistan supported by one simple and comprehensive malaria and Integrated Vector Borne Disease (IVBD)policy document.
2. Need to accelerate and intensify towards greater than 80% universal coverage by 2015 in Global Fund supported districts (38) and rapidly introduce the new malaria policies and interventions in the remaining 15 high transmission districts.
3. Establish functioning malaria and integrated Vector Borne Disease partnership mechanism between the District Malaria Control Programme (DMCP), Provincial Malaria Control Programme (PMCP) and Federal Malaria Control Programme (FMCP) and other programs such as, Primary HealthCare and Lady Health worker program, District Health Information system, DEWES, MNCH etc
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4. To develop a special community based malaria and integrated Vector Borne Disease control strategy for accessing hard to reach populations (Remote areas, emergency situations, IDPS, Nomads ) in selected districts and provinces.
5. To develop a special strategy for public private partnership for malaria and integrated Vector Borne Disease control with private medical care provider and also private retailers and producers of combination drugs, Rapid Diagnostic Tests (RDT), Long lasting Insecticidal Nets (LLIN) , Indoor Residual Spraying (IRS) and Larval Source Management (LSM) chemicals and hand compression pumps to ensure standards of quality and local production at affordable costs in provinces which involves a combination of information sharing ,training of health worker and information to public, legislation, regulation and enforcement.
6. The malaria federal Inter provincial coordinating committee (IPCC) and Technical Advisory Committee on malaria (TACOM) and the technical various working groups be revived with updated TOR on malaria and IVBD and be supported by provincial coordinating committees.
7. Joint annual operational /implementation malaria and IVBD planning started from 2014 at district, provincial and federal with the active involvement and contribution of all malaria partners and stakeholders
8. Joint monthly, quarterly and annual malaria and IVBD program performance reporting at district, provincial and federal level based on a uniform performance framework of input, outputs, outcome and impact towards sustained universal access and coverage.
9. Updating of provincial and federal malaria and IVBD strategic plans by end of April 2015 aligned to health strategic plans and PHC and MHSP based on need and demand for acceleration and intensification towards universal malaria intervention coverage by 2015 and post MDG
Procurement and supply system
1. PMCP. DMCP need to ensure the PPRA, PPHI, LHI and all malaria partners procure all malaria commodities (ant malarial, insecticides and vector control equipment for IRS) according to the WHO/WHOPES specifications.
2. Urgently align DRAP registration for malaria combination therapy with national malaria treatment policy and to support production/import of Primaquine and de registration and ban on use of mono therapeutic formulation for all malaria treatment.
3. To prepare quarterly updates on malaria commodities used and in stock and forecast urgent need
4. Establish a system for RDT quality assurance (QA) using WHO accredited international laboratory and quality control using a national malaria microscopy laboratory.
5. Annual updating of the malaria commodities specification list based on WHO recommendations
6. Annual updating of estimates of malaria commodities based on need and demand to achieve and sustain universal access and coverage
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7. Conduct a review of the current stores and potential need for malaria combination drugs, RDT, LLIN, IRS and LSM chemicals in district and provinces
1. Introduction
1.1 Background Given the concerns for malaria burden and implementation of the new arrangements for the programme, malaria control and elimination unit, in coordination with Directorate of Malaria Control, WHO country office and GFTAM, requested for a rapid assessment of the current situation of malaria control programme in Pakistan. The findings of rapid assessment strongly suggested and recommended an in depth program review to identify gaps and issues with programs especially in wake of devolution and a national and provincial strategic document can be made as a way forward and mobilize resources on new funding model
1.2 Objectives of the MPR
1. To review the epidemiological outlook of malaria disease in each province of Pakistan with particular reference to disease trends, Slide positivity rate, Species wise distribution, Blood Exam Rate (BER), Severe Malaria and Outcome of the managed cases at health facility with particular reference on disease specific mortality.
2. To review the Malaria program structure, capacity and management in each province and at national level (DOMC), in view of its new roles after devolution and identify issues and challenges arising post devolution.
3. To assess the current programme performance by intervention thematic areas and review progress, challenges and towards achievement of targets in each province and progress towards achieving national and regional goals.
4. To identify way forward, priority needs and gaps for improving programme performance and coordination at provincial and federal level.
5. Define steps to improve programme performance and redefine the strategic direction and focus, including revision of policies and strategic plans at provincial levels which can help tapping the available funds from various sources including the public sector and donors e.g. Global Fund from R10 malaria grant phase II and from the new funding model.
6. To assess the effectiveness of Global Fund grants supported projects in highly endemic regions of the country and to suggest ways and means for quality assured interventions following the principals of transparency, accountability and value for money.
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7. To develop the post MDG strategic plan at provincial and national level for Pakistan for 2015 2020, based on the results of PRM, which will help mobilize resources based on new funding model.
1.2 Methodology of the MPR Malaria programme review will involve a mixture of methods, including desk reviews of technical thematic areas based on programme data, reports, documents and published literature; updating country databases and country profiles; mapping of populations at risk; estimating burden and making projections; policy and management analyses; special studies; and group work, individual consultations and provincial and district field visits with interviews and observations.
The programmatic review will be conducted in four phases which will include
Phase I:
Planning Phase It will involve:
1. Needs assessment for a programme review
2. Building consensus to conduct a review
3. Appointment of a review coordinator and establish an internal review secretariat and steering Committee
4. Constitution of Provincial Teams
5. Identify and agree on the terms of references of the internal and external review teams
6. Send an official request to WHO for technical support
7. Select and prepare central, provincial and district sites for field visits
8. Define the objectives and outputs of the review
9. Plan administration and logistics
10. Develop a review proposal, with a budget, and identify funding sources
11. Design a checklist for tracking activities
12. Collecting and summarizing all the available data including technical reports and PC1s
13. Review of available data and preparation of thematic area overviews;
Phase II:
Thematic desk review This will involve:
1. Assembling information from reports and documents, 18
2. Conducting a technical thematic desk review,
3. Compiling a thematic desk review and
4. Score achievement by thematic areas
5. Selecting and adapting data collection methods for the field review.
Phase-III:
Field review This will involve
1. Briefing and team building between internal and external review teams
2. Building consensus on the findings of the internal thematic desk reviews
3. Becoming familiar with the data collection methods for field visits
4. Briefing and forming the teams for field visits
5. Visiting national institutions and organizations (Central level)
6. Making district, provincial, state and regional field visits
7. Sharing reports and presentations from field visits
8. Preparing a draft review report
9. Preparing the executive summary, aide memoire and slide presentation
10. Presenting the review findings and recommendations
11. Meeting with senior management of the ministry of health,
12. High level meeting and signing of aide memoire and stakeholder workshop
13. Media events (press release and press conference) and
14. Completing the final draft of the review report
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Phase-IV:
Final report and follow up on recommendations. This phase will include:
1. Finalize and publish the report.
2. Disseminate the report.
3. Implement the recommendations.
4. Monitor implementation of the recommendations.
5. Update policies and plans and redesign the programme, if necessary.
1.4 Outline of the document This report is structured to cover all the thematic areas mentioned below. The following thematic areas are discussed along with its SWOT analysis followed by recommendations.
• Program Management • Malaria Diagnosis and Case Management • Malaria Vector Control • Malaria Commodities, Procurement and Supply Chain management • Advocacy, Information, Education, Communication and Community Mobilization • Epidemiology, Surveillance, Monitoring, Evaluation and Operational Research • Epidemic and Emergency Preparedness and Response
2. Context of malaria control
2.1 Historical milestones in malaria control Year Activities
1952 56 A five year plan to extend the malaria control activities to other areas aside from selected areas since 1950.
The main strategy was vector control using blanket spraying of DDT.
The results were encouraging and marked decrease in the spleen rate was observed in children below 10 years.
1960 In 1960s, a pre eradication malaria survey was completed.
Results indicated highest malaria prevalence in Punjab, due to the network of irrigation canals and the extension of flooded areas.
1961 69 A nation wide malaria eradication program was launched under the auspices of WHO and with the help of USAID and UNICEF.
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Strategy
The main strategy was vector control using blanket spraying of DDT, with a transient temporary relief during late 60s & early 70s
Results
As a result of this campaign the malaria was nearly eradicated from the country and a marked reduction in malaria cases was observed from an estimated 7 million cases in 1961 to 9,500 cases in 1967. An overall reduction from 15% to less than 0.01% was observed in the slide positivity rate.
1969 74 The malarial infection began resurgence in 1969 & 1970s and included the increase of malaria in urban areas (a quarter of million cases were reported from Karachi alone). All this resulted in the program collapse, subsequently followed by explosive resurgence of malaria assuming epidemic proportion in 1972 73.
Results
USAID reports in Pakistan, there were 9,500 cases in 1968. In 1971 there 108,000 cases which rose to 10 million in 1974.
The reasons of resurgence were : the onset of vector resistance to Organochlorines (DDT & Dieldrin/BHC), under estimation of A. stephensi in maintenance of urban malaria together with financial and administrative constraints, inadequate administration of programs, inadequate research, training, and supplies of chemicals and drugs, inadequate health services infrastructure, the lack of malaria control components in hydraulic development projects, and underdeveloped socioeconomic conditions generally. Premature withdrawal of donor support was also an important factor. 1975 85 The Malaria Program switched from Eradication to Control Program. Initiation of Five years National Malaria Control Program with support of WHO and USAID. Implementation handed over to provincial government and malaria control program was integrated with general health services.
The main objective of the MCP was to reduce the disease incidence to less than 500 cases per million population.
Strategy Vector control by indoor residual spraying was the main strategy.
In 1976 DDT (Organochlorines) was replace with Malathion (Organophosphate) insecticide with two rounds of spraying in most areas.
Results
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Malaria decreased significantly in 1977 78. There has been a sharp decline in the slide positivity rate from 14% to 0.62% and API from 13 per 1000 population to 0.3 per 1000 population in 1978. Malaria Control programme continued till 1985.
1985 2002 In 1985, Malaria Control program was merged with Health Department.
In 2000 20012, Devolution of health and other services
The execution and implementation of the Program went directly under the control of Executive District Officers (H).
Under devolution the malaria staff were declared dying cadre and the MCP directorate was abolished, which further deteriorated the malaria situation in province.
Same Malaria Control Policies and strategies continued.
2003 RBM Strategy adopted in Pakistan as a signatory with Global partners
The key objective was to reduce the disease burden by 50% by 2010.
2004 GF and strategic plans and rounds
2007 13 PC 1 of 329.954 million rupees.
Main strategies:
Early Diagnosis and Rapid treatment, Multiple Prevention, Epidemic Preparedness, Monitoring, Evaluation and Surveillance, BCC, Operational research besides staff component.
Results
Fail to achieve the targets because of lack of financial and administrative constraints
2013 15 • A total of 90.0 million were calculated as KP share of National RBM Program fund. ( PSDP GRANT NO; 23 (2012 13) • Rs.8.025 million was utilized in FY 2011 12 on purchase of goods. The remaining Rs.81.975 million are available as capital cost for this PC I. • The Project Cost Estimates have been prepared in January, 2013 and will continue till 2015. Strategies The main components include Early Diagnosis and Rapid treatment, Multiple Prevention, Institutionalization and Monitoring, Evaluation and Surveillance.
2.2 Malaria control within the national development agenda/national health policy
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In the national policy (2009) of Pakistan , The burden of diseases (BoD) is heavily dominated by communicable diseases,reproductive health and malnutrition issues accounting for 50% of the total burden of diseases. This is further complicated by burden due to non communicable disease group dominated by cardiovascular diseases, diabetes, injuries and neuro psychological diseases. This double burden of disease is a major challenge in the health sector of Pakistan
Among the BoD, Pakistan is considered as a malaria endemic country with little change in the status over past five years. Punjab, NWFP and Sindh have low endemicity of malaria but Balochistan and FATA are high endemic areas
The overall goal of the 2009 policy is to improve health status of the people of Pakistan .The National Health policy aims to improve health status of people of Pakistan by achieving the policy objectives mentioned below and it is envisaged that it will also help Pakistan to make progress towards health related MDGs. i. Enhancing coverage and access of essential health services especially for the poor; ii. Measurable reduction in the burden of diseases especially among vulnerable segments of population; iii. Protecting to the poor and under privileged population subgroups against catastrophic health expenditures and risk factors; iv. Strengthening health system with focus on resources; v. Strengthening stewardship functions in the sector to ensure service provision, equitable financing and promoting accountability; vi. Improving evidence based policy making and strategic planning in the health sector.
The specific Objective 2 of the policy aims to achieve : Measurable reduction in the burden of diseases especially among vulnerable segments of population. In response to the endemic Malaria burden in Pakistan, the programme will continueto implement the Roll Back strategy with effective implementation in high risk districts, using rapid diagnostic kits, expanding the use of impregnated treated nets (ITNs) and using updated treatment protocols. In addition, a comprehensive strategy will to be developed to respond to other vector borne diseases especially dengue fever.
In reviewing the Human and Social Capital Development , working group report for Vision 2025 ( first draft, December 2013) , Malaria control program is not mentioned as such. However , it is mentioned that :”Strengthening of primary care with necessary back up support in rural areas where all health outlets will function as focal point for control of Communicable diseases, family planning services and improvement of surveillance and the diseases early warning system will be addressed through the different national health programs”. DOMC should take the opportunity of the recent MPR to advocate for inclusion of malaria control / elimination among the strategic priorities of the Vision 2025.
2-3 Malaria control in National health strategic plans
In pursuance to 18 th Amendment of the Constitution, health & population sectors have been devolved to the provinces with all administrative and financial autonomy. Most of the province are finalizing their health sector strategies.
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Sindh for example consider as a key issue the rise of Malaria incidence witch has coincided with outbreaks of dengue fever needing a proper vector control. The special area of focus in Sindh will be to Establish links for integrated control at community based, MSDP and ESDP levels, and evidence based intervention enhancements ( Strategy 3.6: Establishing links between TB, Malaria and Hepatitis for integrated control at community based, MSDP and ESDP levels, and evidence based intervention enhancements.)
In Pundjab, The key emphasis of the Strategy is on integrating health services supported by a strong monitoring and evaluation system. The health sector Strategy has been devised with a vision to enhance health status and productive lives of the people of Punjab by improving maternal and child health, nutrition, control of communicable and non-communicable diseases .
2-4 Health services organization and management The health delivery system in Pakistan is a mix of public and private sector services. There is considerable inequity in access to services between rural and urban areas. One estimate indicates that more than two thirds of the population consult private sector health providers as compared to only a third of the population utilizing public sector health facilities 1.
Thus the government is the main provider of rural health services and also the only substantial provider of preventive care throughout the country. Little information is available about the semi regulated private sector.
The public health services are provided through the health care delivery systems and public health intervention. The health system has a well defined pyramidal structure, with Basic Health Units (BHUs) at the base (approximate catchment areas of 15 20,000 people), Rural health centres (RHCs) forming the core of primary health care with a catchment population of approximately 80 100,000 people. Tehsil Headquarters (THQ) hospitals provide in patients services as the secondary level of the health system followed by District HQ providing an upper secondary level of hospital services. There are also major teaching hospitals and specialist centres, provided by a mixture of public and private sectors, The system is supported by Government financing and through the support or Civil Society Organisations with a range of donors, including the Government (using a sub contracting mechanism) and international bilateral donors such as USAID, DFID and many others including World Bank and Asian Development Bank, Islamic Development Bank and numerous others.
Vertical Public health interventions include a number of public health programs which are federally led with provincial implementation and institutional mechanisms. The list of the main vertical public health programs is as follows;
Expanded Program on Immunization (EPI) National Program for Family Planning and Primary Health Care (NP for FP&PHC) National Maternal, Newborn and Child Health Program (MNCHP) National AIDS Control Program (NACP) National Program for Malaria Control (MCP) National T.B. Control Programme (NTCP) Prime Minister Program for Prevention and Control of Hepatitis in Pakistan Cancer Treatment Programme
1 Pakistan Social and Living Standards Measurement Survey (Provincial District) 2004 05 24
National Blindness Control Programme
There are 948 hospitals in 2008 with over 133,956 registered physicians and over 65,387 registered Nurses, 9,012 Dentists and approximately 100,000 Lady Health Workers. The population to facilities ratio in respect of a doctor is 1 per 1,212 persons; a dentist 1 per 18,010 persons and availability of one hospital bed for 1,575 persons 2.
2.5 Organizational structure for malaria control The programme is implemented countrywide with an established organisational set up at federal, provincial and district level. At the federal level there is a Directorate of Malaria Control, which is an attached Department of the Ministry of Health. The Director Malaria Control is assisted by a team of professionals (i.e. Epidemiologist, Entomologist, and Health Education Officer) and support staff. The Directorate is responsible for overall leadership role including strategic direction & policy design (detail described in Annex II). The Directorate of Malaria Control has a separate budget for development and non development activities, which falls under the Federal Ministry of Health.
At the Provincial level there is a complete administrative set up for malaria control Programme, although the structure may differ by province for example; In Punjab the Director (CDC) is the overall in charge with Additional Director of Malaria being directly responsible for malaria control activities. These officers assist the Director General Health Services. There are separate Directorates of Malaria Control in the Provinces of Sindh & Balochistan working under the provincial Health Departments. In KPK (formerly NWFP) the Malaria Control Programme is under the Deputy Director Public Health, with an Assistant Director (PH) being the focal person for malaria control activities.
The Provincial Malaria Control Programmes are primarily responsible for co ordinating and facilitating malaria planning and implementation activities in their respective districts. Each province earmark separate budgets to co ordinate/facilitate malaria control interventions
The Executive District Officer Health (EDO) has overall responsibility for malaria control activities at the district level. The DOH/DDOH (preventive) is the focal person for malaria control activities in the district. The delivery and management of malaria care has been integrated with district healthcare services so that continuing care can be provided close to the patient’s home. The DOH also has two malaria officers i.e. a Communicable Disease Control Officer and an Assistant Entomologist, who assist him in looking after the malaria control activities in the district.
At Tehsil level the Deputy or Assistant DOH would be designated as sub district/tehsil focal person for malaria control activities in the tehsil. They would be responsible for operations of malaria control activities in their respective tehsils. DDOH also has one CDC Inspector (CDCI) to assist in malaria control work in the tehsil.
The district and sub district hospitals and rural health centres (and few selected basic health units) work as microscopy centres. A microscopy centre has a laboratory with laboratory staff and a doctor who is trained to diagnose and treat malaria. The primary health care facilities such as basic health units and dispensaries, where laboratory is not available, work as treatment centres. The district headquarters hospitals also provide specialist care to complicated/severe malaria cases. The CDC Supervisors at the union council level, associated with primary health care facility, carries out community based activities for the control of malaria.
2 Economic Survey of Pakistan Health & Nutrition, 2008 09 25
2.6 Key strategies for malaria control
Goal: In line with MDG 6, the strategy aims to reduce the burden of malaria by 75% percent (from 2000 levels) by 2015.
Objectives: This proposed 5 year strategy aims to provide the basis for achieving universal coverage of malaria control interventions to the most at risk populations in highly endemic districts by 2015. The objectives of the strategy are:
1. To enhance access by the population at risk to quality assured early diagnosis and prompt, effective treatment services. 2. To scale up coverage of multiple prevention interventions (especially LLINS & Indoor Residual Spraying [IRS]) to the level of universal coverage in the target population in high risk districts. 3. To strengthen existing Malaria Control Programme management capacity to coordinate, plan, implement and monitor effective curative and preventive interventions nationwide. 4. To strengthen programme capacity in enhanced epidemiological surveillance for timely detection and curtailment of malaria outbreaks. 5. To improve public sector health facility utilization for early diagnosis, effective treatment and preventive measures through enhanced community awareness and participation.
Targets: These targets cover the 38 highly endemic :
• The proportion of malaria cases diagnosed and provided correct treatment within 24 hours of the onset of symptoms (at facility or community) will be 80% (baseline NA). • The proportion of cases diagnosed as P. falciparum malaria in public sector health facilities being treated with ACTs will be 100% (baseline 8.2%) 3. • The proportion of private sector health care providers providing malaria case management according to the national treatment guidelines will be raised to 50% (baseline 34%) 3. • Universal coverage of freely distributed LLINs in highly endemic districts in the country. • The proportion of women and children having access and availability of community & facility based malaria control services will be raised to 80% (baseline TBE). • All MCPs at federal and provincial level are capable of planning, implementing and monitoring malaria control interventions through long and short term technical assistance. • All provinces (05), regions (03) and districts will have quality assurance mechanisms in place. • All endemic districts will have the capacity to detect, report and respond appropriately to malaria epidemics. • All endemic districts will have provision of malaria control services for population of humanitarian concern (IDPs, refugees, nomads etc). • 100% target population in highly endemic districts reached through behavior change communication interventions. (baseline 0%)
3 Malariometric Survey 2009 26
Strategic Elements of Malaria Control Programme:
The National Strategic Plan for Malaria Control 2011 15 is based on the following key elements: • Case management: Early diagnosis, rapid and appropriate treatment. • Prevention through multiple strategies • Epidemic preparedness • Building capacity at national and sub national levels. • Advocacy, communication and social mobilization. • Partnerships with private and informal sector • Focused operational research.
Additional elements include a focus on geographical areas of importance (such as those with manmade or natural disasters) and on populations of humanitarian importance, such as IDPs and refugees, as well as those with restricted access to health services. Gender issues will be addressed through combining efforts with relevant stakeholders in mother and child health initiatives, including antenatal care and community health workers.
This strategy will provide the basis and guidance for malaria control from 2010 2015 in Pakistan. Crucially, elements of this plan will be used to support applications for donor funding to support the already substantial Government contributions. 2.7 Key players in malaria control Save the Children and Department of Malaria Control (DOMC Islamabad) are Principal Recipients while Merlin and ACD are sub recipients. Since inception, the World Health Organization is providing technical assistance and has recently provided National Professional Officers stationed at MCP in Balochistan, Sindh, FATA, Punjab and KPK.
The Principal Recipients and Sub Recipient working with IVM in FATA:
Districts Sub Recipient Principal Recipient FR Peshawar, Kohat, Bannu, DI Khan, Merlin Save the Children Lakki, Tank, North Waziristan Khyber Merlin DOMC South Waziristan, Orakzai, Mohmand ACD Save the Children Bajaur, Kurram ACD DOMC
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The Principal Recipients and Sub Recipient working with MCP in KP:
Districts Sub Recipient Principal Recipient
Bannu, Lakki Marwat Merlin Save the Children
DI Khan, Tank Merlin DOMC
Mardan, ACD Save the Children
Charsadda, Nowshera ACD DOMC
The partners of Malaria Control Program Sindh include WHO, GFATM and NGOs implementing activities in six selected districts of Sindh as Sub Recipient (SR) and Principal Recipients (PR) under GFATM grant. During floods and heavy rains in Sindh in 2010 and 2011 additional partners such as MERLIN and Islamic Relief also supported Malaria Control Program Sindh.
2.8 Resource Mobilization
2.9 Linkages and coordination The MCP does not collaborate with other DOH departments including MNCH Program and NP for FP&PHC and AIDS Control Program. The MNCH Program implements the Integrated Management of Childhood Illness (IMNCI) strategy and PCPNC as part of the focused antenatal care package. There are no joint plans with several line ministries that include Agriculture, Tourism, Environment, Education, Public Works, Housing, Fisheries, etc. These sectors have access to populations that are affected by malaria but are usually not targeted by interventions delivered through the health sector.
2.10 Conclusions and Recommendations The program should devise mechanisms for malaria control issues to be discussed on a regular basis at the Federal, Provincial and District level using already planned and instituted partnership coordination mechanisms.
Recommendations:
• There is coordination between partners and MCP, but not the Program Managers therefore coordination among stakeholders need to formalized and improved. • Unavailability of guidelines and manuals reflects weak coordination between Province and Federal Directorate of Malaria. • PCPNC guidelines need to be updated. 3. Epidemiology of malaria
Today Pakistan has an estimated population of 173.5 million people, out of which, according to the 2012 national malaria disease surveillance annual report, 9% are living in high transmission districts (34) with an annual parasitic index (API) ranging from 5 to 28, 20% are living in moderately endemic districts (41 districts) with API ranging from 1 to 5, and 71% living in low endemic districts with an API below 1/1000 population. The national API for the entire country is averaging 1.69, which classifies Pakistan as a moderate malaria endemic country. Malaria mappings demonstrate clearly the highly endemic districts 28
are located mainly in the provinces of Baluchistan, FATA, Sindh, and KPK. The lowest malaria incidence was reported in two provinces – Punjab and AJK with combined population of more than 56% of total population of the country.
Figure 1: Proportion of PV to Pf (2008-2012)
The primary malaria vectors are A.culicifacies and A.stephensi. A number of secondary vectors have been reported and their contribution to malaria transmission is being investigated. The last nationwide vector surveillance was in 2009 and a recent survey has been conducted in 2013 and data is being analysed and the report under preparation.
The predominant malaria parasite is P. Vivax with P. falciparum being the secondary parasite. In 2012, Annual Blood Examination Rate (ABER) varied between 1.78% in Punjab to 7.09% in Baluchistan. Out of the 289,759 malaria cases confirmed positive in 2012, 249,504 were identified by microscopy (86.1 %), while 40,255(13.89%) by rapid diagnostic test. Majority of cases were considered as P. vivax (74.39 %) and 23.95 % as P. falciparum and 1.65 % as mixed infections.
Proportion of P falciparum varies widely with a range of 2.4% 44% respectively. Maximum proportion of falciparum cases (i.e. 44%) has been reported from Baluchistan province followed by 27% in Sindh, 11% in FATA, 9% in KPK and 6% in Punjab province. Proportion of PV to Pf over last five years (2008 2012) is shown in Figure 1. Certain areas of Sindh and Baluchistan have year round transmission with falciparum predominance.
Table 1: Malaria Data – Pakistan 2012
Province Population TOTAL Indicators
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Slides/RDT Positive P.V PF Mix % SPR API BER Examined P.F
Punjab 91,943,208 1636079 17522 16426 1008 88 1.07 0.19 5.75
Sindh 39,231,406 1785499 114651 79511 31083 4057 5.56 2.9 27.1
KPK 22,985,802 534516 63494 57402 5804 288 12.4 2.76 9.14
FATA 4,382,727 197571 29926 26432 3232 262 16.2 6.82 10.79
Baluchistan 8,295,628 588558 63733 35372 28248 113 12.85 7.68 44.32
AJK 4,160,025 146744 433 421 11 1 0.29 0.10 2.54
4809 TOTAL 170,998,796 4888967 289759 215564 69386 5.57 1.69 23.9 (1.6)
Malaria indicator survey of 2009 showed malaria prevalence rates in Baluchistan 6.2% (Pf 2.4% Pv 3.8% ), FATA 13.9% (Pf 0.6%:Pv13.3%),Khyber Pakhtunkhwa 3.8% (Pf0.9%:Pv2.9%) and Sind 0.7% (Pf 0.7%: Pv0.4%).
The provincial prevalence is consistent with the reported incidence from the malaria surveillance system. The 2013 prevalence survey is being analyzed and report will be available in early 2014.
Age and sex wise distribution of cases indicates malaria is confined to the age group above 15 years. In the 19 priority districts the % of confirmed malaria cases among children below 5 years was 17.82 % of confirmed cases
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Transmission Patterns P. Vivax P.Falciparum 160 60 140 50 120 40 100
80 30 # CASES #
60 CASES # 20 40 20 10
0 1 3 5 7 9 0 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 YEARLY WEEK NUMBER 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 YEARLY WEEK NUMBER • Seasonal Transmission May – October • Usually two peaks of vivax malaria each year – First Peak (Spring) resulting from delayed attacks or relapses second peak after monsoon. (Rowland 1997 a) – PF shows a single peak after summer because of summer case to case incubation interval of PF (Bouma 1996a)
Figure 2: Typical seasonal transmission patterns of P vivax and P falciparum seen in most of malaria endemic Pakistan.
Transmission of malaria in most parts of the country is highly seasonal and unstable with peaks of transmission in the summer (June Sept) for P. vivax and relapse episodes are observed in the early summer (April June) resulting from transmission in the previous year. Falciparum malaria occurs in the late summer and winter months (August November).
The historical malaria trends in Pakistan from the malaria surveillance system between 1973 and 2012 shows clearly the following:
1) The Annual Parasitic Index (API) decreased rapidly from 1973 (API 13.18) to below 1/1000 in 1977 ( API 0.93) with a sharp decline in the slide positivity rate from 14% to 0.62% with malaria eradication campaigns in less than 5 years;
2) An upsurge of positive cases was observed from approximately 130.000 cases /year (malaria strategic plan) between the years 2005 and 2009 to almost 300,000 positive cases in 2012 ( National malaria disease surveillance report 2012)., The annual parasitic incidence increased from 0.74 in 2009 to 1.46 in 2010 and 1.88 in 2011. Similar trends were observed in low transmission areas of Punjab province which experienced floods, malaria cases escalated from 3,432 cases in 2009 to approximately 30,000 cases in 2010 (table 1);
3) The blood examination rate ( indicator for malaria surveillance ) decreased from 9.36 in 1973 to 5.46 in 1980 and remained quasi stable approximately 2 3 / 1000 inhabitants between 1983 and 2013 , reflecting a poor case detection the past 30 years.;
4) Given the variety of ecotypes in the country (valleys with rivers at various altitudes, agriculture related malaria, peri urban type, migrant malaria) the epidemiology of malaria varies considerably between provinces / districts and union councils. More detailed spatial analysis with micro stratification by districts is critical for malaria control/elimination monitoring
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Figure 3: Malaria trend 1973-2012
Malaria epidemics are a common occurrence in Pakistan which has a history of unstable transmission. Between 2010 and 2013, Disease Early Warning System (DEWS) reported majority of malaria alerts and outbreaks from Baluchistan followed by Sindh, The alerts and outbreaks in both provinces peaked in 2011 and 2012 which was partially attributed to floods and the assignment of DEWS surveillance officers, thereby making the alerts and outbreaks detection system more efficient. Incidentally, Baluchistan province comprised of the majority of alerts and outbreaks during 2010 13 (7 out of the 15 districts) with the highest numbers reported from Jaffarabad (44 alerts and 32 outbreaks).
The new malaria information system launched in 2009 in 19 priority districts and managed by the DOMC observed an increase of API from 7.13 in 2009 to 10.13 in 2012 mainly due to the increased malaria risk associated with major flood emergency and increased access to RDT and Microscopy. Control measures which emphasised increased access to primaquine and ACT propelled API to 7.82 in 2012. . In 2010, out of 122,350 positive slides, 20,051 were taken from IDP camps
The District Health Information System (DHIS) data from primary/clinic health centre health care facilities suggests the proportion of suspected/clinical malaria cases presented to OPDs was highest in Baluchistan with 8.9% and 8.6% of total OPD consultations followed by Sindh with 8.50% and 7.36%, KPK with 3.7% and 2.3% and Punjab with 1.5% and 1.5% in 2011 and 2012 respectively.
Similar trends were observed in DHIS secondary/ hospital health care facilities data with 2.6% and 5.54% malaria OPD consultations for Baluchistan followed by Sindh with 7.8 % and 5%, KPK with 3.1 % and 2.3% and Punjab 0.6% and 0.6% respectively in 2011 and 2012.
Punjab tested the highest proportion of suspected malaria cases with 83% and 86% of total suspected malaria cases followed by low testing rates in KPK with 28.4% and 36.3%, and Baluchistan with 19% and 23% and very low testing rate in Sindh with 18% and 18% respectively in 2011 and 2012.
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Between 2011 and 2012, Baluchistan had the highest proportion of malaria cases admitted to the primary health care facilities where as in the secondary health care facilities, Sindh province had the highest proportion of malaria admission during the same period. Taking admissions as proxy indicator for severe malaria, proportion of inpatient admissions in secondary hospitals was highest in Sind with 6% and 8% followed by Baluchistan with 1.8 and 2.7%, KPK 2% and 2.2 % and Punjab with 0.2 and 0.3% respectively in 2011 and 2012. The hospital fatality rate among the severe malaria cases was highest in Punjab at 2% with 67 deaths in 2011 and in 2012 Sindh had a case fatality rate of 1.73% with 155 deaths. Although inpatient admission from primary health care facilities was highest in Baluchistan with 52% in 2011 and 43% in 2012 highlighting the continued challenges of PF transmission and different level of access to primary and secondary facilities in Baluchistan and Sind.
The nationwide epidemiological data shows clearly that Pakistan is a low to moderate endemic country with an important diversity within and between the provinces and districts.
The MPR revealed the existence of a fragmented malaria and health information system, with very limited capacities of analysis. The geographical information system necessary for the strategic orientation of malaria control interventions is absent at all levels, which has further compounded understanding of malaria epidemiology in all provinces.
Specific issues on Malaria epidemiology in the provinces:
Some additional epidemiological data are included in section 4.6 ( Surveillance, Monitoring and evaluation)
Baluchistan:
• Malaria transmission season in the province is July to November. However, along the coastal areas and western international bordering areas of province the disease prevails throughout the year. In some areas there are two peak transmission, the first start March and April to June and the second peak in September to November (post monsoon).
• The extreme climate events in recent past included earthquakes and floods, these have provided favourable breeding conditions for mosquitos with a raised epidemic threat.
• In Balochistan malaria ranks the 2 nd top priority disease after ARI (Acute Respiratory infection) and accounts for 33% disease burden of the province.
• Table 2 shows the data on malaria diagnostic microscopy from 2007 to 2012, collected by the data management cell of MCP. This data includes the data from the PR sources, which sharing by the PRs has now started recently. The increase in the indicators is possibly due to the improvement of the diagnostic skills, reporting and other resources for microscopy. However, the increase in falciparum is a matter which needs attention.
Table 2: Baluchistan Malaria Microscopy Data 2007-2012
Total Total Population P.vivax P.falciparum API F.R SPR Slides Positive 2007 7,844,715 388,115 46,805 28,051 18,754 5.97 40.07 12.06 2008 8,159,523 371,606 43,848 30,020 13,828 5.37 31.54 11.80 2009 8,355,352 395,263 49,778 33,994 15,784 5.96 31.71 12.59 2010 8,555,880 414,707 63,625 36,480 27,145 7.44 42.66 15.34 33
2011 8,761,221 420,252 57,980 36,146 21,834 6.62 37.66 13.80 2012 8,971,490 421,943 57,111 37,901 19,210 6.37 33.64 13.54
• Specific studies to ascertain exact population at risk are not available, however, given the information for the ongoing stratification (below) it is safe to assume that excluding the low risk (malaria free) districts of Kalat and Ziarat, almost the entire population of the province is at risk of contracting malaria.
Risk mapping and stratification:
• Administratively the province is organized into 6 administrative divisions, 30 districts, which are further organized in 79 Tehsils, and 567 Union Councils. The healthcare facilities are set up along these administrative units and the catchment area for each facility is according to the level of the facility, with the highest level of healthcare facilities in the districts, being the Divisional HQ Hospital located at the divisional headquarters, and at the community level it is usually a Basic Health Unit (BHU) or a Civil Dispensary (all Civil Dispensaries are planned to be for upgraded to BHUs). The Lady Health Worker’s Health House is located within the houses of the LHWs in the communities / hamlets. Therefore, there are no particular boundaries separately for the healthcare services these follow the limitations of the administrative unit within which these exist.
• Malaria Mapping is underway, however, this is an overlooked area requiring guidance and assistance to complete and maintain this activity.
• As a first step a stratification exercise has been completed utilizing multiple indices in addition to the API. The resulting stratification model is given below.
• A very good resource has been the Malaria Atlas Project where based on data of 2010 malaria mapping has been done and is freely available at
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Table 3: Malaria Stratification in Balochistan – Parameters Used.
Variables Stratum-I Stratum-II Stratum-III Endemicity High transmission. Moderate / Seasonal transmission Low transmission
API >5 1 5 <1 Pop: High (Nomadic population) Moderate Moderate movement Geography • Semi urban & rural areas • Semi urban & rural areas • Mountainous High • Rice & cotton fields in • Moderate life style lands Naseerabad Division • Plains and Hilly areas • Poor life style • People residing beside rivers • Orchards • Farmers • Coal mines in Sibi, • Farmers • Low temp Hernai&Dukki. • Inadequate health facilities in Chaghi&Sibi Divisions • Dominant vector species: stephensi • High PF rate • High temperature • Poor road network Population 5,093,115 3,043,480 322,928 Accessibility In Chaghi, Dera Bugti, and In Far flung areas the accessibility In Far flung areas Kohlu few health facilities is a big issue. accessibility is less Stability Stable Unstable Unstable Surface water Slow Rivers, Dams & Canals Valleys & Tube wells with low Springs & Tube wells with breeding sites breeding sites with low breeding sites Species P.V &P.f P.V &P.f P V
Stratum-I Districts: High Risk of Malaria : 1. Sherani2. Zhob3. Musakheil4. Dukki tehsil of Ziarat District (Not District) 5. Barkhan6. Harnai7. Sibi8. Kohlu9. DeraBugti10. Naseerabad11. Jaffarabad12. Noshki13. Chagai14. Kharan15. Washuk16. Punjgur17. Kech18. Gawadar19. Awaran
Stratum-II Districts: Low Risk of Malaria : 1. Lasbella2. Khuzdar3. JhalMagsi4. Bolan5. Mastung6. Quetta7. Killa Abdullah8. Pishin9. KillaSaifullah10. Lorali
Stratum-III Districts: Very Low Risk or Malaria Free Districts : 1. Kalat2. Ziarat
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The above stratification has revealed the entire province with the exception of two districts (out of 30) is under a serious threat of Malaria, with Malaria being endemic in high or low grades in almost the entire province of Balochistan
Epidemiology of Malaria in Sindh
Actual prevalence and incidence of Malaria in Sindh is not known, and available data regarding burden of Malaria in the province is based on surveillance data of Sindh Malaria Control Program, which covers public sector facilities only, with coverage of less than 100%, similarly burden of Malaria at national level is also not known. A national Malaria prevalence study was conducted in 2011 by Aamer A Khathak which revealed highest prevalence of Malaria in the country was in Baluchistan followed by Sindh. Sindh contributed 30% of total reported cases of Malaria in Pakistan which has 25% national population.
Below the graph shows the annual parasite incidence has increased continueusly from 2008 to 2012 in Sindh.
Figure 4: API (2008-2012)
Below graph shows marked reduction in prevalence of Falciparum cases.
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Figure 5: Falciparum ratio (2008-2012)
Table 4: Sindh data 2001-2012.
Year No Of P. Vivax P. Mix Total SPR FR% Slides Falciparum
2001 705126 11988 12532 18 24502 3.47 51%
2002 731038 12938 10282 05 23215 4.17 44%
2003 902021 20445 17795 09 38231 4.23 47%
2004 1521648 27326 13371 0 40697 2.67 33%
2005 1313818 17490 10359 04 27845 2.12 37%
2006 1376923 19051 15558 0 34609 2.51 45%
2007 1021822 16534 8726 0 25260 2.47 34%
2008 954028 17682 8415 04 26093 2.73 32%
2009 1113765 19112 8364 0 27476 2.46 30%
2010 1275732 34304 22289 482 57075 4.50 39%
2011 1290835 48119 34499 4989 87607 6.7 39%
2012 1785499 79511 31083 4057 114651 6.4 27%
Epidemiology of Malaria in KPK
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Table 5: Categorization of districts based on reported malaria incidence, 2007-2012 (average for six years) in KP (source: provincial MPR report).
S.No API index Status Districts
1 Average five year API > 5 Highly Bannu, Buner, Lakki Marwat, Endemic Hangu
2 Average five year > 1API < 5 Moderately Charsadda, DI Khan, Kohat, Endemic Karak, Tank, , Mardan, Malakand
3 Average five year API < 1 Low Endemic Swat, Battagram, Kohat, Dir Lower, Dir Upper, Chitral, Swabi, Haripur, Mansehra, Abbottabad, Peshawar, Kohistan, Shangla, Nowshera Hangu, Malakand
Epidemiology of Malaria in FATA
Table 6: Categorization of Tribal Areas based on reported malaria incidence, 2007-2012 (average for six years) (source: Provincial MPR report).
S.No API index Status Districts
1 Average five year API > 5 Highly Endemic Khyber, North Waziristan, Kurram, FR DIKhan/Tank, FR Bannu/Lakki Marwat
2 Average five year > 1API < 5 Moderately Mohmand, Bajaur, Orakzai, South Endemic Waziristan, FR Peshawar/ Kohat
3 Average five year API < 1 Low Endemic NIL
Epidemiology of Malaria in Punjab
Malaria is considered to be a low endemic disease in Punjab but still has a high burden as compared to other diseases. The District Health Information System data reports that 831117 cases of clinical malaria were diagnosed in 2012 in primary and secondary health facilities outpatient department. A total of 10972 cases were admitted in secondary health facilities and 84 deaths were attributed to malaria. The malaria burden is expected to be fivefold more than the reported because DHIS data is not covering all the public health care facilities of the province and also because 70 80% of the patients utilize private health services. The MIS data shows that there were 17,522 microscopy confirmed cases in 2012 while DHIS reports 23389 microscopy confirmed cases. The API based on six years average (2007 12) is 0.19 which is considered as low endemic. The endemicity of the districts based on six years API data is follows.
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Table 7: Categorization of districts based on reported malaria incidence, 2007-2012 (average for six years). S.No API index Status Districts
Highly 1 Average five year API > 5 NIL Endemic
Moderately Layyah, Muzaffargrah and 2 Average five year > 1API < 5 Endemic Rajanpur
3 Average five year API < 1 Low Endemic Rest of the districts
4. Programme performance by thematic areas 4.1 Programme management
4.1.1 Policy
Federal: Government of Pakistan is committed to combating malaria and to achieving its national targets, which are in line with the Global Roll Back Malaria (RBM) initiative, MDGs and “Vision 2030”. In 1999 Pakistan became signatory to RBM initiative, consequently malaria control was integrated with the National Health Policy (2001). Supporting documents such as the national malaria strategic plans and the Malaria Control Programme PC Is have been developed. Malaria has been included in the national health sector and the national development plan.
The primary RBM strategy objectives include:
• To enhance access of population at risk to quality assured early diagnosis and prompt treatment services.
• To scale up multiple prevention interventions especially LLINs and IRS to the level of universal coverage in target population.
• To enhance technical and management capacity of malaria control program for improved planning, management and monitoring of malaria control interventions.
• To improve health seeking behaviors and practices of target communities in highly malaria endemic districts through enhanced community awareness and participation.
• Improved detection and response to epidemics and malaria emergency situations.
• Developing viable public and private partnerships in the country to combat malaria. 39
Baluchistan: Malaria currently ranks as the second priority disease in the province after Acute Respiratory Infections (ARIs) with an estimated disease burden of 33% in Balochistan. There is no provincial Health Policy or Health Sector Strategy, instead national policies and guidelines are followed. Malaria Control activities are implemented in accordance to the strategy developed by the federal RBM programme (under the guidance of the MDG indicators, the Global fund strategic guidelines) and has been reflected in the federal PC 1 and the provincial PC 1. The draft Provincial Development Strategy 2013 20 has highlighted the need to strengthen Malaria Control Program towards elimination.
The overall objectives highlighted in the provincial PC 1 are:
• To co ordinate province wide efforts for implementation of RBM initiative for 50% reduction in the malaria burden in Balochistan by the year 2012.
• By the year 2015 >70% of the high risk population of the province have access and use effective malaria prevention and treatment.
The national malaria strategic objectives adopted by the provincial PC 1 (end June 2013) are as follows:
• To strengthen early diagnosis and prompt treatment.
• To expand & strengthen malaria microscopy at RHCs and BHU level.
• To strengthen multiple prevention action e.g. use of Long Lasting Insecticidal Treated Nets (LLINs) etc.
• Use of insecticide residual spray.
• Use of alternative methods of malaria control such as environmental and biological Control.
• BCC and Health Education regarding malaria prevention, control treatment, and self protection at grass root level.
• Strengthen surveillance and epidemic preparedness.
• Strengthen operational research.
• Conduct entomological survey for vector control.
• Capacity building of health care provider at district and provincial level.
• To monitor the implementation of the RBM strategies in the province.
• To strengthen the provincial program capacities for monitoring and evaluation and implementation of malaria and dengue control strategies.
• To monitor the progress and technically assist the districts to solve problems encountered in implementation of RBM initiative.
• To strengthen the provincial reference laboratory set up for capacity building for case management and vector control interventions. 40
• To adopt national policy and operational guidelines for control of malaria and dengue in Balochistan.
• To develop provincial strategic plan in consultation with federal.
• To develop category specific training packages for health care providers, managers and entomologists.
• To produce team of Trainers (TOT’s) at district levels.
• To facilitate the operational research by provincial Program on priority issues
• Partnership building with all stakeholders.
FATA: The current PC 1 of IVM has the following goals, objectives and strategies Goals and objectives
• To reduce malaria specific morbidity and mortality by 60% by the year 2015 and to control growing incidence of falciparum malaria.
• To support agencies and FRs in malaria control activities.
• To strengthen the capacity of health staff in diagnosis, treatment, and prevention of Malaria.
Strategies
• Early diagnosis and prompt treatment
• Plan selective preventive measures
• Detect early , contain or prevent epidemics
• Strengthening local capacities and capabilities.
• Community participation
• Inter sectoral collaboration involving partners.
KPK: The initial National Health Policy of Pakistan (1991) focused on strengthening malaria microscopy through upgraded basic health facilities and early diagnosis with prompt treatment. The target was to reduce malaria cases by 50% by 2010, while Plasmodium falciparum cases would remain less than 40% of all malaria infections. Selective spraying replaced mass spraying. The policy was in the process of being revised in 2009, when decision makers delegated more autonomy to the provinces. The 18 th Amendment resulted in transformation of the Ministry of Health to National Health Services, Regulation and Coordination (NHS) whose main role is now a regulatory and coordinating body. Currently, no Provincial Health Policy exists. Following devolution, the Malaria Control Program is responsible for implementing malaria control activities in the province to achieve the MDG targets. The Health Department aims to provide an essential basic health care package including 41
promotive, preventive, curative and rehabilitative health services to the community. The KP priorities in health are designed to achieve the MDG targets and to: • Improve Governance and Strengthen Management • Initiate the Culture of Informed Decision Making • Improve Regulation and Quality Assurance • Human Resources Development: • Preventive Services including control of malaria • Disaster Risk Reduction and Management: • Improve Accessibility to Health Care
Punjab: The MCP follows the National Strategy for Rolling Back Malaria (RBM).
Sindh: Sindh does not have a Health policy and Malaria policy. In 2005 a Health policy was developed and approved by the concerned authorities but no implementation followed. Sindh has developed a health sector strategy in 2012 on the basis of situation analysis done in 2011. Malaria strategic plan for Sindh has not been developed. The recently developed Sindh Health Sector Strategy 2012 2019 includes Malaria as important communicable disease 4.1.2 Organization There is an established set up of Malaria Control Programme at the federal, provincial and district level including Federally Administered Tribal Areas (FATA) and Azad Jammu & Kashmir (AJK).
Federal level : There is a full fledged Directorate of Malaria Control (DOMC), which is an addendum to the Department of the Ministry of National Health Service, Regulation and Coordination (NHSRC) since 13th May 2013. The Directorate is headed by the Director Malaria Control, who reports to the Director General Health Ministry of NHSRC and is supported by a team of technical staff, which includes 1 Senior Scientific Officer (Entomology), 1 Epidemiologist, 1 Health Education Officer, 1 Accounts, Officer, 1 Statistical Officer as well as support staff. Recently the DoMC has established a Programme Management Unit (PMU) with the support from Global Fund SSF Round 10, which provides additional technical support to the programme. The federal level organogram highlights inadequate technical human resource requiring an additional 5 technical staff at the central level in the capacity of a data manager, a M & E Officer, a logistics and supply management officer, a laboratory technologist /Parasitiologist and a operational research expert along with supportive staff. The overall mandate of DoMC is the policy formulation, coordination with international donors and provinces, monitoring and evaluation, technical assistance, operational research, institutional strengthening, capacity building, health education and advocacy. The federal Directorate of Malaria Control also assists provinces in supporting the services gaps during epidemics /outbreaks and natural disasters such as floods.
Balochistan: In 1977 Malaria control activities were integrated with the Communicable Disease Control program in the General Health Services resulting in a change in name from ‘Malaria Eradication Program’ to ‘Malaria Control Program’ (MCP). In continuation of the eradication era, the programme continued to develop programme policies, plans, management and oversee donor funding vertically from the Federal Directorate of Malaria Control, while the provincial programme enforced its role as the facilitator and coordinator in the implementation of the National planning strategies. In 1998, Roll Back Malaria (RBM) was introduced by WHO, UNICEF, UNDP and the World Bank in a phased approach between 2001 2002, supplemented by the provincial PC 1s and extended to the period 2007 2012 with
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further financial support from the provincial and federal PC 1s. Between 1999 2008 the health departments of the District Governments, as the third tier of Government in the country, presided over the respective staff, materials and budgetary grants for malaria control including donor field coordination which may have contributed to the lack of coordination with the provincial headquarters. The District Government system was repealed in Balochistan in 2008 with the change of the Local Government Act by the Provincial Assembly. In 2003 the Global Fund Against Tuberculosis, Aids and Malaria formed a Country Coordination Mechanism for Pakistan, which encouraged donors to work through this mechanism.
The District Health Management Team (DHMT) (present in majority of the districts) comprises of the DHO, the Deputy DHO, Medical Superintendent DHQ hospital, District Coordinator National Program for FP/PHC and the District Officer of Population Welfare department. The DHMT is the monitoring and supervisory system for the activities of Malaria Control in the districts; it conducts visits to the public sector health facilities in the district and approves malaria control interventions. The human and other resources of the MCP come under two separate command structures: the PC MCP and DHO (figure 6), both of which report to the Director General Health Services Balochistan and have limited involvement with malaria activities. The Malaria staff in the districts receive their payroll from the district health offices and do not coordinate with the PC MCP, constraining performance based monitoring. Majority of staff are retained at the provincial headquarters with only District Malaria Superintendent assigned to 7 districts and 1 to the MCP headquarters, consequently 22 out of the 30 sanctioned posts are vacant. The Assistant Malaria Superintendent, initially recommended for Tehsil levels, is presently located at the District Health Offices and assists the Malaria Superintendent, in the absence of a supervisor he acts as the Malaria Superintendent. If more than one Assistant Malaria Superintendent is present then the workload is shared. Presently there are only 15 posts of Assistant Malaria Superintendents but given the number of Tehsils, there should be at least 85 posts. The position of Malaria Supervisor was initially assigned at Union Councils, but due to deficiency of sanctioned posts, the Malaria Supervisors have been assigned to District HQ Hospitals and where there are ample workforce to the RHCs and BHUs. Responsibilities of this position include spraying, larviciding campaigns, collection of blood samples of suspected cases for confirmation and cross checking at the Provincial Reference Laboratory for quality control. Due to shortage of microscopists, a Malaria Supervisor may be trained to perform microscopy and provide treatment according to guidelines, conduct awareness sessions, assist in monitoring and supervision of malaria activities in his assigned area. The Malaria Supervisor is the basic staff member of MCP located at the Union Council level, who is required to perform as the Community – Program outreach and link delivering services, there are 567 Union Councils in the province, while the authorized posts of Malaria Supervisors are only 203. Technical staff are lacking in the areas of data analysis and data management, IT, microscopists, equipment repair, M&E, training coordination, financial management and IRS maintenance. Currently there are only 2 entomology technicians and 9 insect collectors in the province. Access to healthcare facilities is limited to only 30% 40% of the total population. The LHWs perform malaria activities under their respective program duties. The PRs have collaborated with CBOs and local NGOs in their respective districts. The Data Management Cells at the district level for Malaria Control are functioning in several districts and remains to be introduced to other districts by the MCP HQ with the induction of the central Data Management Cell.
Figure 6: Organizational Structure of Balochistan MCP
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FATA: Integrated Vector Management formerly called Malaria Control Program is working in all the tribal agencies and frontier regions funded by the Global Fund. The departmental staff under the Program Manager is limited with no technical persons including case management, vector control, surveillance, M& E, logistic and finance. The Global Fund has recruited a malaria supervisor who works as a data manager. In each tribal agency, Malaria Supervisors work at BHU’s (Union Council level) and microscopists work at RHC level Laboratories. Presently RHC function as Diagnostic centers while BHU’s (FLCF) as Treatment Centers. At agency (district) level, there is a shortage of staff, which has compounded malaria control activities.
Figure 7 : Secretariat/Directorate Level Organogram of Integrated Vector Management
Secretary Social Sector
Director
FATA Health Directorate
Program Manager
Integrated vector Management 44
Computer Operator Class IV Naib Qasid
Driver
Figure 8: Agency/District Level Organogram
Agency Surgeon
Malaria Inspector
Micr oscopist
Malaria Supervisor
Clerk , Porter , Driver
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KPK: The Health Secretariat oversees and provides policy guidelines and directions to autonomous institutions of the health department which include teaching/tertiary hospitals, health foundation, Khyber Medical University, Health Regulatory Authority. There are two Health departments i.e. Director General Health Services and Provincial Health Services Academy. Director General Health Services (DGHS) is the implementing arm of the health department. DGHS office is responsible for ensuring policies, vision and mission of health department are achieved. DGHS office manages 25 districts of the province, overseeing all projects , programs and ensures that services are provided to the population.
Figure 9: Organogram of Health Directorate
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District Health Officer heads the district health system which is responsible for providing health services in accordance to departments guidelines and direction. As a member of Health Management Cadre, s/he manages primary and secondary health care facilities, all preventive programs at primary level and is assisted by Coordinator EPI, Coordinator LHW, Coordinator Public Health and Coordinator HMIS. District Health
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Officers are also responsible for implementing Drug Act 1976 and Food Act and are assisted by Drug inspector and Food and Sanitary Inspector for this responsibility.
Malaria Control Program is fully functional in Khyber Pakhtunkhwa Province through its established organizational setup at Provincial, District, Tehsil and Union Council level. There is complete administrative setup of Malaria Control in Districts under jurisdiction of DHO’s. The organogram of Assistant Malaria Superintendent: (AMS), Malaria Supervisors and microscopists is similar to FATA. The RHC and BHU function similar to FATA. Currently the Malaria control program comes under the Director General Health Services, KP. At the Provincial level, a medical doctor has been appointed supported by limited staff, which in turn restricts programme implementation. A new organogram has been proposed to recruit more staff at the provincial and district level so as to ensure effective delivery of control interventions.
Figure 10: Provincial Organogram of Malaria Control Program, KP
Secretary Health
Director General Health
Program Manager District Health Officer MCP, KP
Deputy Program Manager Stationed at Union Stationed at DHO Office Council /Facility based
Computer Statistical Epidemiologist
Operator Assistant • Malaria • Malaria Supervisor Superintendent • Junior Microscopist Support Staff • Senior Microscopist • Junior Clerk/ Store Keeper 1 • Drivers 2
• Naib Qasid 2
Figure 11: Organogram at District level
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Punjab: In 2009, The Ministry of Health was abolished and converted to National Health Services, Regulation and Coordination (NHS) whose main role is now a regulatory and coordinating body. At present the Provincial Government is responsible for implementing the malaria control activities in the province and to achieve the MDG targets.
Malaria Control Program is fully functional in Punjab Province through its established organizational setup at Provincial, District, Tehsil and Union Council level. There is complete administrative setup of Malaria Control in Districts under control of EDO (H). Each District has Assistant Malaria Superintendent: (AMS) while Malaria Supervisors are working at BHU’s (Union Council level). Similarly Microscopists are working at RHC level Laboratories. Presently RHC acts as a Diagnostic centers while BHU’s (FLCF), as Treatment Centers. The confirmed malaria cases among the fever cases are detected through passive case detection (PCD) and treated.
Malaria Control Program is headed by Director General Health Services and is assisted by Director Health Services CDC Punjab who oversees all the communicable diseases including malaria. At the Provincial level, a medical doctor is appointed who presides over two entomologists, 4 Communicable Disease Control Officers (CDCO), 3 Communicable Disease Control Inspectors (CDCI) and 1 parasitologist.
Figure 12: Organogram of Malaria Control Programme Punjab
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Secretory Health
DGHS Principles of teaching Punjab hospitals
DHS CDC MS Punjab
EDO Health ADHS Malaria Pathologist
MS DHQ District Officer Health Ento=2,CDCO=4,CDCI Lab Assistant/Tech =3,Parasitologist=1
MS THQs DDOH CDCO AE Provincial Reference Lab, Senior Microscp
Pathologist SMO ICs MO ICs CDC Insps Di st CDC Lab (Sr Micro, (RHC BHUs (tehsil Micro Lab Attendants) & ICs Level) level)
Diagnostic Centre CDC Supervisors (UC
level) Lab Assistant/Technicians
.
EDO (H) s heads the district health system and is responsible for providing health services to the district in accordance with health department guidelines and direction. As a member of Health Management Cadre, s/he manages primary and secondary health care facilities including all preventive programs at primary level. Over the past several years all the activities of malaria control program have come to a halt, as the malaria staff are given duties of dengue control and Polio eradication.
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Sindh: Provincial Malaria Control Program in Sindh is headed by the Director Malaria Control Program, who reports to the Director General Health Services Sindh and secretary health, Government of Sindh. The additional Director Malaria Control Program assists Director Malaria Control Program in all administrative and field activities, and co ordinates with District Health Officers (DHOs). There are three components of Malaria Control Program including administrative, evaluation and health education. The evaluation department is headed by the epidemiologist who works as focal point for vector control, surveillance and epidemic control. The epidemiologist is supported by the senior evaluator, entomologist, senior microscopist, microscopist, entomology technician, and insect collector. Senior education officer in coordination with provincial health education cell and district health education officer works as focal point for education, communication, advocacy and community mobilization. Senior microscopist works as focal point for malaria diagnosis. There is no focal point at provincial level for malaria treatment. At district level there are two components of Malaria Control Program Administrative and Evaluation, coordinated by District Malaria focal person nominated by DHO. Administrative component includes Malaria superintendents, Assist Malaria superintendants.
Figure 13: Programme organogram
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Organizational Structure
(Provincial Level)
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4.1.3 Guidance
The programme has developed following guidelines and training materials on key interventions:
1) Case Management Guidelines (uncomplicated and complicated malaria): There are four versions of case management guidelines. The first guideline (a desk guide) was developed during the first phase of RBM implementation in Pakistan and updated in 2005. Following changes in malaria treatment strategy in Pakistan as well as the inclusion of issues not highlighted in the previous version, these guidelines were updated again in 2007 and finally in 2013. The latest guidelines are in the form of Job Aids (charts) and have been introduced to 38 districts supported by TGF SSF Round 10 districts.
2) Desk Guide on Complicated Malaria: The Programme has recently updated the case guidelines for the management of severe malaria aligned with the WHO recommendations.
3) Guidelines on Malaria Microscopy: There are malaria microscopy guidelines (updated in 2007) and quality assurance of malaria microscopy (updated in 2008).
4) Guidelines on Rapid Diagnostic Tests: These guidelines (Job Aids) have been developed with support from TGF 10 and are comprehensive in terms of knowledge on RDTs and conducting the rapid tests as well as interpretation.
5) The LLIN distribution strategy was developed to provide a comprehensive strategic direction and operational mechanism to ensure equitable distribution of LLINs to achieve the target of universal coverage.
6) Emergency Vector Control
7) IRS Training guide and manual
8) IRS strategy (TGF SSF 10)
9) Guidelines for interventions in complex emergencies
10) BCC strategy (TGF SSF 10)
11) M&E Guidelines (developed by TGF 7)
12) Malaria Information System (MIS) guidelines (TGF 7)
13) Surveillance guidelines (TGF SS 10)
The Global Fund through Save the Children has/ in the process of preparing the following documents:
1) LLIN distribution strategy
2) Malaria BCC strategy
3) Malaria Information System (MIS)
4) Counselling cards for LHWs 53
5) Malaria Case Management
6) Complicated Case management of Malaria
7) Malaria Treatment Flow Charts
8) Malaria Microscopy Desk Guide
9) Malaria Microscopy Training manual
10) How to use a Rapid Diagnostic Test (RDT)
11) National Summary Treatment Protocol for Case management of Malaria
12) Training manual for early detection of malaria outbreaks, malaria surveillance, M&E statistics and Data management
13) Supervision and external quality assurance of Malaria Laboratory Services
14) Operational guidelines for DLS
Balochistan: The National Guidelines prepared by the DoMC and Partners adopted and in practice by the Balochistan MCP are: 14) Case Management 15) Complicated Malaria Case Management 16) Use of LLINs at community level 17) Guidelines for anti vector interventions in emergencies 18) Emergency guidelines for vector control 19) Guidelines for anti vector interventions in monsoon 20) Dengue Vector Control 21) Integrated Vector Management 22) BCC and Advocacy 23) MIS 24) Microscopy and Quality Assurance in Microscopy 25) RDT 26) Distribution Strategy for LLINs 2012
FATA, KPK: The federal guidelines as described for Balochistan are followed. Sindh: The following federal guidelines are followed: • Guidelines For Malaria Information System (MIS) • Complicated (severe) Malaria Case management
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• Uncomplicated (severe) Malaria Case management
• Manual for rapid diagnostic test (RDT) • Manual for microscopy • LLIN manual • Indoor residual spray (IRS manual) • Training manual for early detection of malaria outbreaks, Malaria surveillance , M & E statistics and data management • Guidelines for Planning and implementation of malaria vector control at district level
4.1.4 Human resources, training and capacity development
Directorate of Malaria Control (Public Sector PR): The DOMC (Public Sector PR) has established a Programme Management Unit (PMU) with support from TGF Round 7 Grant. The organizational structure of PR Office is given in figure 15 below. The Unit is headed by the Director Senior Project Officer, who reports to the Director, Directorate of Malaria Control. There are well established units for finance, PSM, M&E, PIU and HR Management each headed by a Manager. These units have contributed considerably to enhancing the malaria control programme capacity in case management, surveillance, financial management, and monitoring and evaluation. The PMU has been instrumental in closely working with the malaria control programme and providing technical support. This Unit has a technical unit equipped with technical staff including an epidemiologist, entomologist and a programme Officer. Some of the key achievements of the PMU are:
1) The M&E Unit of PMU has been instrumental in developing a robust information system to meet the requirements of the GFATM as well as providing support to the DOMC in gathering malaria morbidity data on a monthly basis, development of a structured M&E system and M&E Plan; 2) The Procurement and supply management unit has been involved in the maintenance of the supply chain to avoid stock outs which have not been reported during the grant period. The Unit has developed a comprehensive PSM plan and SOPs for storage and quality assurance of commodities; 3) The Finance Unit has been responsible for management of finances and has been instrumental in developing the system of financial management.
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Fig-14: Organogram of the Directorate of Malaria Control Ministry of National Health Services, Regulations & Coordination, Islamabad L.D.C Daftry (BPS 09) (BPS 03)
Director (BPS 19)
HR Management
Senior Scientific Officer Health Education Officer Epidemiologist Superintendent Assistant Account Officer Stenographer
(BPS 18) (BPS 18) (BPS 18) (BPS 16) (BPS 16) (BPS 16) Project Officer Manager HR (SPO)
Stenotypist Assistant Scientific officer U.D.C cum Cashier Naib Qasid (BPS 14) (BPS 14) (BPS 17) (BPS 09) (BPS 02) Assistant Project Officer HR Officer
Assistant Stenotypist & Assistant Naib Qasid (BPS 14) (BPS 14) (BPS 02)
Naib Qasid Naib Qasid Admin Assistant (BPS 02) (BPS 02)
Driver (1,2,3)
Stenotypist Assistant Incharge Assistant U.D.C D.M.O JanitorDriver (BPS 14) (BPS 15) (BPS 14, 04 Posts) (BPS 09) (BPS 05) (BPS 05)
Office Boy (1,.2)
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HR Management
Project Officer Manager HR (SPO)
Assistant Project Officer HR Officer
Admin Assistant
Driver (1,2,3)
Janitor
Office Boy (1,.2)
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Figure-15: PR Office GFATM Round 10, Directorate of Malaria Control
Director Directorate of Malaria Control (DOMC)
Audit Unit
Senior Project Officer Internal Audit
PSM Unit Finance Unit M & E Unit PIU
Manager PSM Manager Finance Manager M & E Technical Unit
Logistic Officer Assistant Finance Manager M&E Office (KPK, FATA) Epidemiologist
Finance Officer M & E Officer (Sindh)
Epidemiologist
M & E Officer
(Balochistan Program Officer 58
HR Management
Project Officer Manager HR (SPO)
Assistant Project Officer HR Officer
Admin Assistant
Driver (1,2,3)
Janitor
Office Boy (1,.2)
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Figure-16: Directorate of Malaria Control Ministry of National Health Services, Regulations & Coordination Islamabad
Country Director
Deputy Country Director Manager Internal Audit Deputy Country Director Deputy Country Director Deputy Country Director Director Director Director Finance & Support Services Program Implementation Program Development & Quality Emergencies Human Resource & OD Security Member Services
Director Controller Finance Director Deputy Director Senior Manager Grants and Compliance Logistics GFATM Round 10 MEAL
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Manager Operation/Logistics Manager Finance & Grants Malaria Program Specialist
GFATM GFATM
Grants Coordinator Logistic / Inventory Officer
GFATM
Epidemiologist
Finance Coordinator Procurement Officer
GFATM Admin Assistant Manager
Training / Communication
Malaria Program Officer
x 2
Provincial Coordinator
x 3
Admin / Finance Assistant
x 3
Drivers
x 3
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Save the Children (Private Sector PR): The PR Office is headed by the project Director who is supported by the managers to the Finance and Grants, Logistics and Operations, trainings and communication and M&E (figure 14). Save the Children, as private sector PR of the Global Fund Round 10 grant has contributed substantially to improving the Malaria Program’s capacity in Monitoring, Evaluation, Accountability and Learning (MEAL) component. In addition to strengthening the existing routine malaria Program’s M&E system at district, provincial and federal levels, SCI has developed an online Integrated Management Information System (MIS) that allows the real time field based data entry, analysis and report generation at each management level for evidence informed decision making. The system also includes a complete training database for all the trainings that have been conducted under the program and has the capacity to generate indicator wise and theme wise reports at various levels to better understand the program’s performance and make timely decisions. In addition, SCI has also developed an interactive grant performance dashboard that is being used as a management tool to achieve the program objectives. SCI has also conducted a number of trainings at provincial and district levels to operationalize the system and is in process of expanding its utilization to DoMC’s districts as well. Other important activities include development of BCC strategy, BCC material and IRS Guidelines.
Balochistan: In the past the National Malaria Program, DoMC, provided support in training of health care staff in capacity building which included local, national and international trainings. A new partnership of the MCP has been formally developed with the Institute of Public Health, Quetta, and (IPHQ). The institute provides support by technical assistance, trainings, and plans are underway for health education and operational research including more emphasis on entomology and epidemiology. The IPHQ is now the training center for the technical Malaria staff including District level Master Trainers. Presently the Provincial MCP regularly organizes trainings for Malaria staff and other health staff also, with the assistance of the partners in the following areas: • Malaria Case Management • Complicated Malaria Case Management • Microscopy • Quality Assurance in Malaria Microscopy • RDT • LLINs distribution • Strategy for LLINs distribution • MIS Tools • Malaria Surveillance & Outbreaks • BCC
To date there are 180 Microscopy centers and 351 RDT centers functioning in the province. The Laboratory Staff in the District HQ Hospitals, Tehsil HQ hospital and RHC levels have been trained on Malaria Microscopy. Majority of the District HQ Hospitals and the RHCs have Malaria Microscopy Centres, while there are ongoing construction of centres in districts without. Other ancillary support staff are also in some districts.
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FATA: The Integrated Vector Management (IVM) programme has 51 microscopists and 144 malaria supervisors. Regular trainings are conducted on case management, MIS, basic and refresher microscopy, RDT and LLIN distribution strategy. The IVM department has no funds in the present PC 1 for training. There is a need to assess the training needs of IVM on managerial and technical issues at directorate and agency levels so that they acquire the sufficient capacity to respond to the changing malaria and partnership landscape.
Table 8: List of Human Resources for IVM in FATA
Agency Microsc RDT Malaria Malaria Lab Por ter Clerk Driver /FR opists Person Supervisor Inspector Atten dent Khyber 19 05 50 01 01
Bajaur 11 01 01
Kurram 15 02 Mohmand 09 01 North 07 14 20 Waziristan South 26 01 03 01 Waziristan 02 Orakzai 13 02 FR 03 07 Peshawar
FR Kohat 03 09
FR DI 03 06 Khan
FR Bannu 03 14
FR Tank 03 08
FR Lakki 03 07
FATA 51 79 144 01 01 03 02 02 Total
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Table 9: List of FATA human resource trained in various areas.
Agency/FR Basic Refresher MIS RDT Case Mgt LLIN Microscopy Microscopy Distribution Strategy Khyber 32 07 28 08
Bajaur 00 17 34 14 33 20
Kurram 00 07 11 10 12 12
Mohmand 04 04 35 20 31 0
North 03 08 19 14 19 05 Waziristan
South 04 05 20 11 18 17 Waziristan
Orakzai 08 05 26 12 21 25
FR Peshawar 03 06 09 07 10 11
FR Kohat 02 06 08 09 07 10
FR DI Khan 02 05 08 05 09 10
FR Bannu 02 06 17 13 16 11
FR Tank 02 05 11 07 12 09
FR Lakki 02 02 08 08 10 09
FATA Total 32 52 193 113 181 107
KPK: The PC 1 2002 2006 documents a total of 925 medical officers were trained on case management and national treatment guidelines. Within the same period a total of 67 microscopists were trained on microscopy in NIMRT Lahore. Limited trainings were also conducted on new malaria tools (FM1 and FM2 etc). The districts funded by GF underwent regular trainings on case management, MIS, basic and refresher microscopy, RDT and LLIN distribution strategy.
Punjab Currently there are 43 assistant entomologists, 22 CDC Officers and 161 microscopists in Punjab. A large numbers of posts have been vacant. 64
Table 10: Category wise vacancy position of CDC staff in Punjab
S.No Name of Post Sanctioned posts Filled Vacant
1 Assistant Entomologist 44 43 01
2 CDC Officer 50 22 28
3 CDC Inspector 114 60 54
4 Senior Microscopists 36 20 16
5 Microscopists 253 141 112
6 Microscope repair technician 01 0 01
7 CDC Supervisor 2230 1661 569
8 Insect Collector 72 60 12
9 Lab Technician 68 57 11
TOTAL 2868 2064 804
There are 385 microscopy centers, 2650 RDT centers. There is a Provincial Reference Laboratory located at Director General Office with only six microscopists out of which four are currently working. The total sanctioned posts are 13. All MCP staff have been trained in their respective fields:
• Microscopy Training: All staff trained at NIMRCT
• Case Management, vector control, Surveillance, MIS Tools: The master trainers were trained by the Health Directorate while remaining were trained by the DHDC.
• Entomology studies including safe use of pesticides, vector control measures: The CDC Officer and entomologists were trained in Health service Academy.
Staff have yet to receive orientation on the updated guidelines and training manuals developed at the Federal level.
Sindh: Due to the non release of budget (2012 13) there have been no recent trainings conducted. The trainings which have been conducted in the past include:
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• 6 week comprehensive training of Microscopists at National Malaria Research Training Institute (NMIRT) Lahore,
• 2 days case management training at Malaria Directorate,
• 6 weeks Sr. Microscopist Master Trainings in Malaria Superintendent at NMIRT Lahore,
• 6 weeks training of Malaria Supervisors as Microscopists at NMIRT Lahore,
• 6 days refresher course in Malaria microscopy of Mal: Supervisors / Microsopists at provincial laboratory,
• 1 day Training for master trainers in vector Control.
4.1.5 Strategic and annual planning
Goal: To reduce malaria burden by 60% in 38 highly endemic districts.
Target Group/Beneficiaries: The target groups are the populations living in 38 high risk districts attending the health care facilities.
Strategies and objectives: To reduce burden of malaria by 60% in 38 highly endemic districts of Pakistan, this includes 19 districts of the Global Fund Round 7. The target population in these 38 high risk districts is estimated to be 24.84 million.
The objectives are as follows:
Objective 1: To enhance access of population at risk to quality assured early diagnosis and prompt treatment services; Objective 2: To scale up multiple prevention interventions especially LLINs and IRS so as to achieve universal coverage in target population; Objective 3: To enhance technical and management capacity of malaria control program for improved planning, management and monitoring of malaria control interventions; Objective 4: To improve health seeking behaviours and practices of target communities in malaria endemic districts through enhanced community awareness and participation.
Planned Activities • Strengthen existing diagnostic services in 19 districts, • Establish RDT Centres at first level care facilities, • Train laboratory supervisors on quality assurance in malaria diagnosis, • Enhance the capacity of healthcare providers in proper malaria case management, • Involve the private sector in the provision of diagnostic and curative services according to national guidelines, • Provision of mobile outreach malaria diagnostic and treatment services to severely flood affected population in 5 districts, • Prevention through universal coverage of LLINs in target districts, • Selective IRS in epidemic prone areas,
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• Strengthen epidemiological surveillance, • Conduct anti malaria drug efficacy monitoring surveys at existing sentinel sites, • Strengthen program management capacity (Supportive Environment), • Conduct operations research studies for evidence based programming, • Program monitoring and supervision, • Review and finalization of national malaria BCC strategy, • Develop and disseminate print and electronic media materials and messages, • Advocacy and mobilization activities, and strengthen community based systems for malaria behavior change communication.
4.1.6 Financing
At the federal level there is a Directorate of malaria control under the administrative control of Ministry of national Health Services, Regulation and coordination since 2013. The Programme has two types of budget i.e. non development budget that is for salaries of regular staff, maintenance etc and the development budget for the developmental activities of the programme through PSDP. The source of development budget is Planning Commission 1 (PC I).
Table 11: Approved Development Budget of the Directorate of malaria control from 2008
to 2013
2008 - 2010 - 2012 -
S.# Service Delivery Area 2009-10 2011-12 Total
09 11 13
Early diagnosis and
1. 30.81 18.22 16.40 14.76 13.38 93.575
prompt treatment
2. Multiple prevention 109.29 52.79 13.03 13.06 10.78 198.95
Malarial Epidemic
3. 18.89 1.93 2.34 1.00 0.20 24.352
Preparedness
Institutional
4. 40.99 36.84 38.23 35.78 38.24 190.079
Strengthening
Behavioral Changes
5. 18.73 18.80 17.20 16.30 16.70 87.73
Communications (BCC)
6. Strengthening of NIMRT 14.98 11.98 12.27 11.92 12.79 63.94
Total 233.69 140.57 99.46 92.82 92.08 658.625
Table 12: DoMC Development budget from 2001-2013
Phasing
Year PSDP allocation Releases Expenditure
as per PC-1
2001-02 146.665 146.00 146.00 97.514
2002-03 30.820 31.000 31.000 25.972
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2003-04 33.182 29.000 29.000 27.336
2004-05 29.509 34.000 34.000 27.199
2005-06 32.861 33.000 33.000 33.000
Total 273.037 273 273 211.021
-
2006-07 60.000 60.000 48.850
-
-
2007-08 100.00 5.00 4.7
-
Total 160.00 65 53.55
2008-09 233.69 100.00 30.0 14.966
2009-10 140.57 100.00 71.7 70.7
2010-11 99.46 100.00 31.5 30.5
2011-12 92.82 Nil Nil Nil
2012-13 92.08 Nil Nil
Total 658.62 300 133.2 116.166
There has been an exponential increase from 273 million Rupees in 2001 05 to 658 million Rupees in the period in the overall development budget through public sector support. However in last 5 years the allocations remain low and the releases were delayed. In addition to the public sector commitment the programme has been successful in securing the donor commitment through increased funding to address the gaps. The main source of funding is the Global Fund and to some extent WHO. To date the programme has been successful in securing four TGF grants in R2, 3, 7, 10. The tables below shows the resources and expenditures from Global Fund TGF 7 & SSF Round 10 Grants over last few years. The expenditure is 96%. Expenditures have been limited due to late grant start. However, all these savings are being disbursed in the following 9 months as a no cost extension that GF has already agreed to. Figures 17 and 18 below show the trend of disbursements and expenditure for TGF Grant (2008 2011& 2011 2013) over the years.
Directorate of Malaria Control
Table 13: Detail of year wise budget, expenses and disbursed by The Global Funds
Amount in US $ Year
Budget Disbursement by TGF Expenses
2008-09 6,799,913 6,444,371 5,276,547
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2009-10 6,086,769 3,926,190 4,557,906
2010-11 4,531,362 2,780,112 3,030,316
2011-12 10,895,424 12,216,049 8,595,845
2012-13 10,858,068 4,971,805 7,717,999
Total 39,171,536 30,338,527 29,178,613
Table 14: Entity wise Breakup of budget for Private Sector PR (Save the Children) (September 2011-September 2013 )
Budget Expenditure S.# Entity name Type
Amount in US$
Save the Children
1. PR 3,109,050 1,654,119
Federation Inc
2. ACD SR 920,736 564,821
3. ASD SR 350,598 153,959
4. MERLIN SR 1,178,693 711,290
5. NRSP SR 660,859 376,471
6. PLYC SR 247417 115,884
Total 6,467,353 3,576,544
Figures 17 and 18: TGF Grant (2008-2011& 2011-2013)
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Pakistan has two active Global Fund grants:
Grant numbers: PKS M DOMC; PKS M SC.
Duration: 01 September 2011 to 30 June 2014
LFA presence in the country: UNOPS is the LFA for Pakistan since 2009. It has a full time team of finance, procurement, public health and M&E specialists. Progress reports are verified on a semiannual basis. There are two PRs in Pakistan: the Directorate of Malaria Control (Ministry of Health Services Regulation and Coordination) and ‘Save the Children (INGO).
Balochistan: The SRs are the ‘National Rural Support Program’ (NGO) and ‘Merlin’ (INGO). The Balochistan Rural Support Program is a SSR of the NRSP and responsible for the 17 high risk districts in Balochistan. The heads under each budget (non development budget and development budget) are designated by the Finance Department and re appropriation between budget heads cannot be made without permission of the Finance Department.
Table 15: Global Fund-PR/SR/SSR and their Districts in Balochistan.
PR SR SSR Sr.# Districts 1 Musakheil MERLIN 2 Pishin 1 Panjgoor SAVE 1 Chaghi NRSP BRSP 2 Kharan 3 Washuk 1 Zhob 2 Sherani 3 K.Saifulla DoMC MERLIN 4 Loralai 5 Hernai 6 Sibi 7 Naseerabad
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8 Mastung 9 Noshki 1 Kech NRSP 2 Gawadar
FY Employee Related Expenditure Operating Expenditure 2011 12 Rs. 28,899,000 Rs.1,117,000 2012 13 Rs. 32,981,000 Rs. 1,271,700 2013 14 Rs.32,557,400 Rs. 1,585,200
Table 16: Non-Development Budget
Figure 19: Comparison of Non-development Budget Grant for MCP Balochistan.
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Table 17: Development Budget under the PC-1 for 2008-13. Total Expenditure Net Balance Not Surrendered Released out of Financial Allocation Released un-utilized during the FY Release’ Year (PKR in (PKR in (PKR in (PKR in (PKR in million) million) million) million) million) 2008 2009 34.612 11.270 23.342 9.696 1.574 2009 2010 25.692 11.270 14.422 11.029 0.241 2010 2011 24.092 11.430 12.662 10.433 1.387 2011 2012 28.560 13.000 15.560 12.995 0.040 2012 2013 29.143 5.000 24.143 5.000 0 51.97 90.129 44.153 3.242 Grand Total 142.099 [37%] [63%] [95%] [5%]
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Figure 20:Comparison Graph of Released/No-released Development Budget (PC-1) 2008-13.
FATA: The main sources of funding for malaria control activities are the IVM Budget and GFATM. The IVM also acquires funding by applying to PC 1. The MCP drafts its annual plan and budget PC 1 (based on the available resources with the government), before forwarding it to Planning Section in Health Secretariat. The Additional Chief Secretary has the authority to approve the budget up to Rs 200 million, Presidential approval is needed beyond this ceiling cost. The PC 1of 2012 to 2015 documents Rs 152.452 being allocated to the integrated management program. A total of Rs 16.207 has been reserved for expenses at Directorate Level while the remaining amount is distributed among the tribal agencies. The reduced budget has undermined all efforts made in the past. In the current budget no financial investment has been made in capacity building and the government does not intend to conduct training till 2015.
MCP Health Directorate Health Secretariat Planning and Development Department PC-1 Planning Cell PDWP Meeting
Administrative Approval Health Secretariat/ Directorate Additional Chief Secretary
KPK: Similar to FATA, the main sources of funding for malaria control activities are the Provincial Budget and GFATM. The MCP seeks funding by following the ad hoc criteria of Planning Commission Document, PC 1 following the same protocol as for FATA, except after approval by the Planning and Development Working Party; the PC 1 is submitted to the Finance Ministry.
MCP Health Secretariat Health Secretariat Ministry of Planning and Development PC-1 Planning Cell Economist PDWP Meeting
Administrative Approval Health Secretariat/ Directorate Finance Department
The PC 1of 2007 13 documents Rs 105.50 million was allocated for insecticide spraying, Rs 120.00 million for larviciding, Rs 5.25 million for fog Spraying and 19.50 million for ITN’s. Although the total
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amount initially forecasted is different from the actual amount released and utilized as indicated in the table below:
Table 17: List of Budget Allocation/Releases/Utilization of RBM PC-I (2007-12) & One Extension year
2012-13 Year 2007-08 2008-09 2009-10 2010-11 2011-12 Extension year Total 90.222 64.873 63.611 55.991 55.256 55.256 Allocations Total 35.788 19.601 20.000 16.756 15.888 19.448 Releases Total 35.788 19.601 20.000 16.756 15.888 To be utilized Utilization
PSDP PC 1 (Budget 2012 2015): From the total of 90.000 million , Rs.8.025 million was utilized in the financial year 2011 12 on purchase of goods, while the remaining Rs.81.975 million was allocated as capital cost for this PC I. The government informed the MCP to prepare the budget within the PSDP share, although the present budget is not sufficient for malaria control activities. There is no money for capacity building and government will not be conducting any training till 2015. Table 18: Component Wise Budget Details of PSDP Rs. In Million Main Total S.No Components 2012-13 2013-14 2014- 15 Cost of Project Early Diagnosis and 1. 18.743 5.444 7.440 5.859 Prompt treatment
Multiple 2. 48.849 10.791 20.369 17.689 Prevention
3. Institutionalization 10.508 Nil* 5.201 5.307
Monitoring, Evaluation 4. 3.875 0.275 1.800 1.800 & Surveillance
Total 81.975 16.510 34.810 30.655
Punjab: Mechanism of MCP Funds Mobilization is through PC 1. Government Budget Allocation for MCP covers the staff salaries. The Punjab government receives Rs 86 million each year as federal share to be utilized for malaria control interventions. There is a special development assistance fund from the health department: Rs 500 million each year out of which approximately 10% is reserved for malaria control activities. The Program purchases drug and other consumables from this fund. The staff of 74
malaria program has their salary component from a permanent source i.e. current budget and not through adhoc PC 1’s. Previous Roll Back Malaria Control Program Punjab PC 1 for the year 2003 4 to 2006 7 was Rs 93.275 million and is summarised below:
Table 19: Component wise budget of Previous PC-1 RBM 2006-7
S. No Description Rs (in million)
1 Case Detection, Diagnosis and Treatment 33.270
2 Strengthening the trained facilities at Provincial HQ 0.740
3 Vector Control Measures 31.195
4 Monitoring, Supervision and Printing Materials 20.840
5 Contingencies 6.480
6 Research Activities 0.750
Total 93.275
The MCP has submitted another PC 1 amounting Rs 999.199 for the year 2011 12 to 2015 16. The proposed PC 1 is awaiting approval.
Table 20: Component Wise Budget Details of Proposed PC-1 2011-16 Rs. In Million Strategy Project Phasing Total
2011 12 2012 13 2013 14 2014 15 2015 16
Early Diagnosis and 97.019 97.323 88.629 89.330 90.156 462.456 Prompt Treatment
Prevention & 19.885 20.246 15.796 14.046 14.046 84.018 Control
Health Education & 14.700 14.700 14.700 14.700 14.700 73.500 Communication
Surveillance & 131.574 46.524 46.524 46.524 46.524 317.672 Monitoring
Program 13.850 10.200 2.800 2.800 2.800 32.450 Management Unit
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Total 277.029 188.993 168.449 167.400 168.226 32.672
Price Contingencies 8.311 5.670 5.053 5.022 5.047 29.103
Grand Total 285.340 194.663 173.503 172.422 173.272 999.199
Sindh: Malaria Directorate received continuous funding from the Government of Sindh and Ministry of Health Federal Government of Pakistan. From 2002 onwards Government of Sindh implemented RBM activities through development budget and PC 1s were prepared and approved by the relevant authorities. The allocated sum from the development budget is utilized by the public health sector but the private health sector is overlooked despite providing care to 70% of the population except for the six districts which receive GFATM assistance.
Public Sector Budget includes the current budget (non development) and development budget. a. Current Budget: The current budget mainly comprises of salary component (98%) and the remainder is allocated for utilities and services. Till early 90s the operational cost of the program was provided by donor agencies (USAID).
b. Development Budget: After discontinuation of foreign assistance in early 90s, the program was supported federally but was inadequate to meet the requirements. The financing of operational cost of the Malaria Control Program was initially from the provincial development budget in late 90s. It included budget for purchases of Anti Malaria Drugs insecticides, bed net, equipment, training, surveillance, social mobilization, health care research, monitoring and evaluation.
The development and non development budget of past years is illustrated in the following tables with their graphs.
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Table 21. Malaria Control Program Sindh - Current & Development Budget for 4 Years (Rs. In Millions)
Budget Allocation Releases Expenditure
Financial % S.No. Year Utilization
Current Dev. Total Current Dev. Total Current Dev. Total
1 2009-10 30.7 93.7 124.4 26.6 70.2 96.8 24.4 69.9 94.2 97.4
2 2010-11 24.3 109.4 133.7 34.3 80.0 114.3 32.3 80.0 112.3 98.2
3 2011-12 31.2 130.0 161.2 22.1 130.0 152.1 20.7 128.7 149.3 98.2
4 2012-13 35.8 105.0 140.8 26.1 105.0 131.1 22.6 104.8 127.4 97.1
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Table 22. Malaria Control Program Sindh - Current Budget (Rs. In Millions) % % Financial Sr.No. Allocation Releases Expenditure utilization utilization Year on BE on RE 1 2009-10 30.747 26.574 24.393 79.33 91.79 2 2010-11 34.262 34.262 32.297 94.26 94.26 3 2011-12 31.191 22.079 20.650 66.20 93.53 4 2012-13 35.822 26.146 22.573 63.01 86.33
Table 23. Malaria Control Program Sindh - Development Budget (Rs. In Millions) % Financial utilization % utilization Sr.No. Allocation Releases Expenditure Year on on Releases Allocation 1 2007-08 52.512 49.092 48.766 92.87 99.34 2 2008-09 54.092 48.900 48.800 90.22 99.80 3 2009-10 93.686 70.200 69.856 74.56 99.51 4 2010-11 109.360 80.000 79.957 73.11 99.95 5 2011-12 130.000 130.000 128.650 98.96 98.96 6 2012-13 105.000 105.000 104.834 99.84 99.84
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Table 24. Malaria Control Program Sindh Intervention/Component wise Allocations in PC-I (2009-2012) Rs. In millions
Sr.# Intervention Allocation A Early Diagnosis & Rapid Treatment (ED&RT) I Lab. Equipment & consumables 24.896 ii Anti-Malaria Drugs 53.540 Sub-Total 78.436 B Multiple Prevention I Spraying 93.950 ii Fumigation 20.010 iii Larviciding 83.668 Sub-Total 197.628 C Surveillance & Monitoring 8.115 D Capacity Building-Training 8.901 E Transport & office Equipment 6.660 F Advocacy & Social mobilization 29.160 G Research 6.310 H Gen. Misc. 2.100 I Third party Monitoring 3.000 J Operational support 2.307 G.Total 342.617
A Early Diagnosis & Rapid Treatment (ED&RT) 78.436 B Multiple Prevention 197.628 C Surveillance & Monitoring 8.115 D Capacity Building-Training 8.901 E Transport & office Equipment 6.660 F Advocacy & Social mobilization 29.160 G Research 6.310 H Gen. Misc. 2.100 I Third party Monitoring 3.000 J Operational support 2.307 G.Total 342.617
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Figure 21: PC-1 2009-2012
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Table 25. Malaria Control Program Sindh Intervention/Component wise Allocations in PC-I (2012-2015) Rs. In millions Sr.# Intervention Allocation A Early Diagnosis & Rapid Treatment (ED&RT)
I Lab. Equipment & consumables 35.528 ii Anti-Malaria Drugs 80.772 Sub-Total 116.300 B Multiple Prevention I Spraying 111.500 ii Fumigation 24.050 iii Larviciding 179.560 Sub-Total 315.110 C Surveillance & Monitoring 7.852 D Capacity Building-Training 9.100 E Transport & office Equipment 5.920 F Advocacy & Social mobilization 26.000 G Research 2.080 H Gen. Misc. 2.950 I Third party Monitoring 3.903 J Operational support 1.190 G.Total 490.405
A Early Diagnosis & Rapid Treatment (ED&RT) 116.300 B Multiple Prevention 315.110 C Surveillance & Monitoring 7.852 D Capacity Building-Training 9.100 E Transport & office Equipment 5.920 F Advocacy & Social mobilization 26.000 G Research 2.080 H Gen. Misc. 2.950 I Third party Monitoring 3.903 J Operational support 1.190 82
G.Total 490.405 Figure 22: PC-1 2012-2015
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4.1.7 Strengths and Weaknesses /federal
Policy & Guidance
Strengths Weakness • Focus on Integrated vector control Malaria – • Malaria is low priority with MDG 6 Dengue Leishmania • Roll Back Malaria now IVM with Dengue • Devolution of health from federal to and Leishmania with increased work load provinces using the same staff and funding resources • Province demanding to take leadership role in post devolved scenario in health • Lack of clarity of roles and responsibilities of different levels of the • Health is more of priority with increasing health system health funding in 2013 • Malaria not included in draft health policy • Provincial funding PC1 2013 2015 of 2009 and in Vision2025 • Potential district funding from district local • Lack of simple and comprehensive government federal malaria policy document • Malaria included in Health policy of 2001 • Lack of federal malaria manual for • Most malaria policies in malaria strategic malaria control/elimination Inadequate plan 2011 2015 and in malaria guidelines security for service delivery, supervision and M&E • Different malaria guidelines in place
• Case management; Vector control (Malaria, Dengue, General vectors);BBC training manual; QA guidelines for malaria microscopy ; IRS: District level decision making; QA protocols and tools for IRS/insecticides management; LLINs distribution strategy in place • Wall charts on Diagnosis and treatment and microscopy • Malaria strategic objectives; Early Diagnosis & Prompt Treatment; Multiple Prevention (IRS, LLINs,;Epidemic Preparedness; Health Promotion campaign ;Partnership Building;
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Operational Research
Planning and Reporting
Strengths Weakness • Malaria five year strategic plan PC1 • Inadequate alignment between goals, 2008/2009 to 2012/2013 objectives and strategies in MOH five year plan and Malaria strategic • Federal and provincial malaria strategic plan framework (2011 2015) 2005 2010 • Lack of comprehensive (evidence • Malaria strategic framework 2011 2015 in informed) strategic planning based on full place to support GF need and demand • Annual malaria operational plan (July/June) • Domestic funding PC1 serious gap • Malaria domestic financing under between approved and releases and development fund and non development expenditure funding • No joint strategic and annual planning • Malaria international financing with with provinces and districts and malaria GF.Rd.10 support for 19+19 high partners transmission districts. • Multiple parallel systems for malaria • USAID support under flood emergency 2011 service delivery Annual malaria disease surveillance reports and • GF only sole international funder with the annual malaria report as part of MOH year book PRS and SRS main partners • No partnership mapping and partnership meetings.
Governance & Partnership
Strengths Weakness
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• Malaria Inter provincial coordinating • Oversight and coordinating committees committee (IPCC) have not been meeting since 2008 • Technical Advisory Committee on malaria • Link between DOMC and national health (TACOM) institute is not clear • Vector control working group • Duplicating roles and responsibilities of implementing partners • Partnership with GF, SCF, Merlin, ACD, ASD and this energy to the DOMC, province • No table of partners and roles and and DHO responsibilities • Partnership with Pakistan Medical Research • No quarterly meeting with partners Council • Last quarterly inter provincial • Partnership with Health service academy coordinating meetings – last was in 2008 • Annual malaria report a section of the MOH • Last meeting of the TACOM was in Year book • Lack of thematic area working groups under TACOM • Lack of a feedback system with accountability through simple reporting
Organizational Structure & Stewardship
Strengths Weakness • DOMC and PMCP structure • Weak health system and general staff working time limited and low motivation • GF DOMC PMU structure • Insecurity and instability affecting • Strong SCF Malaria structure acceleration and intensification activities • Strong ACD Malaria structure • Many posts vacant and Issue of many • Strong Merlin Malaria structure staff reaching retirement. • Provincial malaria structure (PMCP) but • Private sector provides health services to different levels and capacity 70% of the public • Monthly district meetings of SRS and DHO • No uniform minimum malaria structure at • Quarterly provincial meetings of PHO PRS provincial level and SRS • Fragmented and duplicating malaria • Cross border is seen as important but last structures and lack of coordination meetings held in 2009 between DOMC PMCP and malaria partners • Data base on training with SCF
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• Infrastructure and logistics • Structures in place but not fully functional • Strong PPHI structure for BHU PHC • DOMC no case management diagnosis delivery cell • District malaria service delivery structure • DOMC no Epidemic Emergency cell • New malaria staff development within • Inadequate provincial and district multi purpose technicians epidemiologist, entomologist and case management coordinators. • SR Supervision check list, PPHI check list • Lack of a district malaria coordinator in • Training in vector control, case management, all districts to lead and manage all microscopist and MIS Data base for training thematic areas.
• Majority of approved malaria posts vacant and not filled or will be abolished following retirement of existing staff • No follow up of cross border malaria control at provincial and district level • No national malaria master training center • No annual cascade of malaria training before the annual malaria season • No human resource and development plan and comprehensive malaria training course • No border meetings , sharing of information and joint operations and at district and provincial level Pak Afghanistan & Pak Iran
4.1.8 Successes, best practices and facilitating factors
Malaria provincial and federal financing was initiated under Roll Back Malaria initiative though the provincial and federal planning system till 2012/2013 and new cycles are being initiated as part of the integrated vector disease control management. Plans are underway to increase health and malaria financing in 2013 in all provinces. The Federal Malaria strategic framework 2011 2015 has been developed to support the transition of provincial and federal PC1 2013 2018 plans. Different components of malaria control policies have been integrated with the strategic and PC 1
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plans and federal guidelines although they are generally in line with WHO recommended policies. Malaria control activities are being successfully piloted in some union councils with, supply of commodities, capacity building and M&E in 38 high malaria burden districts supported by Global Fund and contracting malaria partners.
4.1.9 Problems and challenges
• However there are serious delays and gaps between funds allocated, released and actual expenditure.
• International financing is mainly though Global Fund and the contracted local malaria partners.
• Malaria control is not seen as a priority by policy makers and politicians at the district, provincial and federal levels with more implementation efforts being placed on the millennium development goals 4 and 5 as well as many other competing health priorities such as dengue, expanded programme for immunization, polio, hepatitis, emergencies and health reform.
• There is inadequate sharing of information and coordination and alignment between the district, provincial and federal malaria control programs with overall lack of clarity with regards to their roles and responsibilities.
• The annual malaria operational plans are only used in Global Fund supported districts and partially in others and not holistically within the overall district and provincial malaria programs.
• Malaria control program is not oriented towards supply based on output including need and demand based on access, equity and coverage towards rapidly achieving and sustaining universal access and coverage.
• There is a fragmented district, provincial and federal public health system which is unable to provide adequate support to the devolution transition, emergency, health reform and is overshadowed by a dominant private sector.
• The formal and informal private sector (approximately 70%) provides a large part of the fever/malaria control services especially in urban areas and in some rural areas.
• Federal cross border meetings (Pakistan Iran Afghanistan) have been held with inadequate practical follow up in border districts and provinces.
• There is poor partnership between malaria program with provincial and federal universities and health institutes to support operational research and training on malaria control and elimination.
• The unstable political and security situation in some districts and provinces has created challenges for access and M&E of the malaria program but also presents opportunity for developing a malaria emergency support.
• Some provincial malaria managers/ coordinators do not have sufficient experience making it difficult to support district health coordinators such as EDOS/DHO. 88
• There is a lack of functioning district malaria focal points/coordinators to comprehensively follow up implementation in all malaria thematic areas.
• There are lack of malaria epidemiologists, entomologists, case management coordinators at federal and provincial levels of the program and malaria supervisors/technicians and malaria microscopists at district and BHU levels.
• There are multiple malaria control activities being implemented at all levels of the health system, resulting in a desynchronized malaria control program at the district, provincial and federal level that fails to achieve systematic coverage and impact that can be sustained.
• District malaria focal points/coordinators have not been assigned to follow up implementation in all malaria thematic areas.
• There is a functional MCP with staff and equipment at the provincial and district levels in Balochistan. However, the province lacks a comprehensive malaria policy and guidelines (some need updating).
• The National Policy, guidelines and training manuals are rigorously followed in Balochistan districts funded by GF but not in non GF districts due to limited funding (PC 1) and insufficient human resources.
• There is need to reinforce the capacities at provincial and district levels in Balochistan if the program is to cope with the prevalent partnership environment.
• The quality control and impact of malaria control activities across Balochistan must be maintained through resource mobilization, training, supervision and monitoring as well as periodic reviews and evaluations.
• Delay in release of budget at provincial level for Balochistan.
• The basic structure particularly the field deployment of malaria staff has been more or less same since 1960s eradication era Balochistan.
• The malaria control staff work under control of DHOs and have no coordination with the Provincial Program Balochistan.
• Despite the Program in FATA changing its role to integrated vector management its organizational structure is not aligned with its present role.
• The frequent changeover of the management is a concern (FATA).
• Security situation and difficult terrain makes implementation very difficult (FATA).
• All the tribal agencies and Frontier Regions are supported by the Global Fund (FATA).
• The coordination between implementing partners and IVM needs to be strengthened (FATA).
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• The PC 1 of IVM does not address all issues and needs to be revised (FATA).
• There are no guidelines or training manuals available at the provincial level. (Punjab).
• All staff are busy controlling the dengue epidemic and polio eradication (Punjab).
• There is no budget for control activities (Punjab).
• The service structure for malaria is not well defined (Punjab).
• There is no logistical support for supervision and there is an overall lack of political commitment (Punjab).
• Malaria Control policy and strategic plan for Sindh is not available. • There is no Malaria Control Program structure available, at divisional level (Sindh). • Trained epidemiologist is not posted at Provincial Malaria Directorate (the post is occupied by senior medical officer) (Sindh). • Malaria diagnostic and treatment facilities are not available at all public sector health facilities and private sector is not covered (Sindh). • There is political commitment at the provincial level for Malaria Control (needs to be improved at the community level), but allocation of resources is not adequate (Sindh). • Steering and technical committees meetings are not held regularly (Sindh). • There is no regular training program for capacity development of staff at provincial and district level (Sindh). • There is inadequate office space, equipment and vehicles (Sindh).
4.1.10 Conclusions and recommendations
1. Development of a new joint provincial and federal vision for malaria control and elimination in Pakistan supported by one simple and comprehensive malaria and Integrated Vector Borne Disease (IVBD) policy document. 2. Need to accelerate and intensify towards greater than 80% universal coverage by 2015 in Global Fund supported districts (38) and rapidly introduce the new malaria policies and interventions in the remaining 15 high transmission districts. 3. Establish functioning malaria and integrated Vector Borne Disease partnership mechanism between the District Malaria Control Programme (DMCP), Provincial Malaria Control Programme (PMCP) and Federal Malaria Control Programme (FMCP) and other programs such as, Primary HealthCare and Lady Health worker program, District Health Information system, DEWES, MNCH etc 4. To develop a special community based malaria and integrated Vector Borne Disease control strategy for accessing hard to reach populations (Remote areas, emergency situations, IDPS, Nomads) in selected districts and provinces. 5. To develop a special strategy for public private partnership for malaria and integrated Vector Borne Disease control with private medical care provider and also private retailers and producers of combination drugs, Rapid Diagnostic Tests (RDT), Long lasting Insecticidal Nets (LLIN) , Indoor Residual Spraying (IRS) and Larval Source Management (LSM) chemicals and hand compression pumps to ensure standards of quality and local production at affordable costs in provinces which involves a 90
combination of information sharing ,training of health worker and information to public, legislation, regulation and enforcement. 6. The malaria federal Inter provincial coordinating committee (IPCC) and Technical Advisory Committee on malaria (TACOM) and the technical various working groups be revived with updated TOR on malaria and IVBD and be supported by provincial coordinating committees. 7. Joint annual operational /implementation malaria and IVBD planning started from 2014 at district, provincial and federal with the active involvement and contribution of all malaria partners and stakeholders 8. Joint monthly, quarterly and annual malaria and IVBD program performance reporting at district, provincial and federal level based on a uniform performance framework of input, outputs, outcome and impact towards sustained universal access and coverage. 9. Updating of provincial and federal malaria and IVBD strategic plans by end of April 2015 aligned to health strategic plans and PHC and MHSP based on need and demand for acceleration and intensification towards universal malaria intervention coverage by 2015 and post MDG 10. Update the current status of approved and vacant malaria human resources at all levels based on set minimum standards followed by a malaria human resource development plan 11. Development of a comprehensive malaria manual supported by simple wall charts in local provincial languages 12. To establish systematic cross border collaboration between Pakistan Iran in Baluchistan provinces and Pakistan Afghanistan in KPK province 13. To develop a special strategy for malaria control in emergency districts and provinces 14. To develop a strategy which builds a partnership between the malaria programme and private medical care provider including private retailers and producers of combination drugs, RDT, LLIN , IRS &LSM chemical and hand compression pumps to ensure standards of quality and local production at affordable costs 15. MCP to adopt an operational research agenda in collaboration with PMRC and MEDVC/HSA 16. MCP to work closely with VBD in order to develop a comprehensive model of collaboration 17. WHO/NPOs to be posted in provincial MCP and trained in GIS and malaria control/elimination
4.2 Procurement and supply chain management
4.2.1 Policy The Procurement and supply management section of the Programme Management Unit of the Directorate of Malaria Control has recently developed a detailed PSM Plan and SOPs for the period 2011 14, Quality Assurance and Quality Control Plan as well as SOPs on good storage practices, The guidelines are comprehensive and address areas of quantification, procurement, distribution, storage and quality assurance. The Directorate of Malaria Control has not procured major commodities since devolution in 2011. The procurements carried out at the
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federal level have been done by the Principal Recipient (DOMC) through TGF support. The specifications and quantities of these products are finalized by the PR and intimated to the VPP according to the planned timelines. The specifications of antimalaria drugs including ACTs, LLINs, equipment and supplies generally follow the WHO specifications. Once the specifications are developed these are shared with the Technical Working Group of the DoMC and all partners for advice and endorsement.
4.2.2 Guidelines
Balochistan: National malaria commodities management guidelines are under process for finalisation.
FATA and Punjab: There are no training modules for management of medicines and other health products.
KPK: There is no plan or strategy guideline to guide the program on emergency supply in case of stock outs. The program is dependant on partners in cases of emergencies. There are no training modules for management of medicines and other health products.
Sindh: Government of Sindh has established a Sindh Public Procurement Regulatory Authority (SPPRA) and adopted the procurement rules of National Public Procurement Regulatory Authority (NPPRA) of Federal Government of Pakistan. The SPPRA public procurement guidelines outline the procurement of different services, goods and consultancies. All public sector procurement is made according to SPPRA rules and guidelines. All procurement of Malaria Control Program including drugs, equipment, vehicles, insecticides, bed nets and services of seasonal labour is done in accordance with SPPRA rules. All procurement tenders of Malaria Control Program are advertised through national news papers and placed on SPPRA website. SPPRA monitors all steps of procurement process and retains copies of important procurement documents.
4.2.3 Registration of products
4.2.4 Specifications Antimalarials
As per revised case management protocol of the Directorate of Malaria Control Pakistan the current treatment policy Artesunate + Sulphadoxine Pyrimethamine is the 1st line treatment for uncomplicated falciparum malaria and Artemether + Lumifantrine (ALU) is the second line drug and for the treatment of mixed infections. For the treatment of severe malaria the first line treatment is Inj. Artesunate 60 mg.IV/IM.
Table 26: Features Specifications of Artesunate plus Sulfadoxine-Pyrimethamine combination in co- blister pack:
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Active ingredients Artesunate 100 and 50 mgs per tablet (for adult and children use respectively) 6 tablets in blister Sulfadoxine/Pyrimethamine 500mg/25mg white tablets packed in plastic blister packs, in pack 3 and 2 Sulfadoxine/ Pyrimethamine tablets. Blister pack should be marked with different colors based on their dosage schedule. Manufacturing source: WHO prequalified GMP certified manufacturers Shelf life Two years.
Labeling and packaging The contents of prepackaged courses of treatment must include in accordance with GMP specs Labeling of primary pack (blister pack) • Minimum requirements for labeling of the primary pack (regulatory): • Name of the product; - international nonproprietary name (INN) and the strength of the active ingredient; • Dose instructions; • Batch number and expiry date; the expiry date of the combination pack should be defined as the earliest expiry date of any of the active components in the product. • The manufacturer’s identification.
Package insert (regulatory) • The present regulatory minimum specification requires that there should be a package insert for prescribers. • The minimum requirements for regulatory approval of the package insert are: o The INN of each active ingredient; o indications of the product; o the name and address of the manufacturer (9). o Information, education and communication materials for prepackaged anti-malarial medicines General considerations: Information (what end-users should • Malaria is a curable disease. know when taking anti - • The earlier you treat it with the right medicine the better. - malarial medicines) Completing the whole course of treatment is important. - If you do not complete the treatment, the malaria is not cured. - People need to use the right dosage for their age and weigh t. • If you become sicker during or after completion of the treatment, see a trained health worker. • If the child vomits, give the unit dose to replace the one which is lost.
Concepts • Malaria is caused by a parasite 93
• The longer the pa rasite is in the body, the more chance there is that it can kill. • The full treatment is needed to kill all the parasites; if the treatment is not completed, malaria will come back. • Bigger and older children require higher dosage levels. • Other diseases may coexist with malaria, or the parasite may be resistant to the medicine. Instructions: • All the instructions on Primary and Secondary pack should be in Urdu. • The language in Primary Insert will be English
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Table 27 Rapid Diagnostic Tests (RDTs): Technical Specification Of Malaria Multispecies Rapid Diagnostic Tests (RDTs) 1. Description A Rapid Diagnostic Test (RDT) Device utilizing whole blood for the detection of malarial species in whole blood samples.
2. Technical Sampl e type: whole blood Specification Shelf life: 24 months or more from date of manufacture. Guaranteed minimum remaining shelf life at time of delivery is 80% Temperature requirement for storage: + 4 0 to + 30 0 C or higher (storage at higher temperat ure will be preference) Parasites: the test must identify at least P.falciparum and PAN High sensitivity and specificity (panel detection rate) (see the table1below) Results being ready within 20 minutes or less
3. Kit components and Each test pack should include the following elements for testing: packaging: 1. A laminated foil pouch that contains ; • Test device that contains a cassette • Desiccant 2. An accessory pack that contains; • An alcohol swab • A lancet • A metered pipette (marked at 5μl) • A developer solution vial • An instruction for use. • All of these components should be individually packed. 3. All the above individual pack should be in a kit box of 25 or above.
4. Instruction for use: Instructions fo r use are included with the test kit. The test procedure should be simple to use and easy to read the results. Test procedure consist ;: 1 Collection of whole blood 2 Addition of the collected blood into test device 3 Addition of clearing solutio n into test device 4 Interpretation of test results 5 Performance proof: 1 Certificate of Good Manufacturing Practice (ISO 13485:2003 or equivalent) 2 Fulfill the following WHOFIND Malaria Rapid Diagnostic Test
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Performance Round 3 Reports as in the following Table:
Performance requirement: should be 80% or higher for Sensitivity( panel detection rate ) both for panels P.falciparum, cultured 200 parasites /μl 2000parasites/μl Sensitivity ( panel detection rate should be 80% or higher for ) for P.falciparum, wild types both 200 parasites /μl panels 2000parasites/μl Sensitivity ( panel detection rate Should ) for PAN infection be 75% o r higher for both 200 parasites /μl panels 2000parasites/μl Overall false positives Should be 5% or less in all criteria Heat Stability Testing Should demonstrate 2 month stability in all criteria
LONG LASTING INSECTICIDE IMPREGNATED NETS (LLINs)
The preference has been for LLINS approved by WHOPES with dernier fiber above The LLINs specifications are as given below:
Table 28: Specifications for LLINs Odor Odorless Colour Green Shape Rectangular Size Double size with 160 cm width, 150 cm height and 180 cm length Active Ingredient Permethrin Impregnation Technology Treated with Permethrin, incorporated into the polyethylene fibers during the manufacturing process Standard: “WHO/WHOPES full recommendation Duration of Insecticide Ef ficacy from first use 5 Years (minimum) Yarn 100-150 Denier Mesh Size(holes/sq inch) 56 (minimum) Packing 100/bale, packed in polythene bags, having all the markings and instructions for use bearing the tag of “Free
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distribution by Directorate of Malaria Control Ministry of Inter Provincial
Coordination in collaboration with Provincial Malaria Control Programs” Not For sale” Sample bag is attached
IRS Insecticides and Pumps
The selection criteria for insecticides include baseline entomologic and vector susceptibility to insecticide studies as well as WHO standards. The main groups of insecticides used are: pyrethroids. The DOMC recommend Hudson X-Pert pumps for IRS. The Hudson based pumps have been procured only through SSF round-10 for 38 districts. However, the pumps purchased from PSDP allocation are locally manufactured but of good quality.
Table 29: Specifications for Insecticide Spraying Pumps Max filing Capacity 10 L. Light weight: >2 kg (net).
High Chemical Resistant polypropylene tank with contents indicator. Translucent tank offer visible indication of filling level
Pressure regulator set at 1.5 bar- 21 psi - to achieve the larger than 200 microns median droplet size required for residual spraying of surfaces and treating other areas with larvicidal according to the W.H.O. Specification Guidelines Set of nozzles included with the equipment:
• 2 x Even Fan nozzle (FE 80/0.8/3) – assembled on elbow + one extra included for I.R.S. • 1 x Even Fan nozzle (FE 80/1.2/3) – included for I.R.S. • 1 x Hollow cone nozzle (HC 80/0.2/3) – included for larviciding.
Directional lance with 50 cm. tube.
Dual filters located at the nozzle and handle (to minimize blockage). Safety Valve with green & red color indicator (red: max pressure)
High Chemical resistant hose (1.55 m) with modular screw-on nuts system (clampless) to ensure safety and durability. .
Fitted with high chemical resistant “viton” seals & washers. Lance fastener – for easy handling. Hose winder – to minimize entanglement
Adjustable straps with shoulder pads, with option to adjust to double-strap system for carrying as back-pack for better comfort .
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TECHNICAL IK-12-VC SPECIFICATION Components
Net Weight 1.6 kg Tank Heavy Duty Polypropylene,100% Leak Proof (3 year warranty on tank) Lance Fiber Glass (Light weight and more durable) Nozzles Polyacetal Highly resistant to chemical wear and tear Pressure Control offering Regulator 3 possible positions: 1.5 -Bar/ 3 -Bar / free Flow Hose Bi-component Hose with internal protection - Totally Chemical Resistant Pressure Chamber Polypropylene Chamber
Insecticides For Indoor residual spraying DOMC recommend synthetic pyrethroids. Currently Deltamethrin WP is in use. Only WHOPES approved insecticides to be used. The specifications are as follows:
Table 30: Specifications for Deltamethrin Wettable Powder 1 Description The material shall consist of a homogeneous mixture of technical deltamethrin, complying with the requirements of WHO specification 333/TC ( April 2005), together with filler(s) and any other necessary formulants. It shall be in the form of a fine powder free from visible extraneous matter and hard lumps. 2 Active 2.1 Identity tests (333/WP/M/2, CIPAC Handbook L, p.45, 2006) ingredient The active ingredient shall comply with an identity test and, where the identity remains in doubt, shall comply with at least one additional test. Deltamethrin content (333/WP/M/3, CIPAC Handbook L, p.45, 2006) The deltamethrin content shall be declared (g/kg) and, when determined, the average measured content shall not differ from that declared by more than the following tolerances: Declared content, g/kg
Tolerance 98
up to 25 ± 25% of the declared content above 25 up to 100 ± 10% of the declared content
Specifications for Microscopes
Binocular Microscope Universal Infinity System Optical System Illumination system Built -in transmitted illumination system. 6V20W (Helogen bulb). 240 V 60Hz universal voltage. Focusing Stage height movement , fine focus graduation : 2.5 um Eyepiece: Field Number (F.N): 18 (antifungal) Objective: Plan Achromatic Objectives (anti fungus). 4X, 10X, 40X and 100X oil Mechanical stage: Wire movement mechanical fixed st age 120 X 153 mm , traveling range : 80x 30 mm Movement range: 80mm x 50mm Observation Tube 30 inclined binocular tube interpupillary distance adjustment range 45 -80 mm Measuring unit Compatible with microscope Condenser ABBE Type with aperture iri s diaphragm N. A. 1.25
4.2.5 Quantifications A quantification exercise for antimalarials, RDTS, LLINs, IRS, health equipment (microscopes and spray pumps) was carried out in 2010 as part of the Procurement and Supply Management Plan for the SSF 10 grant. The DOMC forecast the requirements of antimalarial drugs, RDTs and Microscopes/reagents at the time of developing PC I. A five year forecasting is generally done and quantification is based on the previous year API .The commodities are procured through PSDP allocation.
Quantification of Animalarial Drugs : The quantification of anti malarial Drugs (AMD) including ACTs was calculated for target population of 300,000. The basis of this forecast was the 2009 surveillance data on malaria cases in the target 38 districts. Total number of reported malaria cases was approximatley120,000. The data was not representative of vivax cases because R 7 interventions were mainly falciparum specific. Considering the high endemicity of the 38 target districts, the relative proportion of falciparum and vivax malaria cases was taken as 40% and 60% respectively (Malariometric Survey in Target Districts SoSec 2009). Based on this assumption the estimated total number of malaria cases (both vivax Falciparum) in target 38 districts was taken as 300,000 per year and the antimalarial drugs were forecasted, accordingly.
Quantification for LLINs : The forecast for LLINs and IRS was calculated for target population of 50% of 65% total rural population (i.e. 16.146 Million). The population to be covered under LLINs is forecasted to be 855 and IRS 15% was also taken into account.
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Balochistan: There are two separate methods utilized, while for emergencies the estimates are made differently. These methods are:
o For the procurements made using the regular Non Development Budget, the estimates are directly related to the amount of money available, against which the demands and assessed needs for the districts are weighted and the size of the procurement is decided.
o For the procurements made using the Development Budget, the quantities to be procured for each period, which usually is one financial year, are already decided in the respective PC 1. The actual quantities to be procured are made according to the size of the grant specified for the respective procurement that is released.
For emergency situations, the size of procurement is directly dependent upon the size of population and area where services are to be provided.
• The quantification estimates for item wise procurement during the PC 1 period ending in June 2013 were:
o Formula to quantify Insecticides adopted for the Provincial PC-1
Total Union Councils 492
Total Houses in each UC 2000
30% (n=150) UCs in high risk districts which fall beyond 2 Standard Deviations of the Mean of the Annual Parasites Incidence (API) and Annual Falciparum Incidence (AFI).
According to National Vector Control Guidelines (on WHO criteria) such UCs will be covered (80% of the households) with IRS.
On the basis of 1998 census there are 3 rooms per household and size of each room is 40 sqm. Assuming there are 2000 household (6000 rooms) in each union council and 1600 household (80%) in one UC will be sprayed. The area to be sprayed will be 120 sqm areas per HH, using 0.025 g of 5% strength insecticide per sqm i.e. 0.5gms of 100% strength per sq meter and 60 gms per house hold. Using these assumptions the annual consumption of insecticide for 1600 households per union council = 96 Kg.
o Spray Pumps
• Normally, 4 pumps per union council will be needed for the application of insecticides.
o Protective Clothing for Spray men
• The quantification for protective cloths includes: 100
• Helmet
• Goggles
• Mask
• Uniform
• Long shoes
• Gloves (for spray men and mixer)
• Four sets of spraying cloths will be provided to 300 UCs. o Larviciding
• Granules Fenthion 2G for use in urban areas where mostly water is organically and chemically polluted.
- 7.5 kg of larvicide of strength 2% is required for 10,000 sqm.
- It is estimated the total area of a UC where water treatment with larvicide will be needed on an average is 40,000 sqm.
- 30 Kg of fenthion is required for each cycle.
- For proper larval control there will be 4 cycles each year.
- Therefore total larvicides required are 120 Kg / UC.
• Liquid Temephos (500E) for use in rural areas.
• 1.5 litres of Temephos with the strength of 500E is enough for 1 UC for each cycle and there will be 4 cycles (6 litres) in each year.
• Fogging Machines for Space Spraying
- Fog machines 6 vehicle mounted fog machines and 20 hand carrying fog machines can effectively cover the epidemic prone districts. • Spray men
- A total of 150 Spray men for provincial headquarters and high risk districts under the MCP (other than GF supported districts). - Hired on daily wage / contingent basis, working @ 25 days/month for 3 months. • Long Lasting Insecticide Treated Nets (LLINs)
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- The principal beneficiaries of LLINs will be pregnant women and children < 5 years age of the population of high risk districts of the province which is 3.52 million. - 1 net is recommended for 3 4 persons (mother along with 2 children <5 years age).
KPK: For routine LLIN distribution through the ANC care visit, 5% of the population was estimated to be pregnant yearly and one LLIN would be distributed to each pregnant woman at the time of their first ANC visit. Over 84% of pregnant women access the health care system during their pregnancy. The GF while planning quantities for insecticides takes into account the following variables: type of insecticides to be used, weight per sachet, total area in square meters (m ²) to be sprayed and existing stock at provincial level.
Punjab: The Program has limited funds for LLINs and has no policy to distribute LLINs. The MCP purchases insecticides based on availability of funds and the case load.
4.2.6 Procurement, storage and distribution National procurement is done on a annual basis. The procurement follows PPRA rules 2004. The procurement of amounts exceeding Rs 100,000 tender need to be uploaded on a PPRA website, while procurements above 2 million are uploaded and an advertisement is also needed to be given in the three national newspapers (both English and Urdu). Once the tenders are received these are scrutinized and the comparative statement is prepared. There is a purchase committee that opens the tender and finalizes the procurement. An evaluation committee does the technical evaluation. Once the evaluation is completed, the bidding parties are invited and the financial statements are opened in front of all bidders. A comparative statement is prepared and the lowest bidder offering is selected. The commodities purchased are sent to the provinces hiring private transport. Directorate of Malaria Control Programme procures the items following the government procurement rules S.R.O. 432(I)/2004, section 26 of the Public Procurement Regulatory Authority Ordinance, 2002 (XXII of 2002).
Procurements over one hundred thousand rupees and up to the limit of two million rupees are advertised on the Authority’s website in the manner and format specified by regulation by the Authority. These procurement opportunities may also be advertised in print media, if deemed necessary. All procurement opportunities over two million rupees are advertised on the Authority’s website as well as in other print media or newspapers having wide circulation. The advertisement in the newspapers should principally appear in at least two national dailies, one in English and the other in Urdu. For procurements less than one hundred thousand rupees quotations may be called. At least 3 quotations are required. Procurements less than twenty five thousand rupees are exempted from the requirements of bidding or quotation of prices. The response time should be less then fifteen days for national competitive bidding and thirty days for international competitive bidding from the date of publication of advertisement or notice. Open competitive bidding is done by the DOMC for the procurement of goods and services. The DOMC has formulated a comprehensive bidding document that is made available to the bidders immediately after the publication of the invitation to bid. The bid comprises of a single package containing two separate envelopes. Each envelope shall contain separately the financial proposal and the technical proposal; the envelope shall be 102
marked as “FINANCIAL PROPOSAL” and “TECHNICAL PROPOSAL” in bold and legible letters to avoid confusion; initially, only the envelope marked “TECHNICAL PROPOSAL” shall be opened; the envelope marked as “FINANCIAL PROPOSAL” will be retained in the custody of the procuring agency without being opened. After the evaluation and approval of the technical proposal the procuring agency, shall at a time within the bid validity period, publicly open the financial proposals of the technically accepted bids only. The financial proposal of bids found not to meet the criteria shall be returned un opened to the respective bidders; and the bid found to be the lowest evaluated bid shall be accepted. Emergency procurement system will address national stock outs. Emergency procurement system is in place (PPRA rules 2004 explicitly explain the terms and conditions procurement)
PSM Set up at the Public Sector PR (DOMC) Level: In June 2009, the Global Fund launched the Voluntary Pooled Procurement (VPP) Initiative, which encouraged collective procurement of drugs and related commodities to decrease prices, expand access to quality medicines, and improve the reliability of drug supplies. The initiative focused on four product categories: first line antiretroviral treatment (ART), second line ART, ACT drugs, and long lasting insecticide treated nets (LLINs). By monitoring prices, cost savings, and market shares, the Global Fund hopes to strengthen national procurement systems and supply chain management. The procurements included AMDs, ACTs, LLINs, RDTs and microscopes. The specifications and quantities of these products are finalized by the PR and submitted to the VPP according to the planned timelines. There is a full fledged unit of procurement and supply chain management (PSM) supported by TGF SSF 10 headed by the PSM manager
PSM Set up at the Private Sector PR (SSI): The Private sector PR follows the organizational procurement system of Save the Children. All procurements are done through this system. There is a Manager PSM who is responsible in following all procurement procedures and laising with the SSI procurement unit.
Balochistan : After the 18 th Constitutional Amendment malaria commodities are procured under the provincial budget grants. Procurement is dependent on the timing of the budget release (non development or development), which usually occurs mid way to the last quarter of the respective financial year.
The provincial MCP is the procuring unit for commodities purchased from Development Budget grants. The standards are already included in the approved PC 1 with the specifications and other related requirements. In this case the regulatory bindings are the same as for other procurements including donor requirements. These procurements are made under supervision of the designated Purchase Committee for these procurements. Routine quality control measures are operative for example inspection and testing where applicable. This system is as represented here:
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The PC MCP prepares the lists with specifications, quantities and related information with a draft tender document and submits the same for consideration and approval of the authorities, through the Director General Health Services Balochistan.
After approval from the DGHS the demand is forwarded for consideration and approval of the Health Secretary Balochistan, who forwards it for approval of the Planning and Development Department and Finance Department or the Project Steering Committee as the case maybe.
If the demand is approved and budget is available, a Purchase Committee is
constituted (if not existing already). The Tender is published through the
Directorate of Public Relations, with designated date and time for tender bids, to
be submitted with Surety Bond / Deposit at Call / another agreed security
instrument.
The Purchase Committee evaluates the bids in an open bidding process, and the accepted bidder is placed with a Supply Order, with signing of a Supply Contract with the PC MCP including agreed terms and conditions applicable.
The items tendered are supplied to the designated place by the supplier. Inspection of the supplied item is made for conformation with the tender specifications and quantities. This is done by an Inspection Committee designated for the purpose.
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The Purchase Committee evaluates the bids in an open bidding process, and after approval from the Health Secretary, the accepted bidder is placed with a Supply Order, with signing of a Supply Contract including agreed term and conditions applicable.
If error is corrected the supplies are again inspected by the Inspection Committee.
If cleared and certified by the Inspection
Committee the supplies are formally received by the authorized stores personnel and If cleared by the Inspection If error is corrected the entered on the respective Stock Registers. Committee. supplies are again inspected
by the Inspection
Committee.
• If error is not corrected the supplies are rejected and penalty proceedings are initiated against the supplier as per contract agreement. • Re tendering is done if approved.
• Final Settlement of Supplier’s dues.
• Supply to the districts and for MCP activities initiated.
Figure 23: Procurement system
For the procurements made under the regular non development budget the basic procedure remains the same, with the exceptions that:
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o The procurements of anti malaria medicines, equipment for laboratories and related supplies are made by the Government Medical Stores Department (MSD) from the budget placed at their disposal under the respective budget heads, these procurements are made under their own system. These items are purchased in consultation with the PC MCP.
o The procedure for emergencies is also the same, with the exception that time and type of tendering and supply may be shortened accordingly as provided under the rules.
o Same procedure is applied for the procurement of RDT and LLIN supplies, however, the bulk of these supplies are presently provided from the donor’s side.
The procured items are stocked in the provincial MCP stores, from where they are distributed to the districts on demand and utilized by the MCP HQ for control and intervention activities as required. Each district has a Malaria store or if space is limited in whatever storage space is available. The districts report stock outs to the MCP however; districts in which GFATM Partners operate, the bulk of these items are procured and distributed through their own network, without any coordination with MCP. The commodities are issued under a prescribed indent procedure with a properly maintained issue registers and other documentary records. The disbursement of medicines is made through the regular healthcare system from the health facilities and outreach workers, as the case may be. In all cases patient prescriptions records are required to be maintained and reported. The MCP Balochistan has to follow two sets of regulatory procedures, the first is the regulatory requirements applicable to government organizations like the Balochistan Purchase Manual and the second is the WHOPES quality standards and procedures.
FATA: Procurement procedures are based on the prevailing National Procurement framework and legislation called PEPRA Rules .
KPK: Procurement procedures are based on the existing national and Provincial procurement framework and legislation. In Khyber Pakhtunkhwa Province, the NWFP procurement of Goods, Works and Services rules 2003 are applicable for initiating public procurement of pharmaceuticals insecticides, surgical and non surgical disposables, hospital supplies and bio medical equipment. In Khyber Pakhtunkhwa, all procurement related polices are developed and their administrative approval conducted by the Health Secretariat. The Secretary Health acts as an approving body for the contract award recommendations being chairman Selection (Purchase) Committee and as the Principal Accounting Officer. The procurements are dealt by the Director General Health Services, Khyber Pakhtunkhwa which procures medicines through the pharma Wing of the Govt Medical Coordination Cell (Govt MCC) the newly established Procurement Cell based on the requirements received by the DG office from various Districts & Vertical Programmes. The Procurement Cell, established after the devolution of powers to the Provincial Government in the post 18 th Amendment era, centrally procures the bio medical equipment for all the Districts by conducting all the Pre Award procurement planning, designing the Standard Bidding Documents, conducting technical and financial evaluations, awarding the contract and administering the post award contractual relationships with the suppliers. The Procurement Cell, DGHS is therefore engaged in the Pre award planning, designing the Standard Bidding Documents, bid evaluation and subsequently awards the contract on unit rates through central contracting which remain valid till the next financial year for the selected drugs, medical devices and surgical disposables for all the field formations including EDOs (Health), MS DHQs, Autonomous Medical Institutions (AMIs) and Vertical Programs etc which in turn conduct the post award process by placing the Purchase Orders (POs) themselves on need basis during the whole year on a quarterly basis.
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Roll Back Malaria (RBM) Vertical Program has initiated a specialized procurement activity such as the procurement of anti malaria through the Procurement Cell. The technical specifications for anti malarial items are in the process of preparation with the technical support of Technical Resource Facility (TRF) Khyber Pakhtunkhwa. The Standard Bidding documents have been prepared by the Procurement Cell on the prescribed format of FIDIC (International Federation of the Consulting Engineers). The technical and financial evaluation criteria, previously based on price alone has been replaced with Merit Point Evaluation Methodology having more emphasis on the quality and therapeutic aspects of the pharmaceutical items.
Emergency procurements in the Khyber Pakhtunkhwa Health Department are conducted through local purchases by the autonomous medical institutions such as the teaching hospitals from the market and where necessary, by the vertical programs on single source contracting with proper justification for the same and subsequent to the approval of the Competent Authority.
The Health Department Khyber Pakhtunkhwa has been provided technical support by the TRF – a DFID funded project in health, to develop Standard Bidding Documents (SBDs) and design the technical and financial evaluation criteria based on merit point evaluation with product and firm evaluations done separately. As per the evaluation criteria, the highest ranking product will get the contract based on National Competitive Bidding (NCB).
Punjab: The Malaria Control Program has a very exhaustive system for procurement. The approval has to be granted by many committees like technical evaluation committee, purchase committee and inspection committee. Procurement procedures are based on the prevailing PEPRA Rules of Punjab. Materials are purchased on Single Source Contracting with proper justification for the same and subsequent to the approval of the Competent Authority.
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Collection of
INDENT demand from Figure 24 Districts
Province
Rationalization & Justification
WHOPES Advertisement through Tender Notice specifications docume nt attached
Financial & Technical Quotations from companies
Opening of technical quota tions by Technical Evaluation Committee
PPRA 2006 Meeting of Technical Evaluation Committee rules followed Successful bidders with technical quotations provide Pre Shipment Test at
samples DTL
Opening of Financial Bidding
Technically & financially 108 Contract Awarded sound quotations with lowest bidding
Issuance of supply order
Inspection by
Sindh: After allocation of funds in the budget, a requisition paper is prepared by Malaria Directorate which contains specification, quantity of the required items. The approval is obtained from Secretary Health department Government of Sindh. Procurement committee is constituted comprising of Chair and four members. Usually two third of members are from outside of health department, the Director General Health services chairs the committee. Tenders are floated according to SPPRA rules, and bids are invited. Bids are opened in the presence of committee members and the bidders. After opening of bids, offers are examined in terms of technical requirements and the comparative costs. The contracts are awarded on competitive basis. After specified time, the delivery of goods is received, which are examined by inspection committee notified by secretary health. After examination of inspection committee, goods are entered in the stock registers and payments orders are issued. There is no availability of a proper warehouse however three rooms are available for storage purpose, two rooms are used for storage of insecticide, LLINs, and ULV third room is used for storage of medicines and laboratory reagents and microscopes
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Figure 25: Procurement Process Diagrammatic
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Distribution of goods is made according to indents received from districts. Consumption Reports 111
from the Malaria Districts are sent to the consumption Directorate on monthly basis.
Storage and Delivery at District and Community Level: District Health Office (DHO) does not separate storage facilities for insecticides, LLINs and anti malarial drugs. However each DHO office has common stores for goods, equipment and drugs. Distribution in the community is on the day to day basis and any surplus is returned to the DHO store. Stock register is maintained at provincial and district levels for all procured goods, anti malarial drugs and other logistics.
4.2.7 Inventory Management Managing distribution of commodities: The PR procures the items through VPP and is responsible in receiving items at the port of entry in the country. The stocks are shifted to the SRs regional/ district stores by the PR and the district stocks are received and stored by the respective SRs. Thereafter the stocks are distributed to the public sector facilities/MCH centers at THQ/RHC/BHU by the SRs and handed over to the Public sector facility staff. At the facility level the items are stored at the medical stores of the THQ/RHC/BHU for onward issuance to the beneficiaries. Procurement of Pharmaceutical and health items is carried out biannually and rented transport is used for transfer of stocks from port of entry to the SRs district stores. During Phase 1 PR s outsourced the procurements to one of its SR an NGO and the transportation of stocks from Dockyard to district stores of SR was outsourced. Phase 1 procurements by the Procurement Agent was a success story as timely and economical procurement facilitated the implementation partners in achieving the targets within stipulated time which facilitated PR in better performance grading. However, during phase 2, procurement was conducted through VPP and in view of security risk, inland distribution of stocks was carried out by the PR. To ensure secure transportation of commodities, transport agency with insurance was selected and locked and sealed vehicle were used for transportation, however, insurance of stocks was not done as it was not budgeted.
Inspection committee has been constituted by the PSM unit among the DOMC and PMU staff members which inspects the stock at the central level and verifies that it is ac cording to the specifications and meets storage standards. Provincial Directorate of Malaria Control and District Public sector along with the M&E and PSM unit of PMU is responsible for quality and quantity of the pharmaceutical and health items.
There is a complete inventory management system in place and maintained at three levels. At the first level, the PR maintains the inventory of all the items procured and distributed to the SRs. At second level, the SRs maintain the inventory of items received from the PR and issued to the facility level. The most important tier of the inventory control is the facility level where all the stocks are issued to the beneficiaries. The data maintained on FM1 at facility level is compiled on a monthly basis and conveyed to the district through FM2. The district authorities (EDO Office) compiles all the data received from the facilities on FM3 and conveys it to the provincial malaria control program which forwards the report from all districts on FM4 to the DoMC/PR. Inventory and stock registers are available at each health facility. Reporting of stock outs is made using FM1 form. The PSM guidelines developed by the DOMC from SSF round 10 support gives guidance on the system of inventory.
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Balochistan: The Malaria Indicator Survey is being revived and refurbished on the new FM1 to 4 system, replacing the old G30 system. The new system includes indicators for stock control and reporting. The stores at all levels are required to maintain a card system to monitor the medicines and related supplies on stock.
FATA: There is no plan or strategy guideline to guide the program on emergency supply in case of stock outs. The program depends on partners in cases of emergencies, who have identified one focal person for malaria control intervention in each agency. The GF has a buffer stock for malaria epidemics.
There is no system for storage and distribution of antimalarials and RDT’s. The IVM procures the consumables and stores them in the Fata Directorate Warehouse. The agency staff of all the tribal areas receive and transport the consumables to their respective warehouses located at agency headquarter office. The PR receive consumables and supplies from GF in a regional warehouse located at Islamabad, which are transported to main warehouses at Peshawar, Bannu and Lakki Marwat. The quarterly stock is then transported to the health facilities of the respected agencies.
FATA, KPK and Punjab : There is a system of stock control where the spray operators report at the end of each day the amount of insecticide used and return the sachets. This system is not followed and till date no reporting has reached the directorate. The GF districts however have all the reports and data available on usage of IRS.
KPK and Punjab : There is no scientific system of storage and distribution of antimalarials and RDT’s. The stock of province is kept in the provincial depot and transported to the districts. Similarly insecticides are procured at a provincial level and transported to the district warehouses where IRS takes place.
4.2.8 Quality Control
For quality assurance and quality control measures, the PSM section finalizes the “Quality Policy” encompassing both the quality assurance and control aspects. For quality control purposes, random samples are drawn from the lots of pharmaceuticals/drugs at three levels i.e. central warehouse, regional/district warehouse and facility level. Seven samples of each product are drawn from a consignment and sent to the WHO pre qualified laboratory or ISO 17025 certified laboratory for test/analysis in compliance with the TGF quality assurance policy.
The PSM unit of the PR needs training and capacity building on the PHPM related activities and provision in this regard has been incorporated in the R 10 budget. Regarding distribution of these products procured from the GF grant, as earlier described, all the products are distributed free of cost to the target population while adhering to the prescribed procedures.
Balochistan: Regular Quality Control mechanisms are followed at the time of procurement tendering with clear indication of specifications in the tender documents and through inspection mechanisms at time of delivery. Quality control of stored items on stock is limited to batch and expiry monitoring. The concept of Special Quality Control centers is not operative, with the 113
exceptions that: there is a Drug Testing Laboratory at Quetta, which is however a part of Drug Regulatory System; the Insecticides are sent to the Department of Chemistry, University of Karachi, for quality testing. The report from this department is utilized for quality control and testing of insecticides from time to time as may be required.
FATA, KPK and Punjab : The National Laboratory of Quality Control of Medicines (LNCQM) was established in 1991, in Karachi. Its mandate is the quality control of medicines to ensure adherence to established international quality standards. The products procured are tested before release into the system. There is currently no system in place for quality control of the insecticides.
4.2.9 SWOT analysis
Strength Weakness Opportunities Threats
Procurement policies Low storage capacity at all Preparation for drafting Inadequate funding for available levels the proposal for GF malaria commodities
Procurement guidelines Inadequate systems for Weak standardization of and rules are available quantification of RDT’s GF activity reported vs and other commodities treatment provided vs disbursement causing delays in funding
Trained man power for Inadequate logistics for Long term procurement store management transportation of malaria process available commodities
System for Distribution of SPPRA does not have Transparency in Procurement process may stores available regional and district procurement process be delayed officers
Guidelines are silent on Funds available for Timely targets not certain issues procurement achieved
Proper storage facility not System available Floods heavy rains available
Consumption report from districts not received regularly
Vehicle for transportation of insecticide, drugs, LLINs and other stores not
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available
4.3.0 Successes, best practices and facilitating factors
Malaria PSM is a push system based on supply and not a pull system based on need and demand. There is a PSM plan to support the procurement in Global Fund supported 38 districts. There are estimates prepared for malaria commodities as part of the PC I by the FMCP and PMCP. WHO specifications are being used for procurement of LLIN, IRS insecticides, RDT and ACT. There are multiple malaria procurement and supply systems within the DOMC, PMCP, district health offices and hospitals and the various implementing malaria partners.
There is a standardized procedure for procurement Public Procurement Regulatory Authority PEPRA. There is a good malaria storage system in provinces with partners such as Merlin and SCF. ACT and RDT stock control and reporting system is part of new MIS. There are drug quality control laboratories at federal and provincial level with drug regulatory officers at district level. There are insecticide quality control centers in Kharachi and Faisalabad.
4.3.1 Problems and challenges
• One of the main challenges has been the supply of commodities depends on availability of funds, particularly for RDTs and LLINs, funding for procurement of these items has been far below the requirements due to which reason the targets are often not met. • The delayed release of funds even when allocated, are sometimes delayed up to the last quarter, which in turn delays procurements resulting in a serious operational impediment for MCP. • Inadequate guidance on the quantification of the first and second line alternative anti malarials. • The quality control of products of malaria is an issue that should be given more attention and the rational use of these products. • Lack of focal point in the team at MCP to monitor and track malaria commodities. • Proper storage facilities for drugs, insecticide, LLINs and other stores is not available • Vehicle for transportation for goods not available • Weak reporting system from districts
• There is no quality assurance system in place for RDT.
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4.3.2 Conclusion and recommendations
1. PMCP. DMCP need to ensure the PPRA, PPHI and all malaria partners procure all malaria commodities (antimalarial, insecticides and vector control equipment for IRS) according to the WHO/WHOPES specifications. 2. Urgently align DRAP registration for malaria combination therapy with national malaria treatment policy and to support production/import of Primaquine and de registration and ban on use of mono therapeutic formulation for all malaria treatment. 3. To prepare quarterly updates on malaria commodities used and in stock and forecast urgent need 4. Establish a system for RDT quality assurance (QA) using WHO accredited international laboratory and quality control using a national malaria microscopy laboratory. 5. Annual updating of the malaria commodities specification list based on WHO recommendations 6. Annual updating of estimates of malaria commodities based on need and demand to achieve and sustain universal access and coverage 7. Conduct a review of the current stores and potential need for malaria combination drugs, RDT, LLIN, IRS and LSM chemicals in district and provinces
4.3 VECTOR CONTROL
4.3.1 Introduction Primary and secondary malaria vectors and bionomics In Pakistan over 24 species and sub species of Anopheles have been recorded, out of which only two : An culicifacies and An stephensi are considered as the primary vectors involved in the transmission of malaria. Earlier studies considered An culicifacies as the most important vector in rural areas 13 ,14 ,15 ,16 and An stephensi in the urban areas 17 but a study conducted in Punjab in 1989 incriminated An. stephensi with malaria parasites in the rural areas of Punjab. The vectors are prevalent across a wide range of ecological zones, and are heavily associated with water logged areas. In addition to the above two species Anopheles pulcherrimus and Anopheles fluviatilis are considered as the suspected malaria vectors (which need to be confirmed) especially in the mountainous and foothill areas of KPK and Punjab 18 . Anopheles pulcherrimus has been implicated in malaria transmission in Afghanistan, in countries bordering the Persian Gulf, and Rajhistan desert in western India. Like wise Anopheles fluviatilis is also a known vector in Afghanistan, Iran and parts of India. Anopheles annularis has also been identified in FATA and Baluchistan this species is a confirmed malaria vector in Afghanistan and Iran. The role of species complexes is poorly understood in the country. A species complex consists of sibling species which by definition are species with obscure morphological differences. Anopheles culicifacies has been found to represent a complex of sibling species, provisionally named as Anopheles culicifacies species A and B 19 . Studies so far carried out have indicated the presence of Anopheles culicificies species A in Punjab. Like wise Anopheles stephensi is not a homogeneous species and the possible existence of two species is inferred. Both the primary vectors An. culicifacies and An. stephensi have been considered to be essentially endophilic in their diurnal resting habits. They breed in clean water and are chiefly zoophilic. Both species bite around mid night till 2:30 am. As far as the seasonal 116
abundance of malaria vectors is concerned, A culicifacies is found in the country through out the year with seasonal fluctuations in the population abundance depending upon climate. In Punjab and Sind this species exhibit a bimodal pattern with two peaks, one in April/May and other in August/ September. In cooler areas in the part of KPK, Baluchistan and Azad Jammu and Kashmir, it exhibits a unimodal pattern, occurring between May and September with no clear peak. The density of A. stephensi increases by the end of March, reaching a peak in April May and thereafter falling from September November. In KPK, Baluchistan and AJK this species is more prominent between July and September. No recent studies are available on sporozoite rates, Entomological Inoculation Rates (EIR) and blood index. The species of Anopheles fluviatilis and Anopheles annularius have been reported as confirmed malaria vectors in Balochistan (district Zhob). The role of An. pulcherrimus, An. maculatis, An. turkhudi, An. pulcherrimus and An. superpictus for malaria transmission needs to be investigated for effective control.
Sentinel sites for Vector bionomics
Federal: The Directorate of Malaria control has established 4 sentinel sites in the country. These sites were established to monitor drug resistance and insecticide resistance as well as vector surveillance. None of the sites are currently functional. The DOMC has recently developed new vector surveillance tools which need to be field tested and implemented. Aside from intermittent insecticide susceptibility monitoring and seasonal distribution no additional operational research activities or entomological data collection has been conducted at federal, district or provincial levels
Balochistan : Currently there are two sentinel sites in Zhob and Kech district headquarters, from where regular reports including information on vector bionomics are expected. However, due to the deficiency of properly trained entomology professionals these sites have been used for routine malaria reporting than for collection of key entomological parameters.
KPK, Punjab : The sentinel sites for vector bionomics (breeding, biting and resting habits of mosquito) as well as other inoculation rates, sporozoite rates and human blood index indicators do not exist. There is no vector map in KP province. Punjab has conducted vector density studies which are not regularly reported to the DOMC.
Sindh : Vector surveillance is conducted at district levels and vector density reports are generated.
.
Vector susceptibility to insecticides
Knowledge of vector/pest susceptibility to pesticides, changing trends of resistance and their operational implications are basic requirements to guide pesticide use in vector borne disease and pest control programme. The insecticide resistance monitoring is an integral part of the DoMC strategy for vector control. During early 1970’s resistance was detected among An. culicifacies and An. Stephensi , to D.D.T (Organo chlorinated hydrocarbons) in some districts of Pakistan 20 , compelling the programme to replace DDT with BHC ( same insecticide class) in 1972. In 1979 Malathion and Sumithion (Organophosphate) were introduced although BHC continued to be used until 1980’s to mid 1990’s. A high frequency of malathion resistance was reported among An. Stephensi in some districts of Punjab, while lower frequencies were observed in the NWFP and the Sindh province during mid 1980’s 21 . During late 1980s An. culicifacies also developed 117
resistance to Malathion in certain parts of Pakistan. Since 1996, deltamethrin (Synthetic Pyrethroids) has been used for indoor residual house spraying in Pakistan. A recent survey was conducted in 4 districts of Punjab province (Layyah, Muzafargrah DG Khan and Rajanpur). The results indicated An. stephensi and An. Culicifacies still resistant to DDT and Malathion in four districts. Resistance is slowly developing in some districts to permethrin, lambdacyhalothrin and deltamethrin. The results of the study provide important evidence base for strategic planning of vector control in southern Punjab. Currently the Health Services Academy at Islamabad is conducting vector susceptibility studies in various districts of Punjab but due to financial constraints, the MedVC Unit of HSA is unable to expand surveys to collect data on a National level. There is no system currently in place for routine monitoring of insecticide susceptibility/ resistance in the country.
Balochistan : An. culicifacies and An. stephensi have developed resistance to organochlorines and the latter species has also developed resistance to organophosphate, ‘Malathion’ (not currently in use).
FATA: No entomology reference laboratory exists KPK, Sindh and Punjab: Does not have an insectary and entomology reference laboratory. No insecticide susceptibility testing has taken place.
4.3.2 Policy and guidance
The key components of the vector control strategy include Indoor Residual Spray (IRS), Long Lasting Insecticide Treated Nets (LLIN) and Larviciding. The National Malaria Control Strategic Plan (2011 – 2015) outlines the new national LLINs distribution policy which focuses on universal coverage for the entire population at risk of malaria in areas not covered by IRS targeting specifically pregnant women at IMCI centres and antenatal clinics. The key implementers are the provinces which produce annual plans and reports. World Health Organization recommends integrated vector management (IVM) approach for the control of vector borne diseases including malaria. Pakistan has yet to develop IVM guidelines to guide the implementation of vector borne diseases control. Recently the programme has developed an IRS Manual and training guide with support from SSF Round 10 which includes chapters on safety and waste management procedures. These guidelines provide good directions on standard procedures e.g. how to plan, how to quantify insecticides, the safety procedures and waste management etc. but does not address focal spraying to curtail epidemics and outbreaks. Two other guidelines drafted by the DOMC include i) guidelines on anti vector interventions for monsoon season and ii) guidelines for control of vectors of public health importance after monsoon rains in Pakistan. A comprehensive distribution strategy for LLINs have also been developed in 2012 which has been implemented in 38 TGF supported SSF 10 districts. LLINs guidelines for communities use is currently being finalized. The DOMC has recently developed data collection tools for vector surveillance but these tools have not yet been circulated. . Balochistan : Same protocols are followed by respective PRs in 17 GF supported districts, although their district plans are not coordinated with the MCP. The guidelines for IRS training module are available. No guidelines exist for safety guidelines even at national level.
FATA: The federal LLIN distribution and IRS guidelines are adhered to. The annual and strategic vector control plans are not available.
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KPK: There are no guidelines for IRS or training manuals available at provincial level. LLIN distribution guidelines are available and till date majority of staff of GF districts are trained, whereas no training is conducted by the MCP. There are no vector control plans.
Punjab : The guidelines for IRS training module are available. The annual and strategic vector control plans are not available.
Sindh : National guidelines on IVM have been developed but in Sindh province still no training has been conducted.
4.3.3 Organizational structure At the federal level, the Director, Directorate of Malaria Control heads the malaria control program, supported by an entomologist. Recently an additional entomologist has been appointed in the PMU through GF SSF 10, whose responsibility is to provide guidance to the provinces and districts for IRS and LLINs distribution. The DOMC is not directly involved in any spraying operations or LLIN distribution but these activities are carried out by the provinces.
Balochistan : There are 2 entomology technicians and 9 insect collectors. The vector control activities are conducted by the respective malaria supervisor staff in the respective district health offices, headed by the Malaria Superintendent. The PRs do not coordinate in vector control with the MCP. The capacity of the existing entomology staff need to be harnessed by attending training modules conducted by the Institute of Public Health Quetta.
FATA: There is no malaria vector control department.
KPK and Punjab : The MCP Manager heads the malaria control program but with no vector control department.
Sindh: There is a trained entomologist and insect collector at provincial level and they are involved in vector control activities at the community level.
4.3.4 Guidance The key components of the vector control strategy include Indoor Residual Spray (IRS), Long Lasting Insecticide Treated Nets (LLIN) and Larviciding. The National Malaria Control Strategic Plan for 2011 to 2015 outlines the new national LLINs distribution policy which focuses on universal coverage for the entire population at risk of malaria in areas not covered by IRS and especially the distribution to pregnant women through IMCI centres and Antenatal Clinics. The key implementers are the provinces and they are responsible to produce annual plans and reports.
World Health Organization recommends integrated vector management (IVM) approach for the control of Vector-borne diseases including malaria. Pakistan has not yet developed IVM guidelines to guide the implementation of vector-borne diseases control. Recently the programme has developed an IRS Manual and training guide with support from SSF- Round-10 that also includes chapters on safety and waste management procedures. These 119
guidelines basically provide good directions on standard procedures e.g. how to plan, how to quantify insecticides, the safety procedures and waste management, do’s and don’ts etc. but does not specifically address the MCP strategy of focal spraying to curtail the epidemics and out breaks. Two other guidelines drafted by the DOMC include i) Guidelines on anti-vector interventions for monsoon season and ii) guidelines for control of vectors of public health importance after monsoon rains in Pakistan.A distribution strategy for LLINs have also been developed in 2012 which is quite comprehensive and has been implemented in 38 TGF supported SSF-10 districts. LLINs guidelines for communities use have also been drafted and are being finalized.
4.3.5 Human resources, training and capacity development The provinces are mainly responsible for training of entomologists, spray men on safety operations, handling of spraying equipment and insecticides on annual basis. The Malaria Vector Control Focal Point (Entomologist) at national level coordinates IRS training for Provinces if so required.
Table 31: Capacity building of health care providers on LLINs 19 districts of TGF Round10 (Save the Children International)
Year 1 Year2 Year 1,Year 2
Activity Description Q1,Q2,Q3,Q4 Q5,Q6,Q7,Q8 Q1,Q2,Q3,Q4,Q5,Q6,Q7,Q8
Target Progress Target Progress Target Progress
Training workshops for outlet
staff (district-level malaria
control program staff) on LLIN 364 0 206 552 570 552
distribution strategy, data
management and user guide
Training of master trainers on
LLIN distribution strategy, data 84 0 0 88 84 88
management & user guide
602 39 281 781 883 820
Total
Balochistan: Some infrastructure and human resources are present although acutely deficient in numbers.
Sindh Malaria Control Program at Provincial level has following positions for vector control activities 1. Senior Evaluator 2. Entomologist 3. Entomology Technician 4. Insect Collector and at district level non medical evaluator, assistant entomologist, insect collector are required to work in the field to determine breeding and resting habits and vector density. But due to non availability of mobility support and guidelines the performance of the staff is poor and not properly 120
documented. The only document obtained related to vector control from Malaria Directorate was vector density report.
4.3.6 Annual planning
Targets
• 80% of the target communities sleep under LLIN in malaria transmission season;
• 20% of target localities receive 2 rounds of IRS coverage annually;
• All four provincial sentinel sites regular monitor insecticide resistance;
Indicators
• % of target population sleeping under LLIN in malaria transmission season; • % of households in target localities received annual IRS coverage; • # of sentinel sites reporting on insecticide resistance;
Sindh: Integrated Vector Management (IVM) has been proposed in PC 1 of Malaria Control Program to cover Dengue, Cutaneous Leishmaniasis and Congo Fever.
4.3.7 Service delivery outputs and outcomes
Indoor Residual Spraying IRS is effective in rapidly controlling malaria transmission, hence in reducing the local burden of malaria morbidity and mortality, provided that most houses and animal shelters (e.g. > 80%) in targeted communities are treated. Indoor residual spraying has been the key vector control intervention in Pakistan during the eradication era. The failure of eradication programme prompted the initiation of a five year national malaria control programme plan in 1975, again using IRS as primary method for vector control in Pakistan. At this stage the Malaria control programme was provincialized and implementation was handed over to the provincial governments. The DOMC assumed the responsibilities of policy, technical advice, evaluation, coordination, training, research, procurement, supply of insecticides, larvicides and equipment to the provinces. From early 1980’s to mid 1990’s only malathion was used for malaria vector control. In 1994, malathion was replaced by deltamethrin (synthetic pyrethroids) and since then this insecticide is being used for indoor residual house spraying in Pakistan. The preliminary selection of the union councils (spraying unit) in the districts for IRS are made by the DOMC in consultation with the provinces and partners. The selection is based on previous year‘s reported incidence: API= 30/1000 and AFI=5/1000 populations. The DOMC with support from the TGF SSF 10 conducts IRS in 15% of the high risk populations of 38 high risk districts. The APIs reported from all UCs is arranged in the
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descending order and the top 15% of the population are selected as the target population for IRS. Two cycles of spraying are conducted: pre monsoon (April May) and post monsoon (August September). The insecticide used is Deltamethrin (WP 5%) but will vary among the provinces. A squad of 7 persons are recruited on daily wages (1 supervisor, 1 diluter and 5 spray men) to spray an average 30 40 household per person per day.
Balochistan : The activities under vector control strategy for the GF supported districts (17) are done by the respective PRs and by the MCP in the remaining districts in Balochistan.
Usually two IRS cycles are carried out per year using the following insecticides:.
Deltamethrin Wetable Powder (WP)5%
Deltamethrin Liquid (UL) packing 1littre/Bottle 1 .5 EC
Emergency Spraying is done according to the need. Equipment and transport maintenance facilities are available within the program. Central and district (majority) malaria stores are functional but need to be upgraded into proper ware houses. The planning and site selection for the IRS is done by the district Malaria Superintendent under the respective DHO.
FATA and KPK : The FATA lVM Program uses WHOPES approved insecticides and spray pumps. The MCP purchases alpha cypermathrin and permethrin. IRS spray is done only once i.e in post monsoon period when malaria transmission is at peak. The high risk union councils (communities) are identified by the agency malaria supervisor based on case load or his experience. A total of 15 20% areas are marked as outbreak prone areas. The spraying is done regularly by spray men who are trained by the district malaria supervisor. There is no supervision of IRS activity because of technical and financial constraints.
FATA : The IVM both at directorate and agency level have adequate storage capacity. There is sufficient logistical support for IRS but availability of funds for POL is problematic. The personal protective equipment is available and used. The GF districts have adequate storage space however the FATA Directorate rent their warehouses. KPK and Punjab : The MCP both at provincial and district level have inadequate storage capacity. There is sufficient logistical support for IRS but availability of funds for POL is problematic. There is no personal protective equipment at provincial or district level. Annual trends in coverage with IRS: The MCP does not document the coverage of IRS spraying campaigns. The data of IRS coverage in GF district is less than a year and has yet to achieve substantial coverage.
Punjab: The Provincial Malaria Control Program uses WHOPES approved insecticides and spray pumps. The MCP purchases deltamethrin (WP 5%) IRS spray is done twice i.e. pre monsoon period and post monsoon period. The high risk union councils (communities) are identified by district malaria supervisor based on case load i.e. confirmed vivax cases of 5 or more/or 2 cases of confirmed falciparum or more. Geographical Reconnaisance (GR) is conducted prior to IRS campaign. Spraying is conducted around confirmed cases by sanitary person due to human resource shortage.
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Table 32: IRS Coverage Criteria, Punjab
S.No Population Houses Coverage
1 2000 100% houses
2 2000 3000 75 % houses
3 3000 4000 50% houses
4 4000 6000 25% houses
5 Greater than 6000 10% houses
.
Table 33: Year wise consolidated spray reports (2001-2013) Punjab
Year Name of Population Number of Consumption Insecticide covered rooms sprayed of insecticide (Kg)
2001 Deltamethrin 5% 350430 175230 5841 w.p
2002 ------do------195297 109452 3723.5 ----
2003 ------do------242850 121440 4048 ----
2004 ------do------151850 86214 3033.5 ----
2005 ------do------316620 180735 6154 ----
2006 ------do------110571 61522 2112.5 ----
2007 ------do------119807 66790 2323.5 ----
2008 ------do------171639 91697 3240.5 ----
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2009 ------do------278962 177656 4050 ----
2010 ------do------137756 55000 1925 ----
2011 ------do------No spray Operation was conducted due to Dengue epidemic in ---- province.
2012 ------do------295801 rooms were planned to be sprayed with 10075 Kg of ---- Deltamethrin but spray operation could not be conducted as per order of Provincial DHS CDC due to expectation of Dengue Outbreak.
2013 ------do------942345 376842 13188 ----
In 2013, 13188 kg of IRS is consumed and 376842 houses are sprayed. There was no supervision of IRS activity because of technical and financial constraints
Sindh : IRS is conducted in two transmission seasons: 1 st low peak transmission season between March and April and 2 nd high peak transmission season between August and November. The IRS activities depended heavily on the budget. The IRS plans (number of talukas planned for IRS, number of union councils, number of localities, number of houses, population of district, total number of rooms planned, insecticide required) are developed at the district level and sent to the DOMC Sindh, which finalises the plan depending on availability of the budget. The team of IRS consists of 5 members. Four spray men and 1 person for mixing the insecticide. The team is supervised by malaria supervisor. The five team members are hired on a temporary basis by DHO. The compensation for five temporary members is currently 300/ day. One squad (five team members) sprays120 rooms per day. 1 spray men sprays 8 10 pumps. 1 pump sprays 3 4 rooms.
Table 34: IRS data
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IRS Data five years Year Rooms Sprayed Houses covered 2008 - 09 799965 319986 2009 - 10 909720 291410 2010 - 11 2256493 708567 2011 - 12 3461097 1082969
Long lasting Insecticidal Nets : Since 2001, the NMCP has promoted the distribution of ITNs to selected areas in the malaria at risk region. The target population were pregnant mothers and children under five years. The DoMC recommends the purchase of rectangular white or green colored LLINs (PermaNet) approved by WHOPES. Since pursuing WHO recommendations for universal coverage with LLINs, the DOMC in 2007 embarked on universal coverage. During TGF 7 a total of 1 million LLINs were received and distributed in 19 districts. Under SSF Round 10 another 2.0 Million LLINs were procured and 1.7 Million were distributed in 38 high risk districts, Only 78,000 LLINs were procured from PSDP through PC I (2008 12).
Storage: DOMC procures only small quantities of insecticide and does not require much storage space. Nonetheless, a permanent store which meets storage standards and safety procedures is essential. Currently adhoc storage arrangements are made. The insecticides procured for 38 TGF Round 10 supported districts are delivered to the Sub recipients who are responsible for storing them in their respective districts. An Inspection committee has been constituted by the PSM unit among the DOMC and PMU staff members, which inspects the stock at the central level to verify it is according to specifications and meets storage standards. Procurement of pharmaceutical and health items is carried out biannually and rented transport is used for transfer of stocks from port of entry to the SRs district stores.
LLINs
Distribution method: The LLINs procured for 38 TGF Round 10 supported districts are delivered to the Sub recipients who are responsible for their storage in their respective districts. An inspection committee has been constituted by the PSM unit among the DOMC and PMU staff members which inspects the stock at the central level to verify it is according to specifications along with other aspects of storage.
Balochistan : The LLINs (WHOPES) are distributed in the high risk districts according to the policy guidelines developed by DoMC and GF PRs. The distribution mechanism in the GF supported districts (17 districts) is developed and implemented by the respective PR.
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Sindh: LLINs are procured through funds provided under PC 1 according WHO specifications. However due to inadequate funds available only one thousand LLINs are provided to each district for distribution in the community. The population of each district varies from one to two million. Districts develop distribution plans of LLINs according to local needs keeping in mind needs of pregnant ladies and children in the country .
Table 35: Global Fund Supported Districts in Sindh Details of LLINs Distribution
S.No District Total Target Achievement till Balance June – 13
1 Khairpur 140,182 93,554 46,628
2 Dadu 146,813 38,022 108,791
3 Tharparkar 76,649 55,971 20,678
4 Tando Allahyar 49,658 34,270 15,388
5 Mirpur Khas 76,287 40,730 35,557
Total 489,589 262,547 227,042
KPK : Since 2007 KP has targeted children less than five years old and pregnant women for LLIN distribution. The LLINs guidelines focus on universal coverage for the entire population at risk of malaria in areas not covered by IRS. However due to limited funding the Malaria Control Program in unable to achieve the target. The Global Fund working in selected union councils of high endemic districts following LLIN distribution guidelines. The MCP recommends the purchase of only LLINs that are approved by WHOPES. The MCP does not follow the LLIN distribution strategy nor does it have data related to LLIN coverage.
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Punjab : LLINs intervention is not a major feature in Punjab because of low endemicity. LLIN donated by UNICEF and WHO were distributed during the flood season. The Program does not have a policy to purchase or distribute LLINs.
Larval source management
The strategy for implementing larval control in Pakistan is as follows: 1) In areas where breeding sites are identified as relatively few, accessible and manageable, the community based health workers (such as CDCS, LHW) will encourage volunteer participation of the communities in source reduction. 2) The application of chemical larvicides is restricted to selected urban localities, on the basis of MCP guidelines. However in rural communities with few breeding sites (man-made, such as those used for burrow-pits to make mud-walls), limited chemical larviciding may be considered on the advice of local malaria control officials where appropriate. .
KPK: Larviciding and fog fumigation are conducted using granules but without a proper mechanism.
Punjab: Larviciding and fog fumigation are conducted. Temephos 1% granules or temephos 50% emulsified concentrate or fenthion 2% granules are purchased and used for larviciding. The concentration used is 1 2 gm/meter square depending on water quantity in indoor and outdoor settings.
Table 36: Dose of Temphos for Larviciding
S.No Indoor Quantity of Temphose
1 Less than or equals 25 Liters 2.5 mg
2 50 Liters 5 mg
3 100 Liters 10 mg
In outdoor setting, geographical reconnaissance of breeding site is done first. The distance of breeding site is measured by foot. Twenty steps are considered as 10 meter and single step as 10/20. If the distance is 200 steps then it is calculated as 100 meter distance. Temephos 50% EC is used for big breeding places like hotels swimming pools etc. The granules are thrown at 1.5 meter distance away around the circle. The dose of the larvicide depends on depth of breeding site.
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Table 37: Dosage of Larviciding for Outdoor areas.
S.No Depth of breeding Site Dosage
1 15cm (6 inch) Single dose = 0.55 gm
2 25 cm Two doses = 1.1 gm
3 Greater than 25 cm Three doses= 1.65 gm
Fogging: is conducted using 5% deltamethrin emulsion concentrate. With 10 litre of diesel, 33 ml or 66 ml of active ingredient is mixed which is enough for 1 hectare area.
Sindh : Larvicidal activities are conducted by DOMC at district level but coverage is limited.
Malaria vector control research: Research related to the coverage of LLIN distribution and IRS operations have been carried out in the 2013 Malaria Indicator Survey in collaboration with Pakistan Medical Research Council. The survey results are being analyzed and will be available by January 2014. A study on insecticide susceptibility has been conducted in Punjab in 2012. The results of the study form important evidence base for strategic planning of vector control in southern Punjab .
4.3.8 SWOT Analysis Strengths Weakness • Some targeted provinces have reported high LLIN • Lack of focus towards universal coverage at union level (>80%) GF coverage in all targeted districts with LLIN or IRS • LLIN distribution guidelines with an accountable voucher system – GF supported • Universal coverage of LLINs is not met at the union council and • Adopting supplementary mode of LLIN household level distribution i.e. routine immunization campaigns for registration • “Wear and tear” of recently distributed LLINs • High risk areas and peak transmission seasons are covered by IRS (100%) in some union councils • Inadequate training of follow up support and supervision of district • Functioning vector Control program in some staff in IRS and LLIN in districts provincial and district levels outside Global Fund • Entomologist and Insect collector posted at some • IRS and LLIN guideline not available 128
provincial and district at provincial and district level and in local languages and is complicated for • Recent insecticide susceptibility survey has been field use. conducted by HAS yet to be shared with the programme • entomologists not stationed in all provinces and districts • Developed IRS, LLINs strategies. • Lack of adequate and appropriate • Guidelines for awareness on use of LLINs at equipment, supplies, inappropriate community level, control of vectors of public use, maintenance and storage of health importance after monsoon rains and available ones. prevention of CCHF but limited circulation • No updated vector maps with • Established basic IRS and LLIN database information on vector type, • History of malaria operational research, which distribution, breeding , resting and documents the change in vector composition in biting and insecticide resistance different ecological surroundings, entomology and • Lack of sufficient resources susceptibility survey (2009). (entomology lab and insectaries) and • Dengue strategy and guideline strategy has been skills (by newly recruited and existing developed at the federal level but not circulated staff) to conduct routine • Insecticides resistance management strategy final entomological monitoring on key draft entomological indicators at established sentinel sites • Evidence based need assessment and M&E tools developed at the federal level but not circulated to • No collaboration with provincial the provinces universities for vector surveillance and research • Vector control working group established (2009/10) • No development and implementation of insecticide resistance management strategy at the provincial level • Larviciding applications is not done consistently throughout the transmission season ( i.e. fenitrothion effective for only 1 3 weeks and reapplication is needed), dosages, quantities may not be applied according to breeding sites • Entomology staff are diverted to tackle Dengue • Federal database needs to incorporate the coverage of the LLINs and IRS • No IVM strategy addressing all vector
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borne diseases in a holistic approach • Insufficient capacity to routinely analyse and interpret entomology related data to give strategic direction to the Programme (Federal and provincial) • Larviciding considered only option for LSM
Opportunities Threats
• Health Service Academy are currently conducting a • Insecticide resistance selection comprehensive insecticide susceptibility survey pressure from unregulated public health and agricultural pesticides • The experienced entomology staff from the malaria eradication era should be consulted in identifying • Non immune IDPs/migrant workers the way forward for malaria elimination in selected • Climate change –floods provinces i.e. LSM • Competing priorities between dengue • Strengthen intersectoral collaborations through and malaria vector control working group
• Build on existing capacities for vector control (e.g. Dengue) • Separate budget for vector control activities in PC – 1
4.3.9 Successes, best practices and facilitating factors There is a LLIN distribution strategy with an accountable voucher system (among Global Fund (GF) supported districts), which utilizes a continuous distribution channel i.e. routine immunization campaigns for registration and collection from Basic Health Units. There is a functioning vector control program in some provinces and districts with few trained and experienced staff; this includes an entomologist and insect collector. Pakistan has a long history of malaria operational research, which documents the change in vector composition in different ecological surroundings, vector sampling surveys, entomology and susceptibility surveys. A recent insecticide susceptibility survey has been conducted by Health Service Academy and data analysis is currently on going. The programme has established a technical vector control working group in 2009.
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4.3.10 Issues and challenges
• Insecticide resistance has been reported in Pakistan since 1980s to organochlorine and organophosphate used in past Indoor Residual Spraying (IRS) campaigns.
• No systematic approach towards LLIN replacement has been initiated.
• Universal coverage for IRS and LLINs is not being met in all the targeted districts and union councils and universal equity for LLINs is not being met within all targeted households.
• There has been observed instances of “wear and tear” of recently distributed LLINs.
• The timing of IRS campaigns does not always coincide prior to the rainy season and peak transmission period (on religious grounds) in all the targeted union councils/localities.
• Some provincial programmes conduct larviciding which is not done consistently throughout the transmission season and dosages and quantities may not be applied appropriately according to the type of breeding sites.
• Vector control strategies (malaria, dengue, LLIN distribution), guidelines (IRS, community mobilisation for LLINs, Crimean Congo Haemorrhagic Fever) , training manuals (IRS, LLINs) have been developed by the federal programme but with restricted circulation to the provincial programmes, while vector control guidelines (2007) are utilised in some provincial programmes but this needs updating.
• Furthermore, IRS guidelines are not widely available at provincial and district level nor in local languages making it difficult for field use.
• The Federal programme has established a basic IRS and LLIN database yet lacks tracking of operational coverage of interventions by province and district.
• Evidence based need assessment and M&E tools developed at the federal level have yet to be disseminated to provincial programmes, while a basic monitoring system exists for IRS and larviciding in selective provinces.
• At the provincial level, there is a lack of adequate equipment, supplies, inappropriate use, maintenance and storage of available ones. The provincial programmes are at times incapacitated by poor logistical support which impacts on the quality of service delivery.
• There are no updated vector maps with information on vector species, distribution, breeding sites, resting and biting habits and insecticide susceptibility. This is partly attributed to a lack of adequate resources (entomology lab and insectaries) and skills (by newly recruited and existing staff) to conduct routine monitoring on key entomological indicators at established sentinel sites.
• The programme has yet to develop an integrated vector management strategy, which addresses the increasing demands of dengue and irrational use of public health pesticides.
• There is no collaboration with provincial universities for vector surveillance and research.
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• Aside from Global Fund districts, the MCP has not put in place strategies to distribute LLINs towards universal coverage because of limited funds.
• Limited MCP contribution to IRS in districts that are supported by partner, which threatens IRS sustainability in these districts.
• The MCP does not collect entomology indicators including insecticide resistance.
• The IRS program does not conduct geographical reconnaissance to guide planning quantification and program performance in terms of operational coverage and proportion of population protected.
• There is no full functional collaboration between MCP, Met Office, other relevant line departments of the government, and institutions at the national level.
• Collaboration with IPHQ has just recently initiated which needs technical support, guidance, strengthening and streamlining.
• The deficiency of entomology and vector control professionals is acute and is directly effecting program performance.
• There is no proper waste disposal system for vector control interventions to safeguard the environment.
• Larval source management measures such as larvivorus fish and larval parasites are not in practice in Balochistan and should be introduced.
• Proper ware houses do not exist for malaria commodities at provincial or district levels, storage spaces are made available on as hoc arrangement.
• No clear guidelines and training manuals for IRS intervention • Lack of supervision of IRS operations compromises IRS quality. • Limited IVM contribution to IRS in agencies that are supported by partners. This threatens IRS sustainability in these agencies. • The IVM program does not conduct geographical reconnaissance to guide planning quantification and calculation of program performance in terms of operational coverage and proportion of population protected. • Shortage of equipment for entomology tests. • Although integrated vector control guidelines are available but no trainings have been conducted on guidelines in Sindh. • Insecticide resistance research studies not conducted. • Entomologists are not posted at all districts of province.
4.3.11 Conclusion and recommendations
• Develop a simple stratification and mapping method using reported incidence, topography and local experts opinion to focus evidence based vector control on high transmission districts and union councils. 132
• LLIN gap analysis towards accelerated coverage of 80% in target high transmission districts through mass campaigns supported by routine continuous distribution mechanisms ( outreach, routine, schools, community, commercial sector, social marketing) for hard to reach areas and three yearly replacement
• Revise the LLIN distribution strategy to ensure there is universal equity at the household level.
• Conduct LLIN hole index proportion study
• Reserve IRS (80%) to target high PF transmission districts to control and eliminate PF
• Reserve IRS to prevent epidemics and eliminate malaria foci in pre elimination phase and prevent re introduction
• LSM to be targeted to support urban malaria control & elimination and can be used in general nuisance mosquito control. LSM to be targeted to eliminate malaria foci in districts for pre elimination and elimination of PF and PV
• Develop an integrated vector management strategy, which addresses insecticide resistance management and identifies innovative approaches for inter sectorial collaboration.
• Establish an integrated vector borne disease control program (Malaria, Dengue, Leishmania) with adequate focus on each disease control and elimination as appropriate.
• Establish vector sentinel surveillance in different eco epidemiological settings with standard guidelines by PMCP in collaboration with HAS and provincial universities and research institutes
• Entomological spot surveillance to be conducted by insect collectors and malaria supervisors supported by districts and provincial entomologists with provincial entomological reference laboratory
• Update vector distribution maps stratified at district level which reflects the seasonal distribution (vivax and falciparum) as well as vector binomics and susceptibility status of the predominant malaria vectors.
• Revive the vector control technical committee with updated TOR
• Update and simplify the national vector control guidelines and supporting training materials
4.4 Malaria diagnosis and case management
4.4.1 Introduction Access to diagnostic testing and treatment should be seen not only as a component of malaria control but as a fundamental right of all populations at risk. According to WHO, early diagnosis and treatment of malaria reduces disease and prevents deaths. It also contributes to reducing malaria
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transmission. One of the key strategies of Malaria Control Programme Pakistan is the early diagnosis and prompt treatment of malaria cases.
4.4.2 Policy and guidance
Malaria case management is a thematic area aimed at ensuring those infected with malaria are correctly diagnosed and consequently managed appropriately, using standard and effective medications. The current policy of the Directorate of Malaria Control for the management of malaria cases is to provide parasitological confirmation of all suspected cases before the administration of anti malarial drugs, except in children under 5 years with suspected uncomplicated malaria in areas where diagnostic services are not available. The programme has developed national guidelines on case management and malaria microscopy. There is a long history of development of national case management guidelines in Pakistan. Prior to 2001, the majority of malaria cases were presumptively treated based on clinical symptoms due to lack of availability of diagnostic facilities at the PHC level (though malaria microscopy was available but at limited health facilities). The practice of clinical diagnosis of malaria patients is still being administered across the country. In 1978 the malaria case management service delivery was integrated with overall health care delivery system. Chloroquine and primaquine remained on the essential drug list and all forms of CQ (tablets, syrup and injectable) had been procured and distributed to all health facilities in the province. Until 1999 MCP in the provinces and at the national level advocated for using treatment guidelines of eradication era mainly dependent on chloroquine and primaquine for treatment of both falciparum and vivax malaria. The main difference in the treatment regimen between the 2 species was for falciparum confirmed cases in addition to chloroquine, primaquine was recommended for 3 day as anti gametocidal drug where as in vivax confirmed cases primaquine was recommended for 5 days as a anti relapse drug. Presumptive therapy with single dose of chloroquine in suspected cases was also part of guideline at all level of health facilities. Quinine in diluted form was used to treat severe and complicated falciparum malaria cases. With the implementation of national strategic plan for Roll back malaria in 2001 and the subsequent strategic plans (2005 10, 2011 15) number of national guidelines on case management (both uncomplicated and complicated malaria) were developed in alignment to the WHO guidelines. In 2001 the first country level consultation was held and the “First Treatment Protocol for malaria case management was developed “replacing the presumptive treatment option with the full course of Chloroquine in all malaria suspects, omitting active case detection for treatment of malaria patients in the community. In 2003 the guidelines and policy were reviewed and changes in treatment option for confirmed falciparum and anti relapse therapy were introduced. Based on the falciparum resistance to CQ, Sulfadoxine pyrimethamin was recommended as the first line treatment for confirmed falciparum cases. The treatment duration of primaquine as anti relapse therapy was extended to 14 days compared to previous 5 days treatment. In 2004, Pakistan received GF for the implementation of malaria control intervention in 33 highly endemic districts. One of the major interventions was strengthening early diagnosis and effective treatment. Linked to this grant proposal was a planned output to review and revise the available case management protocol and training manuals of malaria microscopy and case management training manuals.
In 2006 confirmatory tests for suspected malaria became mandatory excluding children under 5 with suspected uncomplicated malaria and in areas where malaria diagnostic facilities are not available. Additionally malaria patients of any age with presentation of severe and complicated were also exempted from confirmation on microscopy in areas where facility was not available. For the first
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time antigen detected tests based on the detection of HRP2 proteins specific for falciparum were introduced in GF target districts. Major policy shift in treatment of uncomplicated falciparum malaria as ACT (artesunate+ SP) was introduced as first line treatment. In line with the recommendation of WHO, the ban on production and use of Artemisinin monotherapies was imposed by the MOH across the country which can be considered as a landmark decision.
In 2008, the new treatment protocol were developed through a consultative process including provinces and national experts but it deviated from the national case management policy. Large number of these protocols were printed without a national consensus which resulted in some critical mistakes being overlooked in the document. During the same period in 2008 when the GF7 project was incepted in 19 high risk districts, the case management guideline and training manuals were updated. In the same year while ,these guidelines were finalized an addition was made for the pre referral cases due to severe malaria diagnosed or suspected at FLCFs, the injectable Artemether was recommended in place of i/m Quinine injection. This change was made to avoid the side effects of Quinine while the patients are referred to higher centres. These guidelines were used during the training session for the healthcare providers in malaria case management in GF districts.
In 2009, the GF Round 10 proposal was developed for single stream funding with round 7 in 38 high risk districts of Pakistan to strengthen diagnostic and treatment services under the approach of universal coverage. WHO recommended a major policy shift in the coverage of case management services and in the available option of 1 st , 2 nd and 3 rd line drugs and was made part of the proposal. This resulted in a major policy shift of selecting the Aretemisinin Lumafantrine as second line drug for failure cases and first line drug for mixed infections. Injection Artesunate (I/M) instead of Artemether (I/M) was recommended as pre referral treatment in severe and complicated malaria at referral enters and Artesunate I/V as the treatment of choice in the treatment of severe and complicated malaria except during first trimester of pregnancy where quinine remained the drug of choice.
During the course of R 10, SCI as a Co PR given the responsibility to review and develop all the technical guidelines for the program including the national treatment protocol and case management training manuals. SCI through technical support of WHO developed the algorithm of malaria treatment at public health facilities incorporating the new policy shifts. WHO released the first edition of training manuals which were completely adopted in country training programs with the 1 st batch of the master trainers being trained by WHO experts using these manuals. In the current treatment guidelines it has been agreed that 1 single dose of primaquine (45 mg) will also be given to confirmed cases due to falciparum malaria. In 2013 guidelines on case management of complicated malaria were also d eveloped. All guidelines developed in 2013 have been implemented in 38 TGF supported districts only. The remaining districts in Pakistan are following the 2007 guidelines.
Approximately 70 80% cases in Pakistan are due to vivax malaria, despite this home management of malaria is not the national policy and is not administered. IPTT during pregnancy is also not the national policy as reliable data prevalence of malaria in pregnancy is not available. Guidelines on Quality Assurance of malaria Microscopy was developed by the programme in 2010 11. However, how far these guidelines have been implemented remains to be assessed.
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Table 38: Pakistan Current Treatment Guidelines
Classification of Malaria Treatment Regimen
Uncomplicated Falciparum Malaria (first -line) Artisunate (100 (adults) or 50mg (6 -14 years)
mg)+Sulphadoxine -pyrimethamine (500/25
mg) for 3 days + Single dose of primaquine
(0.75 mg)/Kg body weight
Note: Dose by age is given in the guidelines
Uncomplicated falciparum Malaria (Second line) Oral artemether -Lumifantrine (ALu) for 3
days.
First dose of 20mg/Kg body weight followed
by 10 mg/Kg body weight 8 hourly (dose by
age is given in the guidelines)
Uncomplicated vivax Malaria (First line) Chloroquine (150 mg base) tablets for 3 days
+ Primaquine 15mg tablets (0.25/Kg Body
weight) for 14 days
Primaquine should not be administered to
pregnant women, children> 5 years and
known G6PD deficiency
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Uncomplicated vivax Malaria (Second line) Oral quinine 20mg/Kg Body weight.
First dose of 20mg/Kg body weight followed
by 10 mg/Kg body weight 8 hourly
Severe Malaria (children and adults) at the If signs of severe malaria are observed, give primary care level health facilities pre -referral treatment with IV/IM or
suppository of Artisunate and refer to
secondary care hospital.
Give I/M Quinine in pregnancy
Sever e Malaria (Children and adults) at Artesunate 2.4 mg/kg bw IV or IM given on secondary and tertiary level. admission (time = 0), then at 12 h and 24 h,
then once a day is the recommended
treatment.
Artemether, or quinine , is an acceptable
alternative if parenteral artesunate is not
available:
Artemether 3.2 mg/kg bw IM given on
admission then 1.6 mg/kg bw per day;
or Quinine 20 mg salt/kg bw on admission
(IV infusion or divided IM injection), then 10
mg/kg bw every 8 hours; infusion rate should
45
137
Classification of Malaria Treatment Regimen
not exceed 5 mg salt/kg bw per h.
Parenteral antimalarials in the treatment of severe malaria should be given for a minimum of 24 hours, once started (irrespective of the patient’s ability to tolerate oral medication earlier). If the patient can swallow, thereafter, the treatment should be completed by giving a complete course of one of the follo wing: 1. full course of the recommended first -line ACT; 2. artesunate (2 mg/kg once daily) plus either clindamycin (10 mg/kg twice a day) or doxycycline (3.5 mg/kg once a day) or tetracycline (4 mg/kg four times daily) to complete a 7 -day cou rse of treatment; 3. quinine (10 mg salt/kg, 8 -hourly) plus either clindamycin (10 mg/kg twice a day), or doxycycline (3.5 mg/kg once a day) or tetracycline (4 mg/kg four times daily) to complete a 7 -day course of treatment.
Note: In patients requiring more than 48 hours of quinine parenteral therapy, the maintenance Dose should be reduced by one-third to one -half (i.e. 5 –7 mg salt/kg bw every 8 hours).
Doxycycline and tetracycline should not be used in children under 8 years of age and Pregnant women .
Malaria in Pregnancy (uncomplicated) Detailed national Guidelines not available
Malaria in Pregnancy (complicated) Detailed national Guidelines not available
Malaria in Children Detailed National Guidelines not available 138
According to malariometeric survey conducted in19 Global fund districts during 2009, only 41.5% facilities had standardized malaria case management guidelines which were about four out of every ten facilities. Almost the same proportion of PHC facilities had staff trained (42.1%) in the use of these management guidelines. Facilities from FATA had no malaria case management guidelines and only one facility had staff trained in the use of guidelines. In KPK three facilities had both trained staff and the guidelines. A little more than half of the facilities in the province of Sindh (55%) and Balochistan (50.6%) had malaria case management guidelines along with trained staff. Summary information is displayed in below:
Table 39: Health facilities having Standard Malaria case Management Guidelines and Staff trained in use of Guidelines Guidelines
Guidelines but no Total Health Province/Region Guidelines Trained staff and trained trained staff
facilities
staff Total He alth
Facilities.
% No % No % No % No
Sindh 55.0 22 57.5 23 55.0 22 42.5 17 40
Baluchistan 56.8 46 55.6 45 50.6 41 39.5 32 81
KPK 10.0 3 10.0 3 10.0 3 90.0 27 30
FATA 0.0 0 5.0 1 0.0 0 95.0 19 20
Total 41.5 71 42.1 72 38.6 66 55.6 95 171
Source: Malariometric Survey in Target Districts-2009
Until 2005 WHO Bench Aids on Malaria microscopy was used to train the malaria microscopists and laboratory technicians. In 2007 new guidelines were developed and aligned with the malaria microscopy guidelines of the WHO. In the same year guidelines on external quality assurance of malaria microscopy were also developed. These microscopy and quality assurance guidelines were again updated in 2010 with no major difference. In 2010 the first ever guidelines on RDTs were also developed for Pakistan.
The diagnosis and treatment guidelines stipulates that all malaria cases require confirmed diagnosis through a parasitological test (RDT or microscopy) before treatment is given and both are provided free in the public sector. The malariometeric survey (2008) indicated 20.5% of clinics surveyed had malaria microscopy (which varied by province) and only 8.2% had an RDT available. Because of the lack of diagnostic services in many areas, presumptive treatment of fever which presents with malaria like symptoms is given routinely. Strict monitoring of malaria diagnosis and treatment practices at the PHC level by the National and Provincial Malaria Control Programmes could lead to better understanding of malaria best possible ways of managing the disease at health facility level. The effects of malaria in young children (<5 years of age) and in 139
pregnancy are not well understood in Pakistan. There are no exclusive guidelines for the management of malaria in pregnancy, but the protocols are described in the national case management guidelines. There is training manual for microscopy and case management guidelines.
KPK: There are training manuals for microscopy and case management guidelines. There is a need to update the IMNCI guidelines and also include guidelines for complicated malaria and mixed infections in children. There are two types of guidelines available for treatment of pregnant ladies: national guidelines for treatment of all type of malaria in pregnancies and Malaria Treatment according to Pregnancy Childbirth Post Partum New Born Care (PCPNC) guidelines which is based on national guidelines. Quinine is the only anti malarial drug that is recommended in pregnancy. WHO in collaboration with other UN Agencies (UNICEF and UNFPA) has developed generic guidelines for Pregnancy, Child birth, Post Partum and New born Child (PCPNC). It has been locally adopted and master trainers are prepared however the malaria treatment portion is still yet to be developed.
FATA, KPK, Punjab : The National Summary Treatment Protocol for Case Management of Malaria documents the clinical malaria, uncomplicated vivax malaria, uncomplicated and complicated falciparum malaria and mixed infections.
Punjab: The IMNCI guidelines also mention the treatment of malaria on national guidelines which need to be updated.
Sindh: Case management guidelines are available and staff have been trained according to these guidelines. However adherence to case management guidelines is an issue particularly in private sector (except in six GFATM supported districts).
4.4.3 Organization of case management services
The DOMC does not have full time technical staff responsible for developing/updating guidelines on diagnosis and treatment. The development of guidelines on case management are generally sourced out and then presented to the technical advisory committee for review compared to the national policy and for endorsement. Once the guidelines are endorsed provincial level trainings are conducted, but there is no follow up mechanism to monitor the implementation of these guidelines at the tertiary, secondary and primary level health facilities except in 38 Global Fund supported Districts through recently developed and implemented surveillance tools (FM1 4). These tools collect information from the BHUs, RHCs and DHQs. Unfortunately there is no system in place for the surveillance of either severe or complicated malaria cases or mortality due to malaria although national guidelines on complicated malaria have recently been developed with support from TGF 10. At present none of the tertiary and district hospital report any data to the DoMC or the provinces, although patients with severe malaria are admitted and managed at this level.
FATA: Physicians, Medical Officers, Technicians, Pharmacists, nurses/lady health visitors work at different level of health care facility. At the community level, CHW known as (Lady Health Worker) handle mainly health education but are also provided with a medicinal kits and are responsible for the diagnosis and management of uncomplicated malaria cases in the communities and referral of those with signs of severity. The cases of severe malaria in 140
FATA cannot be treated even at DHQ level because of non functional ICU or blood transfusion services. Usually all the severe cases are referred to the nearest district of the settled area of Khyber Pakhthunkhwa.
Table 40: Case Management Facilities and Functions at Different Level
Health Human Lab Facilities Medicines Facility Resource DHQ/THQ Specialized Admission For Vivax Physicians 24 hours a Tab chloroquine (phosphate day. or sulfate) 150 mg Medical RDT’s, For Falciparum officers Microsco No Tablets Primaquine py done functional (diphosphate) 15 MG Technicians ICU To be used in combination (coblister) Nurses etc Blood Tab Sulfadoxine + transfusion Pyrimethamine services Tab Artesunate 50 mg available but Management of severe not a routine malaria procedure Artemether Ampule 80mg/ml in 1-ml Artemether + Lumefantrine Tablets 20 mg + 120 mg RHC Medical RDT’s, No For Vivax Officer Microsco admission Tab chloroquine (phosphate (Doctor) py done or sulfate) 150 mg No ICU or For Falciparum blood Tablets Primaquine transfusion (diphosphate) 15 MG services To be used in combination available (coblister) Tab Sulfadoxine + Pyrimethamine Tab Artesunate 50 mg Management of severe malaria Artemether Injection 40mg/ml
BHU Medical RDT’s, No For Vivax Officer Microsco admission Tab chloroquine (phosphate (Doctor) py done service or sulfate) 150 mg For Falciparum Tablets Primaquine (diphosphate) 15 MG To be used in combination 141
(coblister) Tab Sulfadoxine + Pyrimethamine Tab Artesunate 50 mg
CD Dispenser/ NO RDT No Not Available Technician and admission Microsco service py Drug Non NO RDT No All type of medicines Stores/ technical and admission available Pharmacies persons Microsco service py Community LHW NO RDT No Tablet, 150 mg (as phosphate and admission or sulfate) Strip/blister Microsco service 100 tablets/ per LHW/per py month
Syrup, 50 mg/5ml (as phosphate or sulphate) 5 bottles/per LHW / per month Clinic MBBS Treatmen No Not available General t on admission Physicians clinical service diagnosis NO RDT and Microsco py Clinic Treatmen No Not available Specialists t on admission clinical service diagnosis NO RDT and Microsco py
KPK : Physicians, Medical Officers, Technicians, Pharmacists, nurses/lady health visitors work at different level of health care facility. At the community level, CHW known as (Lady Health Worker) handle mainly health education but are also provided with a medicinal kits and are responsible for the diagnosis and management of uncomplicated malaria cases in the communities and referral of those with signs of severity. The tertiary or teaching hospitals have well equipped laboratory where complete parasitology is done. The physicians are highly qualified. The cases of severe malaria in tertiary hospital can be treated 24 hours a day where blood transfusion services as well as intensive care unit available. 142
Table 41: Case Management Facilities and Functions at Different Level
Health Human Lab Facilities Medicines Facility Resource
Tertiary Specialized Modern Admission All type of drugs is available. /Teaching Physicians well 24 hours a Hospitals equipped. day.
Medical officers Intensive care unit RDT’s, (ICU) and Microsco Technicians blood py done. transfusion services available Nurses etc
DHQ/THQ Specialized Admission For Vivax Physicians 24 hours a Well day. Tab chloroquine (phosphate Equipped or sulfate) 150 mg
Medical For Falciparum officers ICU and Blood Tablets Primaquine (diphosphate) 15 MG RDT’s, transfusion Technicians Microsco services To be used in combination py done available (coblister)
Nurses etc Tab Sulfadoxine + Pyrimethamine
Tab Artesunate 50 mg
Management of severe malaria
Artemether Ampule 80mg/ml in 1-ml
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Artemether + Lumefantrine Tablets 20 mg + 120 mg
RHC Medical RDT’s, Limited For Vivax Officer Microsco admission (Doctor) py done Tab chloroquine (phosphate No ICU or or sulfate) 150 mg blood transfusion For Falciparum services Tablets Primaquine available (diphosphate) 15 MG
To be used in combination
(coblister)
Tab Sulfadoxine + Pyrimethamine
Tab Artesunate 50 mg
Management of severe malaria
Artemether Injection 40mg/ml
BHU Medical RDT’s, No For Vivax Officer Microsco admission (Doctor) py done service Tab chloroquine (phosphate in GF or sulfate) 150 mg districts For Falciparum and not in non GF Tablets Primaquine districts (diphosphate) 15 MG
To be used in combination
(coblister)
Tab Sulfadoxine + Pyrimethamine
Tab Artesunate 50 mg
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CD Dispenser/ NO RDT No Not Available Technician and admission Microsco service py
Drug Non NO RDT No All type of medicines Stores/ technical and admission available persons Microsco service Pharmacies py
Community LHW NO RDT No Tablet, 150 mg (as phosphate and admission Microsco service or sulfate) Strip/blister py 100 tablets/ per LHW/per month
Syrup, 50 mg/5ml (as
phosphate or sulphate)
5 bottles/per LHW / per month
Clinic MBBS Treatmen No Not available t on admission General clinical service Physicians diagnosis
NO RDT and Microsco py
Clinic Treatmen No Not available Specialists t on admission clinical service diagnosis
NO RDT and Microsco py
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Specialised Specialized Modern Admission All type of drugs is available. Private Physicians well 24 hours a Hospitals equipped. day.
Medical officers RDT’s, Intensive Microsco care unit py done. (ICU) and Technicians blood transfusion services available Nurses etc
Punjab: There are 385 public microscopic centers and 2650 RDT centers. Large numbers of posts are vacant. There is no focal person for case management at provincial or district level. No technical committee exists which guides the program on case management. Physicians, Medical Officers, Technicians, Pharmacists, nurses/lady health visitors work at different level of health care facility. At the community level, CHW known as (Lady Health Worker) handle mainly health education but are also provided with a medicinal kits and are responsible for the diagnosis and management of uncomplicated malaria cases in the communities and referral of those with signs of severity. The tertiary or teaching hospitals have well equipped laboratory where complete parasitology is done. The physicians are also highly qualified. The cases of severe malaria in tertiary hospital can be treated 24 hours a day where blood transfusion services as well as intensive care unit is available.
Table 42 Case Management Facilities and Functions at Different Level Health Human Lab Facilities Medicines Facility Resource
Tertiary Specialized Modern Admission 24 All type of drugs is available. /Teaching Physicians well hours a day. Hospitals equipped.
Medical Intensive care officers unit (ICU) and blood RDT’s, transfusion Microscop services Technicians y done.
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available
Nurses etc
DHQ/THQ Specialized Admission 24 For Vivax Physicians hours a day. Well Tab chloroquine (phosphate or Equipped sulfate) 150 mg
Medical ICU and For Falciparum officers Blood transfusion Tablets Primaquine (diphosphate) 15 MG RDT’s, services available Technicians Microscop To be used in combination y done (coblister)
Nurses etc Tab Sulfadoxine + Pyrimethamine
Tab Artesunate 50 mg
Management of severe malaria
Artemether Ampule 80mg/ml in 1 ml
Artemether + Lumefantrine Tablets 20 mg + 120 mg
RHC Medical RDT’s, Limited For Vivax Officer Microscop admission (Doctor) y done Tab chloroquine (phosphate or No ICU or sulfate) 150 mg blood transfusion For Falciparum services Tablets Primaquine available (diphosphate) 15 MG
To be used in combination
(coblister)
Tab Sulfadoxine + Pyrimethamine
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Tab Artesunate 50 mg
Management of severe malaria
Artemether Injection 40mg/ml
BHU Medical RDT’s, No admission For Vivax Officer Microscop service (Doctor) y done in Tab chloroquine (phosphate or GF sulfate) 150 mg districts For Falciparum and not in non GF Tablets Primaquine districts (diphosphate) 15 MG
To be used in combination
(coblister)
Tab Sulfadoxine + Pyrimethamine
Tab Artesunate 50 mg
CD Dispenser/ NO RDT No admission Not Available Technician and service Microscop y
Drug Stores/ Non technical NO RDT No admission All type of medicines available persons and service Pharmacies Microscop y
Community LHW NO RDT No admission Tablet, 150 mg (as phosphate and service Microscop or sulfate) Strip/blister y 100 tablets/ per LHW/per month
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Syrup, 50 mg/5ml (as
phosphate or sulphate)
5 bottles/per LHW / per month
Clinic MBBS Treatment No admission Not available on clinical service General diagnosis Physicians NO RDT and Microscop y
Clinic Treatment No admission Not available Specialists on clinical service diagnosis
NO RDT and Microscop y
SpecialisedP Specialized Modern Admission 24 All type of drugs is available. rivate Physicians well hours a day. Hospitals equipped.
Medical Intensive care officers RDT’s, unit (ICU) Microscop and blood y done. transfusion Technicians services available
Nurses etc
Sindh: There is a network of 431 microscopy centers of Malaria Control Program spread to 7 teaching hospitals, 18 DHQs, 26 in major other hospitals, 41 in THQ, and 109 in RHC and 205 in BHUs and 27 in MCH centers.
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4.4.4 Human resources, training and capacity development Capacity building is one of the key components of the Directorate of Malaria Control. During last five years following trainings/workshops have been held to train human resource on case management. Training methods include module based training with combination of knowledge and skills. Generally training sessions use interactive approach followed by lectures and presentation using multimedia. The targets achieved by the TGF were achieved, the following table shows the number of trainings conducted by the DOMC in collaboration with TGF support.
Table 43: Capacity building of health care providers 19 districts of TGF Round-7 (DOMC)(Sept 2011-June 2013)
Indicators Targets Results Progress percent age wise Number of health care providers trained on national Case 2550 2356 92% management guidelines in public and private sectors
Table 44: Capacity building of health care providers 19 districts of TGF Round10 (Save the Children International)
Year 1 Year2 Year 1,Year 2
Q1,Q2,Q3,Q4,Q5,
Indicator Q1,Q2,Q3,Q4 Q5,Q6,Q7,Q8 Activity Description Q6,Q7,Q8
Description
Target Progress Target Progress Target Progress
Training Refresher training of private sector. 79 5 41 80 120 85
s Basic malaria microscopy. 65 43 30 64 95 107
Refresher training of public sector. 76 30 0 83 76 113
Public RDTs. 198 156 182 284 380 440
&ManagementCase Private RDTs. 79 16 41 99 120 115
Diagnosis QA in malaria diagnosis. 43 47 0 0 43 47
Training of private care providers on
malaria case management in 79 8 41 105 120 113
selected 6 districts
50
150
Year 1 Year2 Year 1,Year 2
Q1,Q2,Q3,Q4,Q5,
Indicator Q1,Q2,Q3,Q4 Q5,Q6,Q7,Q8
Activity Description Q6,Q7,Q8
Description
Target Progress Target Progress Targ et Progress
Training of public sector health care
providers on uncomplicated malaria 627 50 0 578 627 628
case management at first level
health care facilities.
Incountry training: WHO advanced 24 23 0 0 24 23
course on Malaria Case
Management (1 week)
Training of master trainers on 38 16 0 16 38 32
malaria case management (03 days)
in 38 districts
Training of public sector health care
providers on severe and
complicated malaria case 92 0 75 125 167 125
management at secondary and
tertiary level health care facilities
Total 1400 394 410 1434 1810 1828
FATA: A total of 181 physicians were trained on case management guidelines, 84 microscopists are trained on microscopy and 113 personnels on RDT’s.
KPK : A total of ??? physicians are trained on case management guidelines, ??? microscopists are trained on microscopy and ???on RDT’s.
Punjab: All human resource are reportedly trained.
Sindh: There is no focal point or case management specialist in Malaria Directorate Sindh to provide technical guidance to the health care providers on malaria case management. However directorate has collaborated with Liaqat University of Health Sciences (LUMHS) Hyderabad, where Prof Dr Salma Shaikh (Dean of Pediatric Ward) to provide technical support and guidance in case management trainings of Malaria treatment according to the National Guidelines.
4.4.5 Annual planning The indicators for malaria diagnosis and treatment have been spelled out in the national strategic framework 2011 15 which are as follows:
• % of patients with uncomplicated malaria getting correct treatment at health facility and community levels, according to national guidelines;
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• % of patients with severe/complicated malaria correctly managed at health facility;
• % of public health facilities with adequate antimalarial drugs and diagnostic supplies;
• % of diagnosed P. falciparum cases treated with ACTs;
• % of private sector health care providers involved in malaria case management according to the national treatment guidelines;
• # of sentinel sites reporting on antimalarial drug resistance.
4.4.6 Malaria Diagnosis Malaria diagnosis in Pakistan is based on microscopy (both thick and thin smears) and RDTs. The RDTs currently being used are for diagnosis of both falciparum and vivax malaria. In addition large numbers of cases diagnosed clinically are reported through DHIS.
According to the existing policy FLCFs (BHUs) have been designated as RDT centers, while, Rural Health Centres (RHCs), Tehsil Head Quarter Hospitals (THQs), District Head quarter Hospitals (DHQs) have been designated as the malaria microscopy centres. The District Headquarter Hospitals and tertiary care (Teaching Hospitals) hospitals have well equipped laboratory and advanced case management services with well equipped Intensive Care Units (ICUs), which act as the referral hospitals for severe cases of malaria. Emergency care services are available 24 hours.
However the staff in tertiary care hospitals have not been trained on national guidelines for the management of severe cases. Table 42 below shows strengthened microscopy centers in 19 high risk districts of TGF 7. A total of 708 have been strengthened in both public and private sector (supported mainly by Global Fund). However, strong political commitment from the public sector is required to sustain these diagnostic centers. In addition the public sector PR Save the Children through TGF SSF 10 support 161 microscopy centers, 378 RDT Centres have been established in Public sector health facilities and 8 microscopy and 53 RDT centers have been established in private clinics (Table 43).
Table 45: Detail of Microscopy Centres and RDT Centres in Highly Endemic TGG Supported Districts of Pakistan for PUDR P-7
Microscopy Private
Province Population RDT Centre Total
Centre Practitioners
KPK / FATA 5,184,596 97 126 13 236
Sindh 4,593,585 89 82 20 191
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Balochistan 2,485,243 90 168 23 281
Total 12,263,424 276 376 56 708
Table 46: Detail of Microscopy and RDT Centres in Highly Endemic TGF Supported Districts of Pakistan TGF – 10
Public Centre Private Practitioners
Province Total Microscopy Microscopy
RDT Centre RDT Centres
Centres Centres
KPK / FATA 95 222 0 35 352
Sindh 22 65 2 6 95
Balochistan 44 91 6 12 153
Total 161 378 8 53 600
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Table 47: Achievement in coverage for diagnosis and treatment 19 districts of TGF Round-7 and 19 districts of TGF-Round 10 Progress
Entities Indicators Targets Results percentage
wise
Percentage of confirmed PF cases
treated with ACT as the first line 95% 97% 102%
treatment in 19 target districts
TGF -7 Number of RDTs used at first level care
Facilities (FLCFs) in 19 R -7 target
611,970 77 1,952 126%
districts including private clinics in 04
pilot districts
Cases treated 80% 92% 115%
TGF -10
Number RDTs done 727380 161095 22%
Balochistan : Microscopists and staff (RDT) have undergone training, but the number of diagnostic facilities needs to be improved and refresher training has to be extended to the private sector.
FATA: The microscopy centers are rolled out to primary health level facilities i.e. basic health units or community health centers. There are 108 public microscopic centers and 152 RDT centers in FATA.
KPK: Currently, The GF funded districts have introduced microscopy centers to primary health level facilities i.e. Basic Health Units, CD’s and private centers while the diagnostic centers in non GF districts are limited to rural health centers and the basic health units as diagnostic centers. There are 70 public microscopic centers and 20 RDT centers. There is limited technical staff in rural areas and serious concerns regarding the quality of laboratory. The introduction of RDT in KP placed an additional challenge for the diagnosis of malaria as their guidelines were unclear concerning criteria for their use along with poor quality training and lack of quality control systems. Even with these efforts of improving diagnosis of malaria, the continued treating of fevers as malaria can be attributed to inadequate guidance on what to do with a negative result. But even when this is provided, the performance of these tests greatly depends on the training of the providers and conditions in distributing and storage especially of RDTs.
4.4.7 Malaria Treatment Balochistan : The paramedical level staff and first level health professionals have been trained on the national case management guidelines.
Table 45, shows the data on malaria diagnostic microscopy from 2007 to 2012, collected by the data management cell of MCP including PR sources. The increase in the indicators is possibly due to the improvement of the diagnostic skills, reporting and other resources for microscopy. However, the increase in falciparum needs further investigation. 154
Table 48: Balochistan Malaria Microscopy Data.
Total Total Population P.vivax P.falciparum API F.R SPR Slides Positive 2007 7,844,715 388,115 46,805 28,051 18,754 5.97 40.07 12.06 2008 8,159,523 371,606 43,848 30,020 13,828 5.37 31.54 11.80 2009 8,355,352 395,263 49,778 33,994 15,784 5.96 31.71 12.59 2010 8,555,880 414,707 63,625 36,480 27,145 7.44 42.66 15.34 2011 8,761,221 420,252 57,980 36,146 21,834 6.62 37.66 13.80 2012 8,971,490 421,943 57,111 37,901 19,210 6.37 33.64 13.54
KPK : Clinical Malaria: First line drug is chloroquine oral only without primaquine. During follow up if the response is partial, or the symptoms reappear within 28 days (recrudescence of falciparum case with initial response to CQ but due to resistance to CQ the symptoms reappear) instead of using Artesunate+ SP suggestion have been made for the prescriber to administer Artemether plus lumefantrine for three days. In case of developing more severe symptoms the patient should be referred to secondary care facility after pre referral treatment with IV/ IM or suppository of Artesunate, Artemether IM .
Confirmed uncomplicated falciparum malaria (by RDT or microscopy): Oral Quinine for 7 days should be prescribed to all cases, in case of failure 3 days Artemether plus lumefantrine
Confirmed vivax cases (by RDT or microscopy): Three days treatment with oral Chloroquine plus 14 days Primaquine (daily single dose) 2 nd line treatment in failure cases oral quinine for 7 days should be prescribed to all cases
PF/PV mixed infections: Artemether plus lumefantrine for 3 days should be given with fatty diet (milk, butter etc.) a 14 days Primaquine should also be prescribed as in vivax cases
Severe and complicated falciparum malaria: IV Artesunate where not contraindicated once daily till the patient takes the drug orally or 7 days treatment is completed with this monothrapy. Patient is switched over to oral ACT for 3 days (Artesunate plus SP). In areas where parenteral Artesunate is not available, IV Quinine in diluted form should be dispensed under close
4.4.8 Performance indicators and targets The indicators for malaria diagnosis and treatment have been spelled out in the national strategic framework 2011 15 which are as follows:
• % of patients with uncomplicated malaria getting correct treatment at health facility and community levels, according to national guidelines; • % of patients with severe/complicated malaria correctly managed at health facility; • % of public health facilities with adequate antimalarial drugs and diagnostic supplies; • % of diagnosed P. falciparum cases treated with ACTs; • % of private sector health care providers involved in malaria case management according to the national treatment guidelines; • # of sentinel sites reporting on antimalarial drug resistance. 155
4.4.9 Service Delivery outputs and outcomes Currently National Malaria Control Programme receives malaria data by vertical Malaria Information system on a monthly basis from all the districts. Two different types of reporting tools are used. The newly developed surveillance tools by the GF (FM1 FM4) are being used for reporting from 38 Round 10 supported districts, whereas in non Global fund supported districts data is being collected using the older version developed during eradication era. . The new forms are more comprehensive and capture age, sex, pregnancy status and stock out for antimalarials, LLINs, Insecticides, Lab supplies apart from information on diagnoses, treatment (both uncomplicated and severe malaria), OPD admissions and deaths.
Clinical diagnosis currently is reported through DHIS which does not routinely share its data with the Programme nor is it analyzed for any planning or M& E activities. Confirmed cases are also collected by DHIS yet figures may not be the same as those from MIS. No data on severe cases or mortality is available from the Programme. There is no established electronic database in the programme and the data is mainly paper based. The Directorate of Malaria Control is considering implementing the new tools in the non global fund supported districts also, but no clear timeline have yet been agreed on.
4.4.11 SWOT Analysis Malaria diagnosis
Strengths Weakness • Existing network of labs at public and private care • Most cases are clinically diagnosed delivery outlets • Lack of systematic quality assurance • Provincial level and national level training through provincial malaria reference institutes, training medics and para medics in lab laboratories techniques • Poorly defined case definition • New diagnosis policy with simple wall charts (DEWS) 2010 • Inconsistency in case definition • RDT and microscopy strengthening in BHUs in GF (DEWS vs. Program & DHIS, supported districts MNCH) • National public health laboratory division in the • Lack of qualified staff national institute of health (microscopists/technicians performing RDTs) • Rehabilitation of diagnostic facilities in 38 target districts (RDT and Microscopy) • Irrational use of RDTs • Integrated approach of malaria Diagnosis at PHC • Poorly defined role of LHWs in package diagnosis of malaria at community level • Free of cost services • Poorly defined indicators (# of RDT • Availability of training manuals and experts 156
trainers trained by WHO in Muscat used) • Low utilization of public health facilities • Inconsistency in number of slide received, examined and reported back to BHUs • Delay in confirmation (at the BHU level) • Poor adherence to infections preventions measures while doing microscopy and RDTs • Large number of vacant positions (microscopists)
Malaria treatment
Strengths Weakness • Availability of: • No universal radical treatment for PV National treatment guideline • Treatment of clinical cases Guideline on complicated case management • Mono therapy for the treatment of PF Malaria case management training manual • New treatment policy not fully approved and internalized at Malaria case management guide provincial level • Primaquine partially supplied for P. vivax • Not enough hard copies of malaria treatment treatment policy • Imposed ban on the production and use of • Need for collaboration with IMNCI monotherapies by DRA and PCPNCP and LHW to update • Free of cost treatment availability at public health their guidelines on malaria facilities/hospitals • Too much focus on project not • Drug quality control system in place for drugs and enough on expanding access enforced with district drug inspectors • Poor adherence to treatment guideline • National program procuring ACT at all levels • Low utilization of health facilities • Fake and low quality medicines due to lacking mechanisms for QA
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• No follow up DOTS compliance system for 14 days P. vivax • Self medication and mono therapy in private sector • Inadequate estimation of total needs for ACT and Primaquine • Second line ACT for treatment of PV and clinical malaria • Use of SP for the treatment of clinical cases • Poor adherence to treatment guideline in public and private health facilities • Poor knowledge of malaria
4.4.12 Successes, best practices and facilitating factors
Malaria treatment in the public sector is being provided free of charge. Second line ACT, and in some health facilities SP, is used for the treatment of PV and suspected cases. Regarding treatment, the national case management guidelines spell out the treatment options for pregnant women both for uncomplicated and severe malaria. These guidelines have been adapted from the updated WHO guidelines on case management of malaria. Antimalarials that are safe in first trimester of pregnancy includes: quinine, chloroquine, progunail and sulphadoxine pyrimethamine. Of these quinine remains the most effective and can be used in all trimesters of pregnancy. A registration system for medicines exist, procurement of anti malarial drugs (with unknown quality) from local market is common at the district level. Monitoring of drug efficacy of first line drugs is conducted regularly and so far is efficacious.
4.4.13 Issues and challenges
Case management:
• Clinical diagnosis very common
• Delay in confirmation
• Lack of systematic quality assurance
• Poor adherence to infections preventions measures 158
• Declining health system in areas where insecurity has prevailed
• War, natural disasters as earthquakes and floods resulting in IDP crises
• No refresher training over the years
• Large number of vacant position
• Lack of coordination between MCP and IMNCI strategy
Malaria treatment:
• Mono-therapy of most clinical cases
• No radical treatment for PV with Primaquine everywhere
• No follow up DOTS compliance system for 14 days P. vivax
• Self medication and mono-therapy for PF and PV in private sector
• Poor knowledge of malaria in districts where malaria is not a priority
• Shortage of supplies ( e.g. Primaquine, first line ACT)
• Mono-therapy still in use in public sector
• Irrational use of AMD
• Lack of availability of new treatment guidelines in public health facilities and DMCP and PMCP (poor adherence to treatment guideline)
• Partnership with private sector in malaria case management still in pilot stage
• No refresher training over the years
4.4.14 Conclusion and recommendations
Case management:
1. Strengthening lab capacity: all suspected/clinical malaria cases should be tested with RDT or microscopy before anti malaria treatment is administered. RDT to be rapidly scaled up to all BHUs in partnership with PPHI, IMNCI and PPNCP programs in malaria high risk districts.
2. Introduction of a systematic quality assurance system: strengthen quality control by establishing provincial and district reference labs with adequate infrastructure, competent lab technicians with support for annual cascade training and supervision, and continuous availability of consumables.
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3. Training and development: after thorough need assessment at the central, provincial and district levels, a comprehensive training plan (refresher, pre service and in service training) for strengthening diagnostic capacity should be developed.
4. Recruitment of new staff: deployment of lab technicians in all relevant vacant positions, particularly in malaria high risk districts is needed.
Malaria treatment:
1 Competent officers should be assigned as focal points for malaria case management at federal and provincial levels.
2 Update the federal and provincial essential drug list for health facilities and follow up the de regulation and ban on all malaria mono therapy in public and private sector
3 Radical treatment for PV with Primaquine with DOTS for 15 days to reduce relapse and transmission, supported by regular supply of Primaquine to all health facilities in malaria high risk districts.
4 Provision of new malaria treatment policy, guidelines and wall charts to all public and private health facilities by April 2014 supported by a ban on mono therapy and standardized training for all clinical staff
5 Establish community based malaria control with RDT and ACT with LHS LHW and community based organizations.
6 Case based reporting system be established for severe malaria cases followed by supportive clinical investigation and audit.
7 Engagement and scale up public private partnership in malaria control through professional association and sharing guidelines and wall charts and orientation sessions
8 Supervision by PPHI and DHO supported medical officer for implementation of high standard of malaria case management.
9 DoMC and PRs should ensure efficient drug supply management system with monthly stock situation update especially for RDTs and ACTs.
4.5 Community mobilization
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4.5.1 Introduction The National Malaria Control Programme recognizes that effective advocacy, communication and social mobilization forms the foundation of any efforts to effectively change service providers ability, community behaviour and overall demand for effective service utilization. Every planning document whether it is PC I or strategic plan has included BCC as one of the key component for disease control through behaviour change.
4.5.2 Policy and Guidance
The key elements of the newly developed BCC strategy are as follows:
• Non use of LLINs • Inappropriate use of LLINs • Self medication • Irrational use of drugs • Delayed treatment seeking Over diagnosis and reporting • lack of practices for preventing mosquitoes breeding • Non compliance with prescription • Treatment seeking from non qualified health practitioners • Non use of IRS
Balochistan: The strategies and targets that have been adopted for MCP Balochistan are:
o Review the existing material on malaria and dengue control in Balochistan, especially on awareness campaigns
o Develop health education messages for BCC aimed at general population through printed material.
o Develop BCC strategy aimed at patients, their families and especially the mothers for seeking early diagnosis and treatment within the first 24 hours of the onset of fever.
o Behavioral Change Communication strategy that will target the population at risk to improve their treatment seeking behavior and proper use of LLINs, repellants, and mosquito control.
FATA, KPK, and Punjab : In 2012 the BCC strategy was developed for Round 10 which has yet to be endorsed by the Ministry of Health and so not implemented. No training guidelines exist.
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4.5.3 Organization The Directorate of Malaria Control has a Health Education Officer who is a regular staff of the Directorate. He is responsible to coordinate all BCC/IEC activities related to malaria control. There is a Communication Manager recruited by Save the Children who has been actively involved in development of BCC materials. There is no separate IEC/BCC/Advocacy working group responsible for coordinating activities.
4.5.4 Human resources, training and capacity development
Balochistan: The MCP has one health educator for the program. A formal health education unit is not available. Staff, concerned with health education activities in the province are located in the Provincial Health Directorate, under the DGHS there is a Chief Health Educator with some health educators posted in the districts. There is a health education unit in each of the preventive programs, and there is a Health Education department in the Institute of Public Health, Quetta.
FATA : There is no focal person for BCC activities at IVM, FATA. Presently the Program has only a Program Manager, a data manager, computer operator and support staff. They are dependent on the old health messages developed by DoMC and Partners. The Lady Health workers, school teachers, religious scholar and health facility are trained on key health messages, who conduct health awareness sessions with community members and are given incentive of Rs 50 for interacting with each person. There are no health education sessions at health facility level.
KPK: The Health Directorate KPK has a focal point (Health Educationist) that coordinates BCC/IEC for all diseases at the provincial level. Due to lack of resources and capacity, the role of this single person is limited to gathering information during emergencies. There is no focal person for BCC activities at Malaria Control Program, KP. Presently the Program has only a Program Manager, a computer operator and support staff. They are dependent on the old health messages developed by DoMC and Partners.
Sindh: Trained Health Education Officers are available both at province and district levels, but due to inadequate allocation of funds and lack of mobility support there is limited implementation of health education component.
4.5.5 Annual planning
4.5.6 Performance indicators and targets As per strategic plan 2011 15 following are the BCC targets and indicators:
• ACSM strategy & implementation plans developed by Yr 2. • At least one event per month per Union Council organized during malaria transmission season; • 80% of the LHWs involved in delivering malaria messages; • All districts conduct mass media campaign during transmission season 162
Indicators:
• # of events per month per UC conducted; • % of LHWs involved; • # of districts conducting mass media campaigns
4.5.7 Service Delivery outputs and outcomes The programme has developed several materials such as: posters, charts, pamphlets, Banners, radio television spots, dramas and jingles. The materials have basically been developed to address personal protection measures using LLINs and early diagnosis and timely treatment. Radio, television, press, community radio, religious leaders and health education at health facilities are the main channels used to disseminate key messages. World Malaria Day is commemorated on 25 th April every year in Islamabad and the Provinces. These days are used to conduct awareness creation on malaria issues. Meetings are held with the policy makers and decision makers at the federal level and importance of theme of the world malaria day is discussed. The World Malaria Day event is followed by a press conference highlighting the burden of malaria and importance of its control. The DOMC developed BCC materials as follows:
1. Printed materials 2. TV and Radio spots The printed material includes posters, charts, pamphlets, banners and newspaper while the media material includes “spots” on radio and television.
Messages on printed materials are as follows.
Malaria is a life threatening disease. How malaria spreads, symptoms of malaria, diagnosis and treatment of malaria and preventive measures. Insecticide Treatment Net is effective against malaria especially for children and pregnant women. Prevention from Malaria fever is possible. Take preventive measures. Instructions for Use of LLIN. Three important steps for prevention of malaria. Quality Malaria Diagnosis and Treatment available in all health facilities of your area. • Malaria is a killer. Protect your family with a treated net. Ways from prevention of malaria
163
Table 49 below shows the spots run on TV Radio and Printed in News papers.
Table 46: Media wise Statement of Expenditure (Pak Rupees) for Electronic and Print Media for the Period 2005 to 2010
Year / 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010
Name of
Add Aired / Amou nt Add Aired / Amount Add Aired / Amount Add Aired / Amount Add Aired / Amount
Media Published Spent Published Spent Published Spent Published Spent Published Spent
147 Spots
120 Spots 117 Spots (PTV, ATV,
211 Spots
Hum, KTN,
Nil Apna, ARY
Digital & News,
Kook TV,
(PTV, ATV, (PTV, ATV,Geo Televisio Khyber news,
n 6908568 (PTV, ATV, Geo 6752593 Nil 3494337 5212663
Geo News, News, ARY, Business Plus,
News, ARY, ARY -
ARY, ARY -D, (non - Express, KTN, Waseeb, Rohi,
D, ATV, TV availabilit ATV, TV y Rohi , Sindh TV Saama, Dunia, One, KTN, Sindh
One, Hum of budget) Dherti, Apna, News One, TV, Hu m TV,
TV, Business Saama, Kook, & Sindh TV,
Business PI,)
PIus, Indus) Business Pius) Mehran, Awaz,
Punjab TV, Star
Asia & CNBC)
Spots
287spots 314 Spots Nil
Spots (PBC, FM -100,
(PBC, FM - (PBC, FM -101, FM -88, FM - Radio 671087 1367773 Nil 804086 1785025 (non - 100, FM101, FM -100, FM -91, (PBC, FM -107, 104, FM -106.2,
availability FM -104 & FM -92 & FM - FM -91& FM -99 FM -105, FM -
of budget FM -105) 105) 97, FM -93 FM -
91 & FM -99)
44 Adds
Nil
(Daily Jan,
Two Adds News, Nawa -e- 107 adds 44 Adds
waqat, Press 2889610 1872104 Nil 3484136
Khabrian, (Daily Aftab) Published Published (non- Waqt, Din,
availability Ausaf, Jinnah,
of budget Expres s,
164
Mashriq & Aaj )
7,579,655 9992470 7782559 6997688
Table 50: Media wise Statement of Expenditure (Pak Rupees) for Electronic and Print Media for the Period 2005 to 2010 Events conducted by Save the Children (Private Sector PR)
Advocacy events with Community awareness Community awareness
community based activists session at community and sessions at community and En tities including lady health facility level in 38 districts facility level in 38 districts
workers by LHWs by CBOs/NGOs
PLYC 2699 32445 11854
NRSP 2212 25258 20067
ASD 2093 18106 10968
ACD 1305 29643 18900
Merlin 5151 66427 34200
Total 13460 171879 95989
Balochistan: The main bulk of BCC activities are being carried out by the PRs in the 17 high risk districts; according to their reports they have made progress in achieving the stated targets, but besides the numbers of the sessions conducted there is no qualitative indicator to measure the quality of BCC activities, but this will change after the initiation of the Partners Coordination meeting mechanism in October 2013.
FATA: World Malaria Day is commemorated every year at the Agency Headquarter Level to create awareness on malaria issues. The IVM in collaboration with Partners conducts a meeting at Agency Headquarter Office to discuss the importance of world malaria day. The Agency Surgeon conducts a press conference highlighting the malaria burden and the importance of its control.
The IVM distributes the already developed BCC materials (messages have been described earlier) by DoMC or Partners. The developed materials are available as
1. Printed materials
2. TV and Radio spots
165
Mosques and health education at community level are also the main channels used to disseminate key messages.
KPK (same as FATA): The Lady Health workers conduct health education sessions on malaria control at household level. At health facility level, there are no health education sessions.
Punjab: The Lady Health workers conduct health education sessions at household level while School health and nutrition officers who are social scientists of Grade 17 conduct health education sessions at school as well as community level.
The MCP Punjab distributes the already developed BCC materials by DoMC.
Sindh : On World Malaria Day Malaria Control Program organizes advocacy workshops and seminars for opinion leaders, peers and community leaders which are presided by Minster or Secretary Health. Walks, rallies and puppet shows are also organized at district level. In the PC 1 there is provision of TV spots and radio messages. Each message is of 30 40 seconds which are telecasted / broadcasted on TV and Radio. For TV five messages for fifteen days per year and for Radio ten to fifteen messages per day are broadcasted for one month per year. Messages are related to awareness of community regarding prevention, diagnosis and treatment of Malaria.
4.5.8 SWOT Analysis
STRENGTHS WEAKNESS OPPORTUNITIES THREATS
Communication and Low involvement of other Existence of many Law and order situation awareness strategy and political leaders at political leaders that could material available provincial and district be recruited to advocate level for malaria control
Commemoration of World No focal point at MCP at NGO, donors, private Malaria day including a provincial or district level sector have shown press conference interest.
Lack of equipment, transport and other means to conduct social mobilization
BCC strategy of GF No mobility support and Availability of trained Lack of Coordination available inadequate financial human resources at allocation for Advocacy, provincial and district BCC, IEC, activates at level provincial level and district level Existence of strong cooperate sector in Sindh
166
province social responsibility funding available
Existence of two Health Inadequate funds for Large number of NGO Misconceptions among Education officer at electronic media function in Sindh can be general public due to lack provincial level. Separate used for advocacy with of education health education cell in the policy makers DG office for all preventive programs and availability of education officer at each district
Funds available for mass Expansive and non Access to the mass media Miss interpretation of the media, TV, Radio in interactive even by the rural messages current approved PC 1 population Prolong electricity shutdowns
Availability of many TV No mobility support and Availability of trained Lack of Coordination channels including local inadequate financial human resources at languages and increasing allocation for Advocacy, provincial and district radio coverage BCC, IEC, activates at level provincial level and district level Existence of strong cooperate sector in Sindh province social responsibility funding available
4.5.9 Successes, best practices and facilitating factors
4.6.0 Issues and challenges • Advocacy for prioritizing malaria control with high level policy makers and political leaders needs to be strengthened to ensure adequate funding for BCC activities.
• A Malaria BCC strategy has been developed at the Federal level but needs to be approved and made available to the provinces and districts.
• There is limited capacity and insufficient staff in advocacy, information, education, communication at the provincial level. 167
• Complex socio cultural settings exist in different provinces and districts, further highlighted by the low literacy rate in provinces such as Baluchistan and FATA and limited access to households, specifically women and children has resulted in the lack of broad based community involvement.
• Hence the need to develop community based malaria control, design context specific IEC messages and ensure the judicious use of communication channels (mass media, interpersonal and printed materials).
• The capacity of lady health workers has been overlooked as a potential for expanding and strengthening community based malaria control interventions.
• Lack of funding prevent activities from being conducted
• Fine tuning of IEC/BCC interventions is dependant on behavioral research on people’s perceptions of malaria issues, malaria prevention and treatment. Currently, there is limited up to date research data to inform proposed IEC/BCC activities.
• There are limited IEC/BCC materials
• Inadequate evaluation of health promotion activities for feedback
• Limited coverage • Lack of mobility support for health education officers at provincial and district levels. • Expensive mass media campaign (use of TV and Radio).
4.6.1 Conclusion and recommendations
1. To develop a strategy for increasing malaria advocacy and prioritization for community, district, provincial and federal government action. 2. To build partnership with LHW program and PPHI for social mobilization and community based malaria control program delivery. 3. Update malaria messages to target the local situation and adopt a local strategy which identifies appropriate inter personal channels for reaching the local communities and families 4. Harness the capacity of lady health workers for improving community BCC and scaling up malaria control activities; 5. Prioritize the use and develop tools for inter personal malaria communication for BCC using schools, madrasas, local traditional and political leaders. 6. Introduce qualitative monitoring tools, which assess how well the elements of the COMBI strategy are being carried out.
4.6 Surveillance, Monitoring and Evaluation
4.6.1 Introduction Malaria is considered a major public health problem in Pakistan. With an estimated burden of 1.6 million cases annually, Pakistan has been categorized by WHO in group 3 countries of the Eastern 168
Mediterranean Region along with Sudan, Afghanistan and Yemen. These four countries account for 98% of the confirmed malaria cases in the region. Mass population movements within the country and across in ternational borders with Iran and Afghanistan, natural disasters and civil unrest, unpredictable transmission patterns due to climatic changes, low immune status of the population, poor socioeconomic conditions, declining health infrastructure, resource constraints, poor access to preventive and curative services and lack of mounting drug and insecticide resistance in parasites and vectors all contribute to this huge disease burden. It is generally believed that public sector health facilities only reach 20% of the population therefore according to a conservative estimate total number of malaria cases in the country could be five times higher. If this presumption is applied to the 2011 data, the number in Pakistan is an estimated 1.5 Million cases. The Government of Pakistan is implementing Malaria Control Program (MCP) in 72 malaria endemic districts with public sector resources and in 19 highly endemic districts with the support from the Global Fund (Round 7). Pakistan has also been successful in receiving the Global Fund Round 10 Malaria grant targeting 38 highly endemic districts. These 38 target districts include 19 districts of the Global Fund Round 7 and additional 19 districts from Round 10. The total target population living in these districts is estimated at 24.84 million people. The malaria burden in majority of the provinces is expected to be fivefold more than the reported as DHIS data does not cover all the public health care facilities and 70 80% of the patients utilize private health services
Balochistan: In some areas there are two peak transmissions, the first start March and April to June and the second peak in September to November (post monsoon). In Balochistan malaria ranks the 2 nd top priority disease after ARI (Acute Respiratory infection) and accounts for 33% disease burden of the province. In 2012, 130 from among the malaria microscopy centers in the province, reported the numbers of confirmed malaria cases to be 60974, this brings the API to 6.90. However the actual caseload may be 4 to 5 times higher due to the public sector diagnosis facilities covering only 20 30% of the attending patients. Annual parasite index (API) of Balochistan is the highest compared to other Provinces in the country.
Figure 1: Burden of Malaria in Balochistan: reported confirmed cases 2007 to 2012.
169
Figure 2: Positive Slides 2012
170
Figure 3: Falciparum Rate (FR) Balochistan – 2007-2012
171
Figure29: Burden of API in Balochistan: 2007 to 2012.
Figure 304: Comparison of P.vivax with P.falciparum in Balochistan – 2007-2012
Table 48: shows data on malaria diagnostic microscopy from 2007 to 2012, includes the data from the PR source. The increase in the indicators is possibly due to the improvement of the diagnostic skills, reporting and other resources for microscopy. Although the increase in falciparum needs to be investigated.
172
FATA: Malaria is a high burden disease in FATA. The District Health Information System data reports that 65944 cases of clinical malaria were diagnosed in 2012 in primary and secondary health facilities outpatient department. Of these 3107 were admitted in a facility and no death was attributed to malaria. The MIS data indicates there were 28791 microscopy confirmed cases in 2012. The API based on six years average (2007 12) is 16.02 which is considered highest among all the provinces/states and is hyper endemic.
KPK: Malaria is a high burden disease in KP. The District Health Information System data reports that 321046 cases of clinical malaria were diagnosed in 2012 in primary and secondary health facilities outpatient department. Of these 5622 were admitted in a facility and 28 deaths were attributed to malaria. The malaria burden is expected to be fivefold more than the reported because DHIS data is not covering all the public health care facilities of the province and also because 70 80% of the patients utilize private health services. The MIS data shows that there were 55928 microscopy confirmed cases in 2012.
Sindh: The Malaria surveillance system incorporates data from only public sector health facilities and is fragmented. It is a passive surveillance system, where, data is collected from patients who report to health facilities. Malaria is not a notifiable disease in Sindh and elsewhere in Pakistan, data from private sector is not included. Public sector is covered partially; only 622 health facilities (41.54%) are covered out of total 1497 health facilities in public sector in Sindh.
4.6.2 Policy, Guidance, Coordination The aim of the malaria control programme is to reduce the burden of disease in these 38 high risk districts by scaling up appropriate intervention including strengthening case management, treating all confirmed malaria cases as per national guidelines, and vector control through IRS and LLINs. In order to achieve the targets the programme requires a bench mark against which progress towards scale up can be measured.
4.6.3 Malaria country profile, risk mapping and stratification Both Plasmodium falciparum and Plasmodium vivax are widely distributed in Pakistan. Table 52 shows statistics for the year 2012 22 . The incidence annual parasite incidence vary widely between provinces ranging from as low as 0.10 cases per 1000 population in AJK to 7.68/1000 population in Baluchistan and 6.82 cases per 1000 population in FATA. The number of confirmed malaria cases reported from all provinces and AJK have been 289759. Proportion of P falciparum varies widely with a range of 2.4% 44% respectively. Maximum proportion of falciparum cases (i.e. 44%) has been reported from Baluchistan province followed by 27% in Sindh, 11% in FATA, 9% in KPK and 6% in Punjab province. Proportion of PV to Pf over last five years (2008 2012) is shown in Figure 31. Certain areas of Sindh and Baluchistan have year round transmission with falciparum predominance.
Table 51: Malaria Data – Pakistan 2012 173
TOTAL Indicators
Province Population
Slides/RDT Positive P.V PF Mix SPR API BER % P.F
Examined
Punjab 91,943,208 1636079 17522 16426 1008 88 1.07 0.19 - 5.75
Sindh 39,231,406 1785499 114651 79511 31083 4057 5.56 2.9 - 27.1
KPK 22,985,802 534516 63494 57402 5804 288 12.4 2.76 - 9.14
FATA 4,382,727 197571 29926 26432 3232 262 16.2 6.82 - 10.79
Baluchistan 8,295,628 588558 63733 35372 28248 113 12.85 7.68 - 44.32
AJK 4,160,025 146744 433 421 11 1 0.29 0.10 - 2.54
4809
TOTAL 170,998,796 4888967 289759 215564 69386 5.57 1.69 - 23.9
(1.6)
Figure 31: Overall PV-PF Ration (2008-12) in Pakistan
The MIS data 2007 2012 includes all the four provinces and Regions (Punjab, Sindh, Balochistan, KP and FATA and AJK). The data shows Plasmodium falciparum and vivax as the prevalent species in 174
Pakistan and which have increased since 2007. There was a significant rise of both species in 2010 which may have been attributed to intensive floods. There has been a steady increase in the number of Plasmodium Vivax cases since 2010 while the number of falciparum cases has declined. Data on mixed infection indicates a rise since 2009
Figure 32: MIS data 2007 -2012
Overall P. falciparum accounted for 23.9% of both slides and RDTs examined as mono infection and 1.6% as mixed infection mainly in association with P. vivax.
Disease trends: Figure 33 shows API, SPR and BER trend over time. The API has shown an upward trend from 2009 2010 with a marginal descend in the subsequent years which coincides with BER. There has been an increase in SPR from 2009 to 2011 with a decline in 2012. Based on this information it is difficult to attribute this to malaria preventive intervention (use of LLINs), or due to quality of services or outbreaks occurring in several districts during the same period. Interestingly there is a weak correlation between the SPR and API which needs to be further investigated. A more worrying observation is the BER which remains at less 3% despite a huge investment made in trainings, equipment, supplies and effective monitoring. Detailed data is given in Table 53 below;
175
Figure-33: Trends in malaria indicators Pakistan (2007-12)
8.00
6.00
BER
4.00
SPR
2.00 API
0.00
2007 2008 2009 2010 2011 2012
176
Table-52 Province wise disease burden: Confirmed cases, SPR and API 2005-2012
2007 2008 2009 2010 2011 2012
Province Positive SPR API * SPR API *Positi SPR API * SPR API
Positive SPR API Positive SPR API
Positive ve Positive
Punjab 1,903 0.10 0.02 3,721 0.21 0.04 4,695 0.6 0.05 46643 2.4 0.5 19699 1.17 0.21 17522 1.07 0.19
32,40 3 6.2 0.80 10286 6.62 2.5 93306 7.76 2.38 90566 5.56 2.9
Sindh 29,330 2.47 0.71 26,070 2.74 0.62
6
25,636 14.0 1.10 56435 9.65 2.6 75384 13.44 3.28 60095 12.4 2.76
NWFP 17,451 2.89 0.80 15,247 3.66 0.68
22,056 28.7 5.50 32518 20.55 7.8 46149 17.93 12.14 28904 16.2 6.82
FATA 23,234 10.86 6.19 17,898 14.02 4.64
45,435 23.8 5.30 79918 13.55 9.0 84579 11.78 10.2 51984 12.85 7.68
B’tan 55,908 8.49 6.33 41,348 10.99 4.56
264 0.30 0.06 316 0.22 0.1 475 0.31 0.12 433 0.29 0.10
AJK 744 0.27 0.21 170 0.11 0.05
3186 9 6.44 1.8 31959 6.98 1.88 24950 5.57 1.69
TOTAL 128,570 -- -- 104,454 -- -- 130,489 -- --
6 2 4
*This includes microscopy and RDT positives
The table below shows gender and age wise distribution of PV and PF in 19 high risk districts supported by Global Fund. The female:male is 0.8. Among pregnant women number of cases with confirmed malaria reported was almost negligible (732 and 514 cases were recorded in 2011 and 2012 respectively). However, proportion of children less than 5 years who had confirmed malaria was 18%. Microscopy was 19% in 2011 and 17% in 2012 whereas RDT positivity was 9% in 2011 and 8% in 2012. Approximately double number of mixed infections was reported in 2012 after the introduction of Combo RDTs. However, there have been negligible mixed infections reported by microscopy. The higher number of mixed infections captured by RDTs need to be investigated as this has policy implications.
177
Table 53: PV and PF in 19 high risk districts s 2011
Male Female Microscopy Center RD Center
Total RDTs S.# DISTRICT Population <5 5-14 >14 <5 5-14 >14 Preg S.Exain PF PV Mix Pos: MC Examined 1 Tharparkar 1,224,523 821 1991 3137 810 1212 1793 8 45951 2422 6620 54 9096 17291
2 Thatta 1,405,071 328 944 1113 438 625 649 3 37710 1737 1484 37 3258 13680
3 Dadu 2,247,627 120 283 652 111 233 371 1 46281 513 1083 0 1596 8545 4 Khairpur 2,013,031 2460 5521 7837 2078 4088 5641 31 75976 6621 7720 11 14352 69719 5 Mardan 1,837,260 510 1139 3941 445 981 4294 80 68886 2393 8803 4 11200 7544 6 Bannu 806,223 1773 3573 4258 1752 3140 4287 206 52428 4917 11851 127 16895 33381
7 Lakki 657,634 467 1145 2739 408 877 1987 45 27085 1730 4980 9 6719 35706 8 Kurrum 567,614 140 619 1133 119 606 953 2 17079 752 2624 66 3442 9200 9 Bajaur 788,914 1217 1260 1242 872 981 1415 14 21617 2641 3653 102 6396 11951 10 Khyber 767,854 568 1464 1929 516 1385 1798 13 20977 2403 5148 48 7599 4349
11 Mastung 195,490 164 417 524 228 574 573 38 11099 763 1413 0 2176 4608 12 Naseerabad 314,830 546 1695 1944 626 1395 1625 15 6588 608 845 6 1459 29237
13 Noshki 158,974 119 403 594 123 328 501 2 17527 566 1247 3 1816 16162 14 Sibbi & 250,081 542 972 1480 477 969 1386 25 9883 1221 1667 3 2891 26375
Total RDTs
S.# DISTRICT Population <5 5-14 >14 <5 5-14 >14 Preg S.Exain PF PV Mix Pos: MC Examined
Harnai
15 Gawadar 246,089 880 991 1157 711 989 1398 55 22801 3104 3032 4 6140 5125
16 Kech 461,864 817 1623 1607 614 1277 1372 16 37378 2980 1428 6 4414 45480 Zhob & 17 493,022 2515 2933 3123 1977 2268 2695 77 17405 1982 1655 500 4137 137872
Sharani
18 Killa Saifullah 233,155 393 619 975 354 464 792 55 9759 579 1724 1 2304 20929 178
19 Loralai 503,743 208 612 894 159 510 693 46 6786 555 285 21 861 21555 1 5 , 1 7 5 1 5 2 1 2 4 1 2 3 5 3 6 0 1 , 4 8 0 2 2 4 3 8 7 1 6 8 9 5 2 2 8 9 2 7 2 4 2 0 7 7 9 8 0 7 1 0 2 3 1 8 6 0 5 0 TOTAL 9 8 4 9 8 2 3 2 6 7 2 2 1 9
Table 54: Data Base of Malaria Cases 2012 (GF 19 Districts)
Male Female Microscopy Center RD Center
POPULATI Total RDTs
S.# DISTRICT ON <5 5-14 >14 <5 5-14 >14 Preg S. Exain PF PV Mix Pos: Examin
MC ed 1 Tharparkar 1,250,237 1103 3099 5145 808 1463 2500 17 55354 887 12922 73 13882 13879 253
2 Thatta 1,434,577 732 1282 1788 762 1101 1220 18 41007 2876 1884 45 4805 14819 2006
3 Dadu 2,294,826 94 321 548 111 283 379 0 48909 204 1393 3 1600 6443 74
4 Khairpur 2,055,305 2035 4040 6190 1596 2861 4516 75 69353 4363 8818 24 13205 60664 7643
5 Mardan 1,875,841 463 1023 1914 386 827 2402 43 67104 321 6501 2 6824 4850 84
6 Bannu 823,153 2039 3497 4279 1789 3183 4375 199 69996 1116 15 545 70 16731 25512 1181
7 Lakki 671,444 484 1108 2357 423 777 1714 32 30054 456 5894 10 6360 20304 372
8 Kurrum 579,534 214 631 771 163 583 675 47 14023 227 2755 16 2998 4140 56
9 Bajaur 805,480 629 783 838 578 681 946 11 18294 342 3467 61 3870 10357 410
10 Khyber 783,978 637 1166 1557 628 1109 1592 8 29755 474 5844 39 6357 4815 154
11 Mastung 199,594 2 2 6 2 4 6 0 464 7 14 0 21 117 1
12 Naseerabad 321,440 322 932 1371 335 884 1349 19 5881 431 688 1 1120 28710 4066
13 Noshki 162,311 55 167 195 53 126 207 1 15728 145 549 3 697 18554 104
Sibbi & 14 255,333 404 732 10 85 357 731 977 0 11961 905 1848 8 2761 22072 1520 Harnai 15 Gawadar 251,256 715 1006 1376 719 1002 1478 9 28685 2691 3606 2 6299 4719 2
16 Kech 471,562 506 828 893 434 640 728 26 29899 1517 1290 14 2821 16539 967
Zhob & 17 503,375 651 979 996 506 832 830 4 14524 826 1216 7 2049 61196 2746 Sharani Killa 18 238,050 178 377 632 149 267 433 3 9710 128 1238 7 1373 14527 666 Saifullah 19 Loralai 514,322 152 399 592 120 291 465 2 7694 344 299 9 652 17883 1369
15,491,62 1141 2679
TOTAL 0 5 22372 32533 9919 17645 2 514 568395 18260 75771 394 94425 350100 23674
179
180
The figure below shows PV Pf ratio from 2009 to 2012. The proportion of PV to PF was 36:64 in 2009 whereas in 2012 the proportion of PV to PF was 65:35.The increase in vivax cases is most likely an effect of introduction of COMBO RDTs introduced through Global Fund in 38 districts.
Figure 34: PV- Pf ratio from 2009 to 2012
The figure below shows Annual Parasite Incidence (API) from 2009 2012 in 38 TGF high risk districts of Pakistan. There has been an increase in API from 7.13/1000 population in 1999 to 10.31/1000 in 2010 followed by a decline in 2012 (API 7.8/1000) indicative of better Programme Performance.
Figure 35: Annual Parasite Incidence (API) from 2009-2012
181
4.6.4 Human resources, training and capacity development
Balochistan: As of November 2013 two M&E Officers have been assigned to the MCP Balochistan with offices at the MCP HQs at Quetta. However, they are responsible only for the GF DoMC supported districts, and do not perform M&E work for the other districts.
FATA: There is no resource person at provincial or district level nor are there any monitoring tools. Similarly there are no surveillance officers at provincial or district level. The IVM doesn’t have the technical and financial capacity to conduct the trainings.
KPK: The MCP doesn’t have the technical and financial capacity to conduct the trainings.
Punjab: The MCP has no monitoring and evaluation system. There are no are no surveillance officers at provincial or district level.
Sindh: There are only 8 surveillance officers in Sindh and face logistical constraints in compiling the data.
4.6.5 Routine Information Systems
Currently National Malaria Control Programme receives malaria data by vertical Malaria Information system on a monthly basis from all the districts. Two different types of reporting tools are used. The newly developed surveillance tools by the GF (FM1 FM4) are used for reporting from 38 Round 10 supported districts, whereas in non Global fund supported districts data is being collected using the older version developed during eradication era. The new forms are more comprehensive and capture age, sex, pregnancy status and stock out for antimalarials, LLINs, insecticides, lab supplies including standard information on diagnoses, treatment (both uncomplicated and severe malaria), OPD admissions and deaths. Clinical diagnosis is currently reported through DHIS which does not routinely share its data with the Programme nor is it analysed for any planning or M&E activities. Confirmed cases are also collected by DHIS but figures may not be the same as those from MIS. No data on severe cases or mortality is available from the Programme. There is no established electronic database in the programme and the data is mainly paper based. The Directorate of Malaria Control is considering implementing the new tools in the non global fund supported districts also, but no clear timeline has been agreed on.
Balochistan: The following information systems are present and functional in the health department including data on patient and Malaria Indicators. (tertiary care and the private sector facilities are not included in any of these systems):
District Health Information Management System which is now developing into eDHIS. Disease Early Warning System which includes malaria. Malaria Information System. (Efforts to strengthen this system are underway by the MCP along with the Data Management Unit at the provincial headquarters and in the districts). DEWS, is the integrated disease surveillance system and reports weekly, monthly, as well annually, including epidemics. ‘Report is communicated electronically.
182
Figure 36 Malaria Stratification Map of Balochistan.
• Malaria is a notifiable disease. • Reports include cases and deaths. • The HMIS/DHIS includes data on mortality and morbidity data. The frequency or reporting is quarterly and annually.
183
• Malaria Information System is Malaria specific, the system is now being streamlined with IT based communication. • Provincial database on Malaria is under consideration. • Health Information Data Base is generated by the HMIS/DHIS. • WHO Database is freely available on the web. • Surveillance data is reported from all levels of healthcare facilities and Sentinel sites.
FATA, KPK, Punjab:
The malaria data is received through three sources
1. Malaria Information System: Malaria confirmed through Microscopy 2. District Health Information System 3. Disease Early Warning System:
Uncomplicated malaria Any one presenting with fever and chills,
Severe Malaria Fever with prostration, altered consciousness, generalized seizures, difficulty in breathing, low urinary output or dark urine, severe anaemia, abnormal bleeding, and hypoglycaemia
FATA and KPK : the MIS data is reported through newly designed FM 3 forms. The data has discrepancies within the program and with partners. The partners report through FM (1 4) forms from selected facilities. Unfortunately due to lack of coordination there are discrepancies in data at agency and directorate level.
FATA: The population figures assumed by the MCP are the same throughout the years as no projections have been done. The districts funded by the Global Fund works in selected union councils and the population (denominator) is taken as whole district without scientific projections.
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40000 30000 Vivax 20000 Falc 10000 Mix 0 2007 2008 2009 2010 2011 2012
Figure 37: Vivax, falciparum and mix cases 2007-2012
Data shows that the Plasmodium vivax and falciparium has increased since 2008. The SPR has significantly increased since 2008 while there is steady increase in API.
Figure 38: BER, SPR and API 2007-2012
District Health Information System (DHIS) was established with help of JICA. There are a total of 698 health facilities reports which includes 305 BHU’s, 246 CD’s, 18 CH and 6 DHQ’s. The primary facility report shows that 67151 patients were diagnosed as suspected malaria cases from Jan Dec 2012. A total of 15832 slides were examined of which 3228 were MP positive and 684 PF positive. The secondary facility report indicates that 50112 patients were diagnosed as suspected malaria cases in OPD from Jan
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Dec 2012. A total of 61399 slides were examined of which 13573 were MP positive and 1407 were PF positive. There were 3017 admissions while no death was reported due to malaria.
There are limitations of DHIS as all the public health facilities are not reporting. Similarly the DHIS does not include the private health facilities.
KPK:. The population figures assumed by the MCP are the same throughout the years as no projections has been done.
Figure 39: Vivax and falciparum cases Data shows that the Plasmodium vivax and falciparium is on rise since 2007. The SPR is significantly on rise since 2007 while there is steady increase in API.
Figure 40: BER, SPR and API
District Health Information System (DHIS) was established with help of JICA and report of 2012 is the first comprehensive report. The record is based on information of 23 districts and only Torghar district is not included. A total of 1728 health facilities reports which includes 10 teaching hospitals, 22 DHQ’s and 760 BHU’s. The primary facility report shows 198281 patients were diagnosed as suspected malaria cases from Jan Dec 2012. A total of 75006 slides were examined of which 12839 were MP positive and 1622 PF positive. There were 464 admissions while no cause of death was reported. The secondary facility report shows that 122765 patients were diagnosed as suspected malaria cases in OPD from Jan Dec 2012. A total of 163889 slides were examined of which 22999 were MP positive and 1453 were PF positive. 186
There were 5158 admissions of which 28 deaths were attributed to malaria. There are limitations of DHIS as all the public health facilities are not reporting. Similarly the DHIS does not include the private health facilities.
Punjab: The MIS data is reported through G 30 forms. The data is incomplete and has discrepancies when compared with the federal program.
Figure 41: Vivax, falciparum and mixed cases (2007-2012)
Data shows that the Plasmodium vivax and falciparium has increased since 2007. There is marked increase in cases of malaria in 2010 due to floods.
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Figure 42: BER,SPR and API (2007-2012)
The API had increased in 2010 because of floods in Punjab.
District Health Information System (DHIS) was established with help of JICA and report of 2012 is the first comprehensive report. The primary facility report indicates 674810 patients were diagnosed as suspected malaria cases from Jan Dec 2012. A total of 568153 slides were examined of which 12072 were MP positive and 1584 were PF positive. There were 464 admissions while no cause of death was reported. The secondary facility report shows that 156307 patients were diagnosed as suspected malaria cases in OPD from Jan Dec 2012. A total of 413307 slides were examined of which 8722 were MP positive and 1011were PF positive. There were 10972 admissions of which 84 deaths were attributed to malaria. There are limitations of DHIS as all the public health facilities are not reporting. Similarly the DHIS does not include the private health facilities.
Sindh: MIS is based on the confirmed Malaria cases and data is collected from Microscopy centers (453) and RDT centers (169) established in public health facilities (except 20 RDT centers in Khairpur and 4 in Tnado Allahyar in private health sector facilities). Data is collected from health facilities and documented on (G30) Performa on daily basis. There is no strategy for validation of data, such as inter district and intradistrict meetings to validate surveillance data. Active surveillance to collect data from community is not done.
District Health Information System is functioning in all districts of Sindh since January 2012 and collects data on 49 health conditions, including Malaria. The information includes malaria suspected cases, total slides examined, total slides positive for malaria, P. Falciparum positive, total admission for malaria and total deaths due to malaria.
The data is collected from primary (BHUs, RHCs, MCH centers and dispensaries) and secondary health facilities (THQs and DHQs) on a daily basis using specially developed data collection tools. Filled Performas are signed by the in charge of health facility and sent to district coordinators of DHIS by the in charge of health facility. The district coordinator checks these for completeness and if the data is found lacking, the Performas are sent to the health facility for correction. All completed Performas are entered into the data base by data entry operators after which the file is sent to the Director General Health and 188
Health Sector Reforms Unit (HSRU). The quality of data is compromised because DHIS staff district health facilities check the quality. Moreover all health facilities don’t report regularly to DHIS coordinator.
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Table 55. District wise Suspected Malaria Cases
Districts Suspected Malaria
211-Badin 130518
212-Dadu 67869
213-Hyderabad 48101
215-Jamshoro 40666
216-Tando Allahyar 31103
217-Thatta 40130
218-Matiari 44508
219-Tando Muhammad Khan 48510
221-Karachi 5707
231-Jacobabad 32401
232-Larkana 94902
233-Shikarpur 72902
234-Kamber @ Shahdadkot 60361
235-Kashmore @ Kandhkot 32104
241-Khairpur 209520
242-Naushero Feroze 50888 243-Shaheed 133920 Benazirabad(Nawabshah) 244-Sukkur 29414 245-Ghotki @ Mirpur Mathelo 50782 251-Mirpurkhas 65940
252-Sanghar 124436
253-Tharparkar @ Mithi 44490
254-Umerkot 84137
District Total 1543309
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4.6.6 Sentinel Surveillance Systems
Balochistan: Focal points of DEWS at the district and provincial level collect data, including malaria on a weekly basis. There is no epidemic reporting system in the Programme. Last outbreak was reported in December 2012 (Sakka) based on rumors from the Media, the Programme investigated and confirmed it was not malaria.
FATA: Malaria is also reported through WHO established “DEWS”. Only three agencies report on priority diseases including suspected malaria. The report is not comprehensive and as such DEWS is not fully functional in FATA.
KPK: The malaria is also reported through WHO established “DEWS”. A total of 21 KP districts provide surveillance data to the DEWS from 984 health facilities which include 566 BHU’s, 208 CD’s, 67 RHC’s, 35 CH’s, 31 Tertiary hospitals, 18 MCH’s, 14 THQ’s, 12 DHQ’s, 12 SHC’s, 7 Others, 6 TBC’s and 5 LC’s.
Khyber Pakhunkhwa Disease name # of Cases % Acute Respiratory Infection 1,516,532 22.5 Bloody Diarrhea 43,496 0.6 Other Acute Diarrhea 587,797 9.0 Suspected Malaria 102,026 1.5 Suspected Typhoid Fever 22,737 0.3 Pyrexia Unknown Origin 353,066 5.2 Scabies 176,395 2.6 Other diseases 3,930,897 58.4 Grand Total 6,732,946 -
Table 56: 2012 DEWS
A total of 6,732,946 consultations were reported in 2012. ARI consultations were the highest reported percentage i.e.22.5% or 1,516,532 cases of the total cases while suspected malaria ranked 4 th having 102,026 cases or 1.5% of total cases.
Punjab: The Disease Early Warning and Response System (DEWS) in Punjab started as a weekly review of health facility data and notification of epidemic prone diseases from the health facility (HF) level during subsequent disasters culminating in the 2010 Floods. In addition to immediate reporting of epidemic prone diseases including Malaria, aggregate numbers of consultations for major syndromes are collected and analysed on a weekly basis. Investigation and response to alerts and outbreaks are organized at the district level. The devastation of the 2010 super flood disaster was still apparent throughout the first half of 2011 and Punjab was trying to recover from its adverse effects, especially transmission of water borne and vector borne diseases including malaria and access to safe drinking water, sanitation, proper nutrition and health care. At the end of June 2011, political control of health care services devolved from federal to provincial control, and the transition had only begun when, in August 2011, the country was hit by the unprecedented monsoon rain causing floods at mass level in many districts in Sindh and Balochistan 191
provinces. At the same time Punjab province experienced a huge dengue fever outbreak, especially in Lahore city. Surveillance Officers deployed in the affected districts are supported by provincial DEWS coordinator and data assistant; they investigate and respond to alerts and outbreaks of epidemic prone diseases including Malaria.
DEWS Surveillance Officers (SOs) in collaboration with the District Health Office (DHO) investigate and respond to disease threats which are notified from the health facilities such as malaria, suspected cholera or measles cases. They also respond to disease threats revealed in the weekly reports as crossing standardized “alert thresholds” – for instance, a cluster of cases of confirmed disease or weekly syndromic trend showing doubling of cases. When notified, and having prepared stockpiles of relevant medicines and supplies in advance, the DEWS SO, with the district health team, investigates, takes specimens for laboratory confirmation, and takes action to control the outbreaks in the early stages.
Figure 43: Week wise percentage of Malaria 2013 Punjab
This graph shows the weekly trend of suspected malaria cases from all over DEWS implemented districts of Punjab during year 2013 till week 46. Highest percentage of suspected malaria cases (1.74%) is evident in week 01 2013. The trend line indicates downward trend towards the end of year. In week 29 (1.4%) and 37 2013 (1.33%) a sudden rise in suspected malaria cases was observed which can be attributed to monsoon spell.
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Figure 44: Yearly comparison of Malaria 2011 to 2013
Figure 44 shows yearly comparison (2011 13) of suspected malaria consultations reported through DEWS in Punjab. The trend lines of each year do not follow a specific pattern of suspected malaria consultations. In year 2011 & 2013 an overall decrease in malaria consultations was evident while the trend was opposite during 2012. The inconsistency in the yearly malaria trends points towards issues related to reporting methodology of suspected malaria cases. One possible way to confirm this may be through physical validation of the DEWS data available at district level.
Figure 45: District wise percentages of Malaria 2013
Figure 45 provides district wise break up of suspected malaria cases reported from 13 DEWS implemented districts in Punjab during year 2013. It can be clearly noted that Muzaffargarh district reported the highest malaria cases (36.84%) followed by DG Khan (10.57%), Rahim Yar Khan (8.88%), Bhakkar (8.12%) and Mianwali (7.37) as the most endemic areas in southern Punjab. District Jhelum 193
seems to be the most endemic (7.27%) area in Northern Punjab. Slide positivity rate for each district, during year 2013, can be a good indicator to scale endemicity of the area.
Figure 46: District wise percentages of malaria for 2012 and 2013
Figure 46 shows 2 year comparison of 13 dews reporting districts regarding suspected malaria cases, which was maintained in the respective districts between the years.
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Figure 47: District wise SPR And Falciparum rate (FR) according to eDEWS data 2013
Figure 47 shows the SPR & FR in DEWS implemented districts of Punjab in year 2013. Graph shows that District Multan has highest (50%) FR followed by D.G Khan (36.5%), Layyah (21.4%), Muzaffargarh (12.8%), Mianwali (12.1%). Highest FR was seen in Layyah (13), Muzaffargarh (7), Rajanpur & Bhakkar (6).
Table 57: District wise Yearly cases of Malaria
District 2011 2012 2013 Attock 0 0 5070 Bahawalpur 18490 0 0 Bhakkar 15763 21768 11131 DG Khan 35164 14725 14488 Gujrat 0 0 1024 Jhelum 0 0 9966 Jhang 36386 0 0 Khushab 13187 0 0 Lahore 0 153 3129 Layyah 23126 20189 8878 195
Mianwali 27374 21788 10105 Multan 6513 3746 1585 Muzaffargarh 73835 78466 50494 Rahim yar khan 49661 34583 12166 Rajanpur 31641 22712 7409 Sahiwal 0 0 1614 Sargodha 27028 0 0
Table 58: Malaria Alerts from 2010-2013
District Total Number Year Year 2011 Year 2012 Year 2013 of Alerts 2010
Bahawalpur 02 0 0 0 2
Bhakkar 05 0 0 5 0
D.G Khan 03 0 0 1 2
Layyah 07 0 4 3 0
Mianwali 06 0 3 3 0
Muzaffargarh 13 0 5 8 0
Rahim Yar 06 0 0 3 3 Khan
Rajanpur 02 0 1 1 0
TOTAL 44 0 13 24 7
Since establishment of DEWS system a total of 44 alerts were picked up and responded by surveillance officers (table 55). Maximum number of alerts were responded in year 2012 (24) followed by year 2011 (13) & 2013 (7). Maximum number of alerts were reported from District Muzaffargarh (13) followed by Layyah (7), Mianwali (6), Rahim yar Khan (6), Bhakkar (5), D G Khan (3) while Districts Bahawalpur & Rajanpur reported 2 alerts each.
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Table 59: Malaria Outbreaks from 2010-2013
District Total Number Year Year Year Year of Outbreaks 2010 2011 2012 2013
D.G Khan 02 1 1 0 0
Muzaffargarh 01 1 0 0 0
TOTAL 03 2 1 0 0
Table 56 indicates 3 outbreaks were reported & responded: 2 were reported from District D G Khan one ( 2010 & 2011). District Muzaffargarh reported 1 outbreak in year 2010.
Sindh: Disease early warning system is functional in Sindh since 2007 and as of 2010 all districts are reporting to DEWS. The objective of DEWS is to a decrease morbidity and mortality caused by communicable and epidemic prone diseases, including malaria out breaks DEWS also responds to alerts and outbreaks and conducts epidemiological surveys.
DEWS has provided weekly disease reporting formats to every health facility, in which the number of slides taken, number of malaria positive slides and falciparum positive slides are entered to calculate SPR and FR. Data is collected directly from health facilities. Constraints include less number of slides taken, therefore that data is not reliable because from 30 40 slides are not reflective of the whole district. Secondly all the districts do not send the complete malaria data. Third all suspected malaria cases are not tested for MP. Fourth expertise and honesty of testing staff is questionable. No data is collected from the private sector. Malaria information DEWS receives information from districts through online system on weekly basis, the system compiles reports and disseminates to all stakeholders including Malaria Control Program.
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Figure 48: District wise % of malaria cases
Figure 49: Week wise distribution of malaria cases
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100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0 Dadu Badin Thatta Feroze Ghotki Sukkur - Karachi Matiari Kambar Larkana Sanghar TMKhan Khairpur Umerkot N Jamshoro Shikarpur Kashmore Jacobabad Hyderabad Tharparkar Mirpurkhas T. ALLAH YAR ALLAH T. S. Benazirabad S.
Slide Positivity Rate Falciparum Ratio
Figure 50: SPR and Falciparum ration
4.6.7 Monitoring and Evaluation Plan
The National Malaria Control Programme has a recently developed Malaria Monitoring and Evaluation Plan in 2012 (M& E Plan Round 10 Malaria,2012). The plan provides the foundation for measuring progress through the identification of goals, objectives and indicators across malaria intervention strategies. The Malaria M&E plan also outlines the available and desired data sources, the strategies for quality control, validation of data and identifies the role of key malaria stakeholders in M&E. The DOMC does not have M & E officer, but the programme management unit has established with support from TGF SSF 10 Grant provides M&E support to the Directorate. There is a qualified M&E Manager at the federal level supported by an IT In charge/Data analyst and a data officer. Similarly the Private sector PR SSI also has an experienced M& E officer.
The Management Units have experience in:
Collecting and analyzing programmatic data on a Sub national level. Experience in producing regular reports on program progress and results. Written terms of reference with each Sub reporting Entity establishing data reporting requirements and deadlines. Mechanism/procedure in place to periodically verify training numbers reported (e.g., random review of attendance sheets). 199
The Management Unit can demonstrate that site visits for data verification have taken place.
At the provincial levels (KPK, Sindh and Baluchistan) Provincial Management Units have been established each having a trained M&E Officer equipped with a computer. At the district level District Management Units have been established in each district with a M&E Officer. There are well structured plan, guidelines and clear monitoring & evaluation indicators and well defined roles and responsibilities. There is a M&E system in place at the provincial levels in high risk 38 districts. M&E budget has been ear marked in the TGF Grant SSF Round 10. During Round 7 implementation there were 684 monitoring visits by the SRs, 9 visits by the Provincial Managers, 651 visits by Data management In charges and 22 visits by M&E officer (Table). The Save the Children SSSF Round 10 has made 1011 visits in total to monitor case management practices in public and private facilities.
Table 60: Monitoring visits in 19 districts of TGF-Round-7
Provincial - District Budgeted
District SRs Vi sits Manager Data Management PR -M&E Officer visit
visits Incharger
Actua M&E Officer Actual Budgeted Actual Actual
Planned Planned l Planned Visit
visit Planned visit visit
visit per month
Total 785 684 114 684 551 19 22
9
% 87% 8% 81% 116%
Table 61: Monitoring visits in 19 districts of TGF-Round-10
Year 1 Year2 Year 1,Year 2
Activity Description Q1,Q2,Q3,Q4 Q5,Q6,Q7,Q8 Q1,Q2,Q3,Q4,Q5,Q6,Q7,Q8
Target Progress Target Progress Target Progress
Monitoring & supervisory visits
from federal & provincial level 5 5 5 10 5
to the districts
Monitoring and sup ervision of
case management practices in 774 162 774 972 774 972
public & private sector
DHMT 114 0 114 39 114 39
Total 893 167 893 1021 893 1011
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4.6.8 Malaria Surveys Operations research (OR) is critical in providing scientific evidence for health and disease control programs to improve their quality and “learning” as they scale up. RBM puts a major challenge for broadening research base for its successful implementation in Pakistan. The PC I has a separate component on operational research highlighting the priority research areas. However, there is no separate research unit within the DOMC and in most of the cases the research is out sourced or done in collaboration with the research organizations like PMRC,HSA, AKU, INGOs. The health institutions in the country also conducts research on diverse issues related to malaria. There are a number of research institutions in the country both in public and private sector. The known institutions include PMRC, HAS, NIH and AKU. PMRC and AKU have established their field research centres. In addition there are 15 Universities those have major research programmes. Some key universities include Punjab University, KEMU, Karachi University, Peshawar University, and AKU.
Approved PC 1 of Malaria Control Program Sindh has research as separate component, but budget allocation is only Rs0.36 millions for three years. The staff of Malaria Control Program both at Provincial and District levels have limited research capacity. There is no research capacity development program to enhance the research capacity of staff. Malaria Control Program Sindh has received very limited support from international technical agencies such as WHO, to enhance research skills of staff. During last five years there has been no one from provincial Malaria Directorate or any district who has been trained to improve research skills. Although PC 1 of Malaria Control Program has indicated the development of research collaboration with Medical Universities in Sindh, but no such collaboration have been developed and MOUs signed. However one study has been conducted by LUHMS, using data of Malaria Control Program during last five years. Chloroquine resistance was first reported from Pakistan in 1984 and was followed by several reports confirming it in Punjab, Afghan refugee camps and areas borderingAfghanistan 9,10 ,11 .12 . Over the last decade, resistance surveys conducted by the National Institute for Malaria Research and Training using the WHO extended invivo test(WHO1973) have shown that chloroquine resistance is widespread in many areas of the Punjab and North west Frontier Province (Shah et al. 1997) WHO latest survey. Drug resistance management is one of the key components in the federal PC I and the national strategic plan. The Directorate of Malaria control at the federal level established 8 sentinel sites in various provinces for surveillance of drug resistance, but these sites are yet not functional. World Health Organization is providing technical assistance to the programme for conducting drug efficacy and monitoring studies in various provinces.
Balochistan: Two studies have been conducted till date one by the WHO for drug resistance monitoring for Plasmodium falciparum in district Zhob, and in a sampled region of Balochistan by the PMRC. The reports are still waiting to be submitted. Regular prevalence survey or operational research systems are not in place. Two studies have been conducted till date one by the WHO for drug resistance monitoring for Plasmodium falciparum in district Zhob, and the second in a sampled region of Balochistan by the PMRC. A survey on Community Perceptions on Malaria (2004) has also been conducted, however, the report is not available locally. No other regular national or provincial level studies or surveys have been done with the exception of studies conducted by individual research students or faculty of the universities. Despite a local Institute of Public Health at Quetta existing, there are limitations of resources and capacity issues, which require technical guidance.
KPK: The following surveys have been conducted at national level which also highlights the findings of KP Province. Pakistan Demographic Health Survey, Malariometric Survey, MICS and PSLM. Findings are given in national report.
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4.6.9 Malaria Reporting The Malaria data is collected and recorded under the following programs. o Malaria Information System (MIS), includes the secondary data generated at the Provincial Malaria Reference Lab, and other diagnostic centers in the province. o Disease Early Warning System (DEWS) does not act as a information system for malaria o Health Management Information System (HMIS), does not act as a information system for malaria o Information from other preventive program sources, such as National Program is also generated, but it is not a regular resource for malaria information.
The reporting frequency is monthly, gathered by the index health facility or health professional concerned, assimilated and refined by the Data Management Unit at the MCP headquarters at Quetta.
FATA : The malaria reporting is done as highlighted in table 62:
Malaria slides/RDT examinati on data in year 2012 Slide Slides / P. P. Falcipar Mixe P. Total Positivity Vivax District RDT Falcipar Mixe um Rate d Vivax +Ve Rate Rate examined um d (FR) Rate (SPR) Abbottabad 0 0 0 0 0 0.0 0.0 0.0 0.0 Bannu 1,993 51 402 94 547 27.4 26.5 73.5 17.2 Batagram 0 0 0 0 0 0.0 0.0 0.0 0.0 Buner 4 0 0 0 0 0.0 0.0 0.0 0.0 Charsadda 12,422 187 2,718 40 2,945 23.7 7.7 92.3 1.4 DI Khan 8,191 195 1,770 40 2,005 24.5 11.7 88.3 2.0 Dir Lower 5,871 10 815 139 964 16.4 15.5 84.5 14.4 Hangu 5,759 54 1,761 9 1,824 31.7 3.5 96.5 0.5 Haripur 237 4 17 0 21 8.9 19.0 81.0 0.0 Kohat 9,804 190 1,728 168 2,086 21.3 17.2 82.8 8.1 Kohistan 0 0 0 0 0 0.0 0.0 0.0 0.0 Malakand 5,736 1 355 50 406 7.1 12.6 87.4 12.3 Mansehra 515 1 134 2 137 26.6 2.2 97.8 1.5 Mardan 19,136 71 1,979 79 2,129 11.1 7.0 93.0 3.7 Nowshera 5,993 37 1,393 16 1,446 24.1 3.7 96.3 1.1 Peshawar 240 0 0 0 0 0.0 0.0 0.0 0.0 Shangla 1,042 0 206 3 209 20.1 1.4 98.6 1.4 Swabi 405 0 1 1 2 0.5 50.0 50.0 50.0 Swat 4,084 76 124 3 203 5.0 38.9 61.1 1.5 Tank 0 0 0 0 0 0.0 0.0 0.0 0.0 202
Upper Dir 46 0 2 0 2 4.3 0.0 100.0 0.0 13,40 14,92 Total 81,478 877 644 18.3 10.2 89.8 4.3 5 6 A total of 81,478 slides were tested for Malaria. Out of which 14,926 slides were positive and accounted for SPR is 18.3% with 10% (1,521 slides) for the falciparum ratio, 90% (13,405 slides) for Vivax ratio and 4.3% for Mixed ratio.
KPK : The malaria data is not reliable, there are flaws in data at district and provincial level. The partners report through different format and have no coordination with MCP. There is a need to conduct a detailed analysis and triangulation of various data sources to determine the current epidemiological situation in KP from which decisions on scaling up malaria control interventions could be based. The MIS need to be made reliable and efficient so that it helps in detecting any epidemiological transitions that would warrant a change in delivery of services.
Sindh: District reports are compiled on monthly basis on developed Performa and sent to provincial Malaria Directorate. The provincial reports are compiled on monthly basis and disseminated to stake holders. Reporting from health facilities to District Health Officer (DHO) and from districts to provincial Malaria Control Directorate is not regular and there are administrative and logistic issues. The GF districts also reports on confirmed cases (microscopy as well as RDT) having a different format i.e. F1 to F4. Unlike G 30 reporting mechanism it does include stock outs. There is no separate Monitoring and Evaluation plan developed at provincial and district level, however Director Malaria Control Program, Additional Director and Epidemiologist visit different health facilities and communities during IRS activities, larvicidal activities and during out breaks. Entomologist and insect collectors visit different sites for determining vector density.
The Surveillance Program is assessed through indicators including Annual parasite incidence (API), Plasmodium Falciparum Ratio (PFR), Blood Examination Rate (BER), Slide Positivity Rate (SPR), Passive Case Detection (PCD). The data of several years is available with the program in the form of graphs and charts, but annual evaluation reports are not available to know trends and patterns of malaria in Sindh.
4.6.10 Malaria database and informatics System Computers, software, e mail and Internet network for districts and provincial malaria focal points: (Exists) Country websites and process for updating (Yes) Web based reporting (No)
Balochistan: MIS includes a logistics information but the system needs strengthening. The Log Information system by the Global Fund Partners pertaining to the GF supported districts is reporting on these items and is shared with the MCP, however, the log information from the remaining districts is presently being revamped from G30 to FM 1 to 4, and will become operational soon. Laboratory Data on Malaria Microscopy and RDT is regularly processed .
The WHO database and country profiles are available on the WHO site with free access. The district malaria profiles will be developed in line with stratification process. Presently these do not exist. 203
The district profiles in general however exist developed by the Planning and Development Department of the Government of Balochistan. The Balochistan MCP is progressing with progressive improvement of the IT systems. Till date computers are available only in 11 districts (which are limited in connectivity and dependent on electricity), the remaining districts do not have this facility for MCP related work; and is one of the reasons these districts delay in submitting their reports. Web based reporting is as yet not in practice.
KPK: The MCP (office at provincial level) has one computer but have no database. Recently they were connected with internet facility and now partners sent the reports and other information through internet. At district level there are no computers and net services. Reports are sent through courier. Program is planning to establish web site which needs technical and financial support.
4.6.11 Progress towards achievement of targets DOMC:
Performance indicators Target Result Percentage of Achievement (P1-P7) (P1-P7)
Number & percentage of health facilities with malaria N: 656 N: 657 testing capability in 19 target districts. D: 656 D: 656 100% P: 100 % P: 100.2 %
Number of Rapid diagnostic tests done and read in 19 611,970 757,117 120% * target districts.
Number of health care providers trained on national case management guidelines in public and private sectors in 19 2,826 2,441 86% target districts.
Percentage of confirmed PF cases treated with ACT as the 95 % 98 % 103% first line treatment in 19 target districts.
Number of LLINs distributed to people in 19 target 632,000 570,102 102% districts.
Number of households ( or structures or walls) in 19 new target districts sprayed by indoor residual spraying in the 215,650 100,232 46% last 12 months (MAL-P2).
Number of health personnel trained on malaria data 175 208 119% management, M&E and early detection of malaria
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outbreaks
Percentage of monitoring visits conducted vs planned in 80 % 72 % 90% 19 target districts.
Save the Children:
Performance indicators Target Result Percentage of Achievement (P1-P7) (P1-P7)
N: 551 N: 535 Health facilities with microscopy and/or rapid diagnostic D: 551 D: 551 97% testing capability (number or percentage) P: 100 % P: 97.1 %
Number of RDTs done and read in 19 new target districts. 591,030 84,731 14%
Number of health providers trained on malaria diagnosis 834 905 109% (microscopy and RDT) and QA in 19 new target districts.
Number of health care providers trained on national case management guidelines, LLIN distribution, Vector Control 1,689 1,561 92% and Medical Entomology in 19 new target districts.0
Percentage of lab/RDT confirme d P. falciparum malaria N: N: 1,922 cases correctly treated as per national guidelines in new D: D: 1,922 120% * 19 target districts. P: 70 % P: 100 %
Number of LLINs distributed to people in new 19 target 381,667 315,528 83% districts
Number of LLINs distributed for women (15 to 49 years) and children under 5 years of age in new 19 target 145,032 119,900 83% districts.
Number of households (or structures or walls) in 19 new N: 65,150 N: 64,153 target districts sprayed by indoor residual spraying in the D: 65,150 D: 65,150 98% last 12 months (MAL-P2). P: 100 % P: 98.5 %
Number of health personnel trained on malaria data 715 689 96% management, M&E and early detection of malaria
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outbreaks.
N: 625 N: 1,017 Percentage of monitoring visits conducted versus planned D: 893 D: 1,115 120% * in 19 new target districts. P: 70 % P: 91.2 %
Number of people reached by behavior change 362,900 227,754 63% communication community outreach in 38 target districts.
Balochistan: The overall targets for MCP Balochistan are the same as the national targets for control and elimination of Malaria, these are consonant with the MDG indicator 21 and 22 which state the objective to be: o Reduction in morbidity and mortality associated with malaria. o Increase proportion of population in malaria risk areas using effective malaria prevention and treatment measures.
The targets set in 2010, however which targets have as yet not been acquired, were: o 50% reduction in the malaria burden by the year 2010. o By the year 2015 >70% of the high risk population of Pakistan having access and using effective malaria prevention and treatment so that malaria is no longer a potential public health threat. . Sindh : The Malaria Control Program uses following indicators to assess and to monitor the malaria surveillance.
• Annual parasite incidence (API) • Plasmodium Falciparum Ratio (PFR) • Blood Examination Rate (BER) • Slide Positivity Rate (SPR) • Passive Case Detection (PCD)
In the graph below slide positivity rate in Sindh during last five years from 2008 to 2011 has increased while in 2012 there was a slight decrease. There was also continuous increase in number of slides taken.
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Figure 51: SPR
Figure 52: No. of slides
Figure 53 : Annual Parasite Incidence (API)
Above graph shows the annual parasite incidence has increased continuously from 2008 to 2012.
207
Figure 54: Falciparum Ratio (FR)
Above graph shows marked reduction in prevalence of Falciparum cases.
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Table 63.
Year No Of P. Vivax P. Mix Total SPR FR% Slides Falciparum
2001 705126 11988 12532 18 24502 3.47 51%
2002 731038 12938 10282 05 23215 4.17 44%
2003 902021 20445 17795 09 38231 4.23 47%
2004 1521648 27326 13371 0 40697 2.67 33%
2005 1313818 17490 10359 04 27845 2.12 37%
2006 1376923 19051 15558 0 34609 2.51 45%
2007 1021822 16534 8726 0 25260 2.47 34%
2008 954028 17682 8415 04 26093 2.73 32%
2009 1113765 19112 8364 0 27476 2.46 30%
2010 1275732 34304 22289 482 57075 4.50 39%
2011 1290835 48119 34499 4989 87607 6.7 39%
2012 1785499 79511 31083 4057 114651 6.4 27%
4.6.12 Successes, best practices and facilitating factors Monitoring and evaluation is critical for performance assessment of malaria control activities, the keys indicators mostly available at central, provincial and district levels are the API, SPI, BER and Parasites species proportion. Indicators of the program are complied by, district, province and federal levels. Multiple malaria information systems are in place such as the old malaria surveillance system, new malaria information system (MIS), DHIS and DEWS generating different malaria indicators. Comprehensive federal annual malaria surveillance reports and malaria reports are prepared as part of Ministry of Health year book. In some provinces such as Punjab active case detection and case investigation surveys are conducted by CDC officers. The information systematically collected for M/E is based on the “Malaria information system’ in place in the 38 priority districts funded by the global fund and managed through malaria databases.
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4.6.13 SWOT Analysis
STRENGTHS WEAKNESS OPPORTUNITIES THREATS
Existence of an M&E plan has been Current political context Weak information culture epidemiological developed based on strongly in favour of at all levels of the system surveillance system that requirements of the M&E in the public sector provides monthly data on GFATM and may not have the malaria burden been embraced by the MCP and partners as M&E plan for the strategic plan
Weak capacity in the Increased interest by Current human resource malaria M&E. partners to support M&E crisis in all public sector
Monitoring indicators and Lack of skills in Existence of a central unit Staff are not motivated documenting tools available monitoring and evaluation of M&E at Federal level due to weak incentives by managers in malaria control specially in the MCP structures
Existence of separate Limited experience of Multiplicity of reporting research component in existing staff to system approved PC 1 implement monitoring and evaluation activities
Full time sectioned post of Low quality data from Poor coordination epidemiologist in the routine systems. between MCP and program partners in terms of information/data sharing
Weak capacity of MCP in integrating data from different sources Malaria Indicator Survey will provide more Policy implications Lack of plan for studies of Devolution is an malaria to be carried out Lack of provincial capacity opportunity for the and resources may provinces to effect programme plan realistically performanc
Covers only Public sector Public private partnership in True burden of disease partially private sector not six districts of Sindh difficult to calculate. supported through GFATM 210
covered projects.
No community based prevalence survey conducted
Non existence of M&E plan M&E budget available, Non availability of Mobility Posting of National support for M&E No system of validation of Program Officer recently data
Limited funds allocation Availability of funds for Lack of research capacity and limited research research. capacity
No trained epidemiologist Budget allocation available Political interference in posted recruitment and posting
4.6.14 Issues and challenges • Impact indicators such as percentage of malaria admissions and deaths among hospital admissions and percentage of severe malaria cases are poorly collected, with few exceptions.
• There is no comprehensive ONE malaria data base at district, provincial and federal level to collate malaria information from different sources and systems. Concerns have been raised on the accuracy and completeness of the malaria information from the public sector especially as an estimated 70% of malaria cases are seen in the private sector.
• Different malaria case definitions used by DEWES and DHIS , new and old malaria surveillance and information systems .Lack off comprehensive compilation of access and outcome coverage
• Mapping of malaria data IS limited due to poor GIS capacity in the malaria programme but can be resolved through collaborations with other programmes such as EPI, Polio, DEWS and WHO malaria atlas who have strong GIS systems in place.
• Malaria Epidemiological orientation capacity is inadequate at all levels with many vacant provincial posts of malaria epidemiologists although the capacity of M&E officers is being enhanced in districts and provinces.
• The data illustrated above suggests PRs and SRs are performing quite well ( Rate A1 and A2 ), however the question of representativity of these data (mainly process indicators)with respect to the total population at risk, the distribution of malaria cases in all union councils and geographical reconnaissance ( for IRS in particular) is questionable .
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• The responsibility of MCP in setting the targets must be underlined, specifically coverage of interventions implemented. The denominator of the proposed interventions must be based on the total population at risk, the epidemiology of the disease in the district
• Coverage of malaria diagnostic centers through the country needs to be consistently monitored.
• Majority of the Basic health units at union councils are poorly equipped and staffed. Other impact indicators such as % of malaria admissions among hospital admissions and % of severe malaria cases are collected intermittently.
• The outcomes and impact indicators need to be collected systematically through appropriate channels such as DHS, MIS, and KAP surveys.
• There is limited capacity within the MCP to coordinate and implement activities of well established M&E unit. Currently, there is no responsible person for M & E within the MCP. • Data collected by MCP and GF is not comparable .The data quality in terms of diagnosis and completeness is questionable and does not allow confident analysis of the trends. • Inadequate personnel and supplies leading to poor M&E. • Weak use of data for decision making. • Inadequate training and human resource development in malaria surveillance, monitoring and evaluation. • There are also delays in data submission to all levels. • Data is not readily available for the managers for their use and the quality of the data is low. • There are weak linkages between the MCP and research institutions resulting into limited operational research on malaria. • The data quality in terms of diagnosis and completeness is questionable and does not allow confident analysis of the trends. • Weak use of data for decision making and inadequate training and human resource development in malaria surveillance, monitoring and evaluation. • Surveillance system covers only public sector health facilities partially. Private sector is not covered, therefore actual burden of Malaria in the province is not known. • No community based prevalence surveys conducted. • Monitoring and Evaluation plan at provincial and district levels not developed. • Limited mobility support available for monitoring and evaluation. • Limited allocation of funds for operational research (0.36 million rupees for three years) • Limited research capacity development of provincial and district staff. • Although there is some collaboration between Malaria Control Program Sindh and some research organization such as Liaquat University of Medical and Health Sciences, but no formal MOU have been signed and there is no active collaboration agenda. • Trained epidemiologist not posted as head of evaluation component of Malaria Control Program.
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4.6.15 Conclusion and recommendations for surveillance/Monitoring and evaluation
1. Production of monthly, quarterly and annual district, provincial and federal malaria program reports based on strategic information at district and provincial level such as outcome/impact and mortality data 2. Update information on needs and gaps on RDT, ACT, Primaquine, LLINs and IRS to achieve universal coverage. 3. Establish one standard malaria case definition for diagnosis and treatment and , MIS, DHIS, DWES . 4. Review and update the old malaria surveillance system in place in districts targeting elimination of Malaria 5. Move to one malaria information system with data collection tool for an integrated malaria M&E system in all malaria risk districts by first quarter 2014.(Harmonize the M&E system among the PRs and SRs) 6. Malaria program to collect data on malaria inpatients and mortality from secondary and tertiary hospital DHIS reporting. 7. To establish GIS and malaria mapping capacity within the provincial and federal malaria program using WHO country office EPI and malaria atlas programs to guide malaria epidemiological analysis and target interventions at districts level. 8. DEWS to be sustained and transferred to the DHIS provincial and district departments to support malaria epidemics detection and response and in the future district malaria elimination. 9. MDC/PMRC/WHO/MEDVC HSA to propose an agenda for operational research to support malaria control efforts 10. Use the available GF funds to extend the M/E system to all district under malaria control strategy and adjust the M&E system for the districts targeted for elimination
4.7 Epidemics In the past malaria epidemics have occurred in Pakistan at 6 10 years interval, with the the most recent having occurred in 1972 73. Since then cyclical reoccurrence of these epidemics are no more observed but small scale outbreaks have occurred. Following t he floods in 2010 a resurgence in confirmed malaria cases was noted in 2011 (50 000) compared to 16000 in 2010. A Disease Early Warning System is in place, but malaria control programme does not get alerts through this system highlighting a lack of coordination between the MCP and DEWS as well as limited capacity of Disease Early Warning System and Focal Points in the districts. According to the recent assessment by WHO, the focal points of DEWS at the district and provincial level collect data, including malaria on a weekly basis. There is no bulletin, no newsletter or regular reporting system in the Programme. The last outbreak was reported in December 2012 (Sakka) based on rumors from the Media, the Programme investigated and confirmed it was not malaria. DEWS have never contacted the Programme to respond to malaria outbreaks.
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4.7.1Determinants of malaria epidemics and emergencies and risk factors Sindh : Past outbreaks have occurred in Sindh in 2003 at Mirpurkhas, 2006 at Tharparkar, 2010 at Kasmore, 2011 at Tharparkar, 2013 at Tharparkar . The terrain in Tharparkar is desert and mountainous and has ideal breeding sites for mosquito. Other risk factors include lack of awareness about malaria, communities are remote from health facilities and the quality of care being provided to the people.
4.7.2 Forecasting malaria epidemics
Balochistan : In the absence of studies on malaria cyclical trends, forecasting is not a routine activity. Nor does the programme have links with Met services for the purposes of Malaria Control activities and forecasting. After the initiation of the inter partner (GF PRs and MCP) coordination process in October 2013, developing a system for epidemic forecasting is underway.
Sindh : There are no maps present at district or sub district level and there is no any coordination with the metrological department.
4.7.3 Preventing malaria epidemics Balochistan : The MCP (and districts have been advised to do so) maintains special stores for these emergency stocks. In case of emergencies the government also allocates special funds for emergency procurements of commodities needed, this system needs to be streamlined with particular emphasis on training for diagnostics, case management, personal safety, identification of cases requiring referral and the referral system, offensive and defensive anti vector measures, environmental management, and an efficient surveillance system.
4.7.4 Preparedness and planning for malaria epidemics Sindh: There is no preparedness plan present, however DOMC Sindh has a buffer stock (10%) transported immediately upon identification of an epidemic. There is an epidemic preparedness team but they are not trained properly and perform epidemic assessment based on the guidelines present.
4.7.5 Early warning and surveillance of malaria epidemics Balochistan: Early detection containment and prevention of an epidemic is an important element of the MCP strategy. Surveillance forms the basic tool to allow proper response and preventive modality, however, this system is still fully functional. A DEWS system with weekly reporting is fully operative in the province, and sends regular reports to the PC MCP. Regular Malaria Indicator Surveys (MIS) with the establishment of the Data Management Cell at the MCP will strengthen and streamline the epidemic detection process. The epidemic threshold indicator is not routinely utilized, but is expected to be monitored with the streamlining of the overall MIS. Insufficient resources and poor capacity compound a strong epidemic surveillance system.
Sindh: Metrological department don’t provide any monthly or weekly warnings during peak months to DOMC but they provide information directly to media and other departments. Disease Early Warning System (DEWs) is operational in Sindh and all districts are reporting to DEWs since 2010, DEWs received information from district through online system on a weekly basis and compiles reports, circulating to stakeholders including Malaria Directorate. DEWs reports alerts, outbreaks and conducts epidemiological surveys. There is no weekly surveillance during peak months. Epidemic investigation is completed within two weeks of occurrence is conducted by a provincial team comprising of an epidemiologist, senior malaria evaluator, microscopes, and one community member along with technical support from WHO. 214
4.7.6 Rapid response to malaria epidemics
Balochistan: The provincial arrangement for epidemic preparedness is under the Epidemiologist of the MCP, who heads an epidemic response team, which oversees the epidemic containment activities comprising of Space Spraying, emergency IRS, distribution of LLINs, diagnostic and treatment services. The districts particularly the GF supported districts, have recently reported a designate emergency and epidemic response team under the District Malaria Superintendent is in the process of being appointed. However, the actual performance capacity of these teams and the respective emergency plans still needs to be assessed. The case reporting and assessment indicators are routinely operational and monitored. Special WHO checklists and tools that are also utilized.
FATA: At Federal level there are guidelines for malaria and dengue control in case of emergencies, however, comprehensive updated policy and guidelines are not available. No document specifying the roles and responsibilities during epidemics do not exist at provincial level. There are no contingency plans including quantities buffer stock for malaria emergency preparedness and response at directorate or agency level.
KPK: In the past, KP has experienced emergencies on a large scale such as earthquakes, floods and conflicts emphasising the need for timely response. Poor preparedness and response was seen during recent dengue outbreaks in three districts of KP.
Sindh: Response to epidemics are immediate with the team performing a malaria metric survey (MMS), collecting slides (from those with fever and people who have history of fever since last week) to check on microscopy from where there is higher number of cases along with the peripheries and analyzing the data before compiling a report, data of last 5 years of that district is also collected. In this survey team collects slides. They check slides on microscopy and come up with the analysis whether this outbreak or not. All fever cases without diagnosis receive full doses (radical) of ACT if PF is dominating in the area.
4.7.7 National control systems for malaria epidemics and emergencies Balochistan: The DoMC is the national focal point. National Guidelines are in place and followed for epidemics and emergencies. There is presently no Technical Working Group at the provincial level for malaria epidemic. The provincial Health Directorate and the MCP are the focal and coordination points in the province; a formally designated group for Malaria Control is not available. The IPCC at the national level is functional for overall IPCC for malaria control activities in the country. Sentinel Surveillance sites and early warning systems are functionalized to provide support and cover for epidemic control, as a part of emergency response.
FATA: No organization or focal point exists at national, directorate or agency level to lead malaria emergency preparedness and response. There has been no training in emergency preparedness and response. No training manual exists. The present PC 1 does not have any funding for emergency preparedness and response.
KPK : The PC 1 of MCP documents a malaria epidemic in KP in 1974 however the details are unknown. There is neither documented history of Malaria Epidemics in KP nor any malaria epidemic risk mapping. There is no contingency plan including buffer stock for malaria emergency preparedness and response at provincial or district level. No organization or focal point exists at national, provincial or district level to lead malaria emergency preparedness and response. There is no training in emergency preparedness and
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response yet. No training manual exists. The previous PC 1 has allocated one million Rs for establishing early malaria warning system but this budget was not released and consequently halted implementation. The present PC 1 does not have any funding for emergency preparedness and response.
Punjab: At Federal level there are guidelines for malaria and dengue control during emergencies, however, comprehensive updated policy and guidelines are not available. There is no document specifying the roles and responsibilities during epidemics. There is no contingency plan including buffer stock for malaria emergency preparedness and response at provincial or district level. In the past oonly 20% of the buffer stock was kept aside for epidemics but in the absence of a PC 1, the stock no longer exists. There is no focal point that exists at provincial or district level to lead malaria emergency preparedness and response. No training in emergency preparedness and response has been conducted. No training manual exists. The present PC 1 does not have any funding for emergency preparedness and response.
Sindh : An EPR team is present (provincial) but there is no focal point for malaria epidemic and emergencies. There is a district level malaria focal person. There has been no training conducted on epidemic assessment. Sentinel surveillance, epidemic warning and early detection systems are not in place.
4.7.8 Advocacy, information, education, communication and community involvement Studied data to assess the KABP for Malaria epidemic as during routine times is not available. The importance of BCC for epidemic containment is fundamental but the situation is the same as for BCC overall, particularly to improve the treatment seeking behavior of the communities and preventive practices. There is a need for the BCC campaigns to target the health professionals of all categories in their response to malaria containment and control, particularly following prescribing practices under the treatment guidelines. PRs oversee BCC campaigns (community meetings, seminars, walks) in the GF supported districts, while MCP is constrained by a lack of funding.
Sindh: Health education officer does sessions on epidemic.
4.7.9 Summary
There is no proper surveillance system in place for epidemic forecasting and alerts for timely response by the Programme. The programme there is no separate unit for epidemic preparedness and response. Disease early warning system (DEWS) supported by WHO includes malaria outbreak detection and alert and rapid response.
4.8.0 SWOT Analysis
Strengths Weakness Opportunities Threats
Malaria surveillance at Malaria surveillance Support from Global Fund Increasing development of place at provincial and system not yet involving for implementation of new urban settings in big district level. use of epidemic thresholds main malaria epidemic cities without an for early detection of preventive measures infrastructure supportive malaria epidemics. of vector control and new large scale irrigated
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agricultural schemes without in built vector control methods, like Tube Wells, Dams, Ponds, and in the cities the sewerage disposal works.
Absence of an early Presence of some warning system for international and national prevention of malaria NGOs experienced in epidemics. supporting efforts for prevention and containment of malaria epidemics.
Delay in release of Lack of seasonal spray running cost needed to men and other workers implement preventive or needed to implement containment measures at additional preventive times of malaria measures during the rainy emergencies. season or at times of malaria epidemics, due to low payments.
Poor documentation of malaria epidemics witnessed in the province in the past period.
DEWS is functional in Coordination of DEWS System is in place can be Lack of staff motivation Sindh and all districts with DOMC is weak. improved report to DEWS on weekly basis since 2010 Limited Number of surveillance officers
DOMC Sindh keeps 10% No – Epidemic forecasting Availability of resources Community support buffer stock as Epidemic system no maps available stock
Epidemic response team at No preparation plan Human Resources is Law and order situation DOMC investigates the available trained available epidemic Epidemiologist not posted
4.8.1 Issues and Challenges
• Malaria transmission is unstable with high risk of epidemics but there are no maps of districts with high epidemic potential and those with reported malaria outbreaks over the last 5 or more years.
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• Malaria emergency risk is high due to political and security challenges in some districts and provinces and past risk of floods and earthquakes. • There are no malaria epidemic emergency focal points in the federal and provincial malaria programs supported by a technical working group. • Malaria epidemic threshold for detection of malaria outbreaks being used by the DEWS system but no thresholds are in use in by the malaria information (MIS) system and the DHIS system. • There is a lack of trained malaria program teams on malaria epidemic emergency preparedness and response at all level. • There is a malaria emergency guideline to support malaria control in refugee camps and to some extent in IPD camps but does not address people living in security affected districts. • There are numerous partners such as WHO provincial sub offices and emergency programs such as OCHA, UNHCR, UNICEF working in health emergency but inadequate partnership by malaria program to address universal access and coverage of malaria control interventions in emergency affected districts and provinces.
• At Federal level there are guidelines for malaria and dengue control in case of emergencies, however, comprehensive updated policy and guidelines are not available.
• The document specifying the roles and responsibilities and other actions during epidemics do not exist. No such guidelines exist at provincial level
4.8.2 Conclusion and recommendations
1. Update risk maps and tables on malaria epidemics and emergencies
2. Prepare the policies, guidelines and training manuals for emergency preparedness and response.
3. Provincial quarterly malaria emergency update on needs and gaps in emergency affected populations and districts for follow up with provincial health emergency cluster
4. Malaria program and DEWS, DHIS to jointly review and update malaria case definitions and malaria outbreak and emergency thresholds and guidance for malaria outbreak control
5. To develop specific malaria emergency strategies such as simple community based malaria control to access and deliver malaria control to emergency affected areas.
6. To build malaria partnership with other organizations such as OCHA, WHO, UNICEF, UNIHCR, IOM, JICA, etc. to move to universal coverage with malaria interventions by MDG 2015 in emergency affected districts
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ANNEX 1 : Agenda of all MPR phases
ANNEX 2 List of people involved in MPR
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