Inform Asia: USAID’s Health Research Program Associate Award 2: Year 4, Quarter 1 Progress Report
Submission Date: Resubmitted: February 28, 2019
Cooperative Agreement Number: AID-486-LA-15-00002 Activity Start Date and End Date: September 24, 2015 to September 30, 2020 Agreement Officer’s Representative Name: RAO Name:
Submitted by:
This document was produced for review by the United States Agency for International Development (USAID) Regional Development Mission for Asia. It was prepared by RTI International.
DISCLAIMER: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. This document is intended to comply with Section 508 Standard of the Federal Acquisition Regulation. If you have any difficulties accessing this document, please contact [email protected]. Table of Contents List of Figures ...... iii List of Tables ...... iii List of Acronyms and Abbreviations ...... iv 1. Program Overview/Summary ...... 1 2. Activity Implementation Progress ...... 5 3. Management and Administrative Issues ...... 30 4. Planned Activities for Next Quarter, Including Upcoming Events and Travel ...... 32 Annex 1: Y4 Milestones, Deliverables, Targets, and Timeline Against Results in Q1, Y4 ...... 34 Annex 2: Monitoring, Evaluation, and Learning Indicator Reports (as of Q1, Y4) ...... 41 Annex 3: Financial Report (as of December 31, 2018) ...... 47 Annex 4: Timeliness of Malaria Reporting – Indicator 1.3 ...... 48 Annex 5: Malaria cases with complete information – Indicator 1.4 ...... 52 Annex 6: Drug Efficacy Evaluation ...... 55
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 ii
List of Figures
Figure 1. Associate Award 2 Results Framework, Y4 ...... 1 Figure 2. Current vs. proposed workflow to improve the information from the weekly R506 to the MIS...... 9 Figure 3. Work flow for 1-3-7 strategy in Vientiane province ...... 13 Figure 4. Flowchart for malaria case follow-up in Thailand ...... 14 Figure 5. Foci reversion cohort analysis and Kaplan-Meier survival curve ...... 21 Figure 6. Inform Asia’s organogram, Y4 Q1 ...... 31 Figure 7. Proportion of reporting units reporting on time, by month and organization type ...... 49 Figure 8. Percentage of reporting units that submitted data to the MIS according to the recommended timeline in Thailand ...... 50 Figure 9. Percentage of Lao PDR reporting units that submitted a monthly report according to the recommended timeline ...... 51 Figure 10. Number of cases by reporting unit type ...... 52 Figure 11. Treatment information completeness by reporting unit type ...... 53 Figure 12. NTG compliance by reporting unit type ...... 54 Figure 13. Drug efficacy evaluation – NTG treatment compliance ...... 55 Figure 14. Drug efficacy evaluation – complete follow-up rate ...... 56 Figure 15. Drug efficacy evaluation – Follow-up and parasite recurrent rates ...... 56 Figure 16. Drug efficacy evaluation – Parasite recurrence for patients treated with NTG...... 57 Figure 17. Drug efficacy evaluation – DHA-PIP ...... 57 Figure 18. Drug efficacy evaluation – CQ + PQ ...... 58
List of Tables
Table 1. Summary of progress toward achieving results achieved during Q1, Y4 ...... 2 Table 2. Summary of malaria activities and their sources of funding ...... 11 Table 3. Current list of tools for data collection, monitoring, and supervision for malaria elimination in Lao PDR ...... 12 Table 4. MIS readiness assessment team member roles and responsibilities ...... 16 Table 5. SI and knowledge products under development in Q1, Y4 ...... 25 Table 6. STTA inputs named in the Year 4 work plan and their contribution by the end of Q1 ...... 31 Table 7. International travel proposed for Q2, Y4 ...... 32 Table 8. Number, proportion, and mean number of malaria cases reported in the MIS by organization type, Q1, Y4 ...... 48 Table 9. Treatment completeness by reporting unit, Q1, Y4 ...... 53 Table 10. Facility with the greatest number of non-compliant NTG treatment cases ...... 54
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 iii List of Acronyms and Abbreviations
ABER Annual Blood Examination Rate AFRIMS Armed Forces Research Institute of Medicines AJTMH American Journal of Tropical Medicine and Hygiene AOR Adjusted Odds Ratio AS Artesunate ASTMH American Society of Tropical Medicine and Hygiene BIOPHICS Center of Excellence for Biomedical and Public Health Informatics BMGF Bill & Melinda Gates Foundation BMP Border Malaria Post BOE Bureau of Epidemiology BVBD Bureau of Vector Borne Diseases CBA Cost-Benefit Analysis CHAI Clinton Health Access Initiative CMPE Centre for Malaria, Parasitology and Entomology COP Chief of Party CQ Chloroquine DAMN District Anti-Malaria Nucleus DDC Department of Disease Control DHA-PIP Dihydroartemisinin-Piperaquine DHIS2 District Health Information System 2 DHO District Health Office EOC Emergency Operation Center FY Fiscal Year GF RAI2E Global Fund to Fight AIDS, Tuberculosis and Malaria, Regional Artemisinin-resistance Initiative 2–Elimination GIS Geographic Information System HIS Hospital Information System HPH Health Promotion Hospital iDES integrated drug efficacy surveillance IR Intermediate Result IRS Indoor Residual Spraying IT Information Technology JITMM Joint International Tropical Medicine Meeting
LAO Local Administrative Organization LLIN Long-Lasting Insecticidal Net LOE Level of Effort MC Malaria Clinic MEL Monitoring, Evaluation, and Learning mHealth Mobile Healthcare MIS Malaria Information System MOA Memorandum of Agreement MOH Ministry of Health MOPH Ministry of Public Health MORU Mahidol-Oxford Research Unit MOU Memorandum of Understanding MP Malaria Post MQ Mefloquine N/A Not Applicable NGO Nongovernmental Organization NHSO National Health Security Office NMES National Malaria Elimination Strategy NTG National Treatment Guidelines ODPC Office of Disease Prevention and Control PAMS Provincial Anti-Malaria Station Lao PDR Lao People’s Democratic Republic Pf Plasmodium Falciparum PHD Provincial Health Department PHO Provincial Health Office PMI President’s Malaria Initiative PQ Primaquine Pv Plasmodium vivax Q Quarter RDMA Regional Development Mission for Asia RDT Rapid Diagnostic Test SCD Special Case Detection SI Strategic Information SOP Standard Operating Procedures SOW Scope of Work
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 v STTA Short-Term Technical Assistance TA Technical Assistance TBD To Be Determined UCSF University of California, San Francisco UNOPS United Nations Office for Project Services USAID United States Agency for International Development USG US Government VBDU Vector Borne Disease Unit VMW Village Malaria Workers WHO World Health Organization Y Year 1. Program Overview/Summary
Inform Asia: USAID’s Health Research Program, Associate Program Name: Award 2
Activity Start Date and September 24, 2015 to September 30, 2020 End Date:
Name of Prime RTI International Implementing Partner:
Agreement Number: Associate Cooperative Agreement No. AID-486-LA-15-00002
Geographic Coverage: Thailand and Lao People’s Democratic Republic (Lao PDR)
Reporting Period: Year 4, Quarter 1: October 1 to December 31, 2018
1.1 Program Description and Introduction Under the Leader with Associates Cooperative Agreement, Inform Asia was awarded a second Associate Award for technical assistance (TA) in malaria by the United States Agency for International Development (USAID) Regional Development Mission for Asia (RDMA). The period of performance for Inform Asia’s Associate Award 2 is from September 24, 2015 through September 30, 2020. As part of the President’s Malaria Initiative (PMI) support for malaria efforts in the Greater Mekong Subregion, Associate Award 2 promotes the use of evidence-based strategic information to inform decision-making, policy, and advocacy in Thailand and Lao PDR. The goal is to support malaria elimination in Thailand by 2024 and in Lao PDR by 2030. Figure 1 shows the Associate Award 2 results framework and Year (Y)4 activities.
Figure 1. Associate Award 2 Results Framework, Y4
SI = strategic information
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 1 The Y4 work plan for Associate Award 2 was approved on September 27, 2018. This progress report focuses on Y4 Associate Award 2 activities conducted in Thailand and Lao PDR during quarter (Q)1 (October 1–December 31, 2018).
1.2 Summary of Q1, Y4 Table 1 summarizes progress toward achieving results during Q1. Please see Section 2 and Annex 1 for additional detailed information regarding progress under each activity.
Table 1. Summary of progress toward achieving results achieved during Q1, Y4 Please note that Section 2.1 contains more detailed information on each activity.
Intermediate Results Summary of Progress Toward Achieving Y4 Results (IR): Activities
IR 1. Strengthened malaria surveillance systems in Thailand and Lao PDR Thailand Malaria Information System (MIS) Working Group: Three meetings were held in Q1: October 1, November 28, and December 24, 2018. The Activity 1.1. Strengthen the meetings provided technical leadership to the Bureau of Vector Borne leadership capacity of the Diseases (BVBD) MIS work and stewardship of Inform Asia’s workplan. national malaria programs in malaria surveillance and Lao PDR strategic information World Health Organization (WHO) Partner’s meetings: RTI participated in- person for the two meetings held in Q1: October 17 and December 12, 2018. The November Partner’s meeting was cancelled by WHO as the timing coincided with WHO’s surveillance meeting. Thailand In Q1, the Chief of Party (COP) and Epidemiologist provided technical input via the MIS Working Group to improve the Hospital Information System (HIS)-MIS for responses. Meeting participants agreed upon the pathway for integrating R506 information within the overall MIS architecture, which is expected to improve the link between case reporting and case response. Lao PDR Activity 1.2. Improve the In Y3 Q4, Inform Asia, in collaboration with the Centre for Malaria, quality and completeness of Parasitology and Entomology (CMPE), developed an activity plan that will reporting and responses (1) guide our work in Lao PDR and (2) serve as the reference document malaria cases, including the for RTI’s operational permit renewal application and memorandum of 1-3-7 strategy agreement (MOA). The MOA was submitted to the Ministry of Health (MOH) in October 2018. On November 26, 2018, a consultative meeting was held with local counterparts in Vangvieng, Vientiane province to discuss the activity plan. Q1 achievements include: • Activity plan developed • Activity plan and MOA submitted to MOH; awaiting approval by the MOH Cabinet. Thailand In Q1, Inform Asia provided TA to the BVBD to improve their standard operating procedures (SOPs) for iDES. The SOPs were updated using information gained from health staff during field observations and include Activity 1.3. Strengthen the standardized forms to promote consistency in the field. Inform Asia also integrated drug efficacy helped revise tools designed to support the provinces and districts to plan surveillance (iDES) and implement iDES and to process biological samples in a systematic manner. These improvements included a revised workflow for patient referral and follow-up, workflow for sample collection for processing blood slides and dried blood spot, reporting forms, and a sample collection form. In Q2, Inform Asia will support the translation of the updated SOPs and tools from Thai to English.
2 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Intermediate Results Summary of Progress Toward Achieving Y4 Results (IR): Activities Additional achievements in Q1 are listed below. • Improve the BVBD’s routine monitoring for iDES activities: During Q1, the BVBD appointed a focal point ( and it is hoped that this initiative will help progress this activity. The revised SOPs and tools will be used during future monitoring visits. • Conduct a formal review of iDES data: The BVBD was supported by Inform Asia to conduct review of the iDES and the results were presented/shared in a slide presentation format. The slide presentation is continuously updated to include new information as it emerges and in response to requests for additional information from the BVBD and the WHO. To date, the data has been presented at the following meetings: - American Society of Tropical Medicine and Hygiene (ASTMH) 2018 (October 28 to November 1). Presentation titled, “Integrated Drug Efficacy Surveillance (iDES): Feasibility of using routine case management and follow-up to monitor drug efficacy and resistance in Thailand”. - Drug monitoring and resistance in Thailand technical meeting (November 13th). The meeting was attended by representatives from BVBD, WHO, Armed Forces Research Institute of Medicines (AFRIMS), Mahidol-Oxford Tropical Medicine Research Unit (MORU), UCSF, USAID, and Inform Asia. - Joint International Tropical Medicine Meeting (JITMM) 2018, (December 12 to 14). Presentation titled “iDES: Using routine case management and follow-up to monitor drug efficacy and resistance in Thailand”. Thailand During Q1, Inform Asia began preparing to support the MIS Readiness Assessment. The in-country field assessment will be conducted from Activity 1.4. Conduct an March 4 to 16, 2019. In November 2018, replaced MIS readiness assessment as the team leader for this activity. Additionally, a local consultant ( ) was identified and contracted to work with the RTI home office team for this activity. Local data collection commenced in December 2018 and will continue in Q2. IR 2. Conducted research activities to evaluate strategies and tools for implementation and scale up for malaria elimination Thailand National level: No national-level meetings were scheduled or held in Q1. Subnational-level activities: The following subnational-level activities were undertaken during Q1: • Inform Asia provided TA to district/provincial health staff in Chiang Mai province and facilitated a workshop in Chiang Mai province on October 12, 2018 for 29 participants (14 men, 15 women) from Local Administrative Organizations (LAOs) in nine districts. • Based on recommendations from the Chiangmai workshop the Activity 2.1. Support Provincial Health Office (PHO) sent a letter to the Chief LAOs asking national- and subnational- them to consider funding support for malaria elimination activity. The level advocacy letters also provide information regarding the malaria situation in Chiangmai and suggest the LAOs’ roles and responsibilities in malaria elimination in their respective subdistricts. • Follow-up was provided to the Chiang Dao District Health Office (DHO) and Muang Na subdistrict LAO representatives who participated in the LAO workshop in Nonthaburi in August 2018 (see Y3 annual report). Nine key informants were interviewed: four from Muang Na LAO, two from Ban Muang Na health promotion hospitals (HPHs), one from a malaria clinic (MC), and one village leader and one village health volunteer from Ban Muang Na village. Thailand
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 3 Intermediate Results Summary of Progress Toward Achieving Y4 Results (IR): Activities
Inform Asia’s approach to this activity is to provide the BVBD with TA to review their policies and procedures in support of malaria elimination. As a result, during Q1, Inform Asia facilitated several meetings with BVBD to discuss strategies for simplifying the case investigation form, drawing on information from the MIS data review analysis conducted in Q4 Y3 by Inform Asia. Key findings include the following: • The results from this work was presented at the JITMM 2018 conference (December 12–14). The paper, “Malaria Case Investigation Review in Thailand, 2012–2017”, was presented as a poster and turbo talk. • Questions on the date of ailment onset, prior overnight trip, and the date and camping place are reportedly used to classify case and to determine the infection source site. • Other questions, such as the history of blood transfusion or repeated Activity 2.2. Evaluate the infections, had a low response rate. Therefore, Inform Asia suggested malaria elimination strategy, that the Center of Excellence for Biomedical and Public Health protocols, and results Informatics (BIOPHICS) extract a new set of data from the MIS (matching patient registration forms EP1 and EP3 data, including if the patient had was a Plasmodium vivax [Pv] episode during the last three month) to assess the completeness of this information on the EP3 form. Once completed, the Epidemiologist will assess the accuracy of the case classification, e.g., if the relapses match with the indigenous status of the malaria cases. • In Q2, Y4, further analysis will be conducted to confirm the accuracy of the case classification system and the source site determination in the case investigation database. Inform Asia will facilitate another stakeholder meeting to determine if there is a need to simplify the case investigation form and procedures. Lao PDR No activity occurred during Q1 as activities in Lao PDR are in the preparation phase. IR 3. Strengthened capacity of national malaria programs to generate, analyze, and use SI Thailand Inform Asia has been working with BVBD focal points, and , to improve SOPs and tools designed to streamline workflow, the sample collection process, and the submission process. The SOPs will serve as reference for monitoring and supervision. Activity 3.1. Strengthen the This effort is linked to Activity 1.3: Strengthen the iDES. supervisory capacity of the Please refer to Activity 1.3 for updates. national programs to promote data quality and use Lao PDR Inform Asia conducted an introductory visit with CMPE and assisted CMPE to organize a consultative meeting for Vientiane work planning. Please see Activity 1.2 for more details. Discussion with CMPE to plan and prepare for Malaria Elimination Training began in Dec 2018. No other specific activities were conducted in Q1 related to Activity 3.1. Thailand and Lao PDR combined activity Cost-benefit analysis (CBA) manuscript titled, “The investment case for malaria elimination in Thailand: A cost-benefit analysis” • CBA manuscript was submitted to the American Journal of Tropical Activity 3.2. Support the Medicine and Hygiene (AJTMH) on November 12, 2018. Positive national malaria programs to feedback was received and Inform Asia is revising the article for generate and disseminate SI resubmission in Q2. • ASTMH 2018: 1 oral paper and 2 poster presentations presented. • JITMM 2018: 1 oral paper and 1 Turbo Talk / poster presentation presented.
4 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 2. Activity Implementation Progress 2.1 Progress Narrative IR 1: Strengthened malaria surveillance systems in Thailand and Lao PDR Activity 1.1: Strengthen the leadership capacity of the national malaria programs in malaria surveillance and strategic information Thailand In 2017, with support from Inform Asia, the BVBD established the MIS Working Group with the goal of improving coordination, networking, and information exchange among BVBD partners, as well as providing TA on surveillance and strategic information. The working group also oversees Inform Asia’s activities under IRs 1, 2, and 3. Participants include BIOPHICS; BVBD; the Global Fund to Fight AIDS, Tuberculosis and Malaria, Regional Artemisinin-resistance Initiative 2–Elimination (GF RAI2E); Inform Asia, and Chemonics. Other short-term technical working groups are also established under the auspices of the MIS Working Group. Together, these working groups provide an important vehicle for technical and programmatic leadership and oversight. Meetings were not held regularly during Y3; therefore, some of the leadership potential of the working group was diminished. The MIS Working Group committed to meeting at least monthly during Y4 and in Q1. This commitment was honored and, hopefully, bodes well for the future. Inform Asia also committed to providing the working group with greater technical and secretariat support to help it realize its potential as a leadership body. In Q1, Y4, Inform Asia proposed to develop a policy agenda to guide the work of the MIS Working Group plus a two-year sustainability plan to prepare for the transition of Inform Asia activities. Neither of these tasks were commenced in Q1 due to the announcement of the resignation of , Inform Asia’s COP, which is effective February 15, 2019. Inform Asia decided that it would be better to delay the start of these activities until the new COP is appointed. It is anticipated that work will commence on both activities in Q2. Thailand: Year 4 subactivities
• Support the MIS Working Group to meet and function as leadership group In Q1, Y4, Inform Asia supported the BVBD to host a total of three MIS Working Group meetings, as follows: • The October 1, 2018 meeting included participants from the BVBD, BIOPHICS, ibitz, UCSF, Chemonics, Inform Asia, Akros and the Clinton Health Access Initiative (CHAI). • The November 28, 2018 meeting included representatives from BVBD, BIOPHICS, ibitz, UCSF, Chemonics, and Inform Asia. , team leader, Malaria Elimination Group, was unable to attend the meeting; therefore, Senior Public Health Technical Officer, led the meeting with support from Inform Asia. • The December 24, 2018 meeting was attended by participants from the Information Technology (IT)-Department of Disease Control (DDC), BIOPHICS, ibitz, UCSF, Chemonics, and Inform Asia.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 5 Key topics from the meetings are summarized below. Geographic Information System (GIS)-MIS: The GIS component in the MIS was offline in October 2018 to change from the fee-based Google Map platform to an open-source GIS platform. In November 2018, the IT-DDC informed the MIS Working Group of its recent procurement of the ArcGIS software and database, which cost 16 million Thai Baht (~$503,000), are available for use. The ArcGIS software and database contains layers of GIS information, including maps of housing structures and businesses, but does not have subdistrict or village boundaries. However, it can be customized for the MIS and boundaries can be added manually or with a global positioning system position. An existing limitation is that the number of users may affect the usage of the ArcGIS, particularly during training workshops. To align with the DDC strategy, the MIS Working Group agreed that all GIS-based information in the MIS should be synced with the ArcGIS software and database, including the GIS component in the MIS, the risk-mapping model, and mobile healthcare (mHealth) application. It was agreed that the team from ibitz will lead the development of the new online GIS- MIS webpage with technical support from the MIS Working group. The online GIS-MIS webpage is anticipated to be ready to view in April 2019 (Q3). Risk-mapping model and linking to the MIS: As discussed previously, the malaria risk- mapping forecast model was built on and integrated with the Google Earth platform by UCSF. Inform Asia provided the necessary information and dataset for model building. The model will be overlaid onto the new GIS-MIS (currently being developed as discussed above). The MIS Working Group agreed that ibitz will lead this activity with support from BIOPHICS, Inform Asia, and BVBD. mHealth application: The MIS Working group prioritized the development of mHealth application for malaria foci response and investigation. In this regard, at the October meeting of the MIS Working Group, the CHAI and Akros team presented their current mHealth application, which was built to support indoor residual spraying (IRS). As a result of this presentation, a field visit by BVBD, BIOPHICS, and Inform Asia to Maesot and Huaypakong districts in Tak province was undertaken from December 3 to 6, 2018. The information gathered during the field visit will be used to inform the development of the mHealth application to support foci response and investigation. The overall consensus was to let Akros continue to develop the mHealth application for foci management on the open-source GIS platform. However, the mHealth application will need to sync with the GIS-MIS webpage, which will be built on the ArcGIS platform. The ArcGIS platform was adopted and purchased by Thailand’s DDC-Ministry of Public Health and is available for use for all the Bureaus, including the BVBD. Data migration from the mHealth cloud-based database is not anticipated to be a major concern since the variables from MIS will be provided to the developer to build the mHealth application. The proposed timeline is to have the mHealth application (to be developed by CHAI and Akros) available by March 2019 (Q2) for review and ready to go live in May 2019 (Q3). The pilot is anticipated to begin in June 2019 in the following five provinces under Office of Disease Prevention and Control (ODPC), Region 10: Mukdahan, Yasothon, Amnat Charoen, Sisaket, and Ubon Ratchathani. Adjustments and updates to the mHealth platform should be completed prior to the rollout in 42 provinces, which will be done by GF RAI2E, in December 2019. To secure GF RAI2E funds allocated for mHealth rollout, Inform Asia assisted the BVBD to draft a proposal for the mHealth pilot, as well as
6 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 clearance request from the MOPH’s institutional review board. The Akros team will lead the development of the mHealth application with support from CHAl. The pilot of the mHealth application is a priority for the BVBD and the Bureau has requested that Inform Asia continue to support this work. Inform Asia will ensure that the MIS Working Group is regularly monitoring progress from now until the application has been developed. Improve HIS-MIS data and responses: The MIS Working Group prioritized the need to close the reporting loop between the R506 weekly epidemic report to improve the case notification-investigation-response activities under the 1-3-7 approach. As a result, BIOPHICS was tasked with designing this feature with technical support from Inform Asia. The due date for the new feature is February 2019 (Q2). In addition to data from R506, the MIS Working Group also identified the need to develop an case-based data entry system and identify the number of malaria tests for the Shoklo Malaria Research Unit. This new feature should improve the completeness of malaria surveillance information. Inform Asia provided technical and administrative support for this work via the MIS Working Group. Specifically, Inform Asia, as secretariat of the Working Group, ensured that the Working Group was updated on progress and was able to take any remedial action that may be needed. Once the new feature is completed Inform Asia will assist the BVBD in reviewing and verifying the data. The feature was completed in December 2018. Please refer to Activity 1.2 for details on the process. MIS Readiness Assessment: During this quarter, Inform Asia developed and shared the scope of work and timeline for the assessment. The local consultant, , was also introduced to all the MIS Working Group. As part of the assessment process, members of the MIS Working Group will be invited to share their insights and experiences of the MIS. The MIS Working Group agreed that the results from the assessment will be used to help determine priorities and resources for strengthening the MIS in the short-, medium-, and long-term. This activity is discussed further under Activity 1.4.
Lao PDR
Lao PDR: Year 4 subactivities • Participate in the Malaria Partners’ Meeting Two meetings were held in Q1 by WHO’s representative office in Lao PDR, one on October 17th and the other on December 12th. The November meeting was cancelled by WHO as the timing coincided with its surveillance meeting. Meetings are organized by WHO and provide a platform for all implementing partners, including Inform Asia to provide updates, raise issues or concerns, gather inputs, or collectively advocate to CMPE or relevant decision makers. A summary of the key outcomes from each meeting is below. October 17, 2018 meeting: The malaria outbreak in Nong district, Savannakhet province was discussed. All 137 patients were residents from the affected villages located in forest fringed areas. Half of the adult patients report that they had stayed overnight in the forests or in rice fields in the forest prior to infection. Infected children had no travel history. Entomological surveys found competent vectors in the village and in the rice fields and forests. Data collected from the District Health Information System 2 (DHIS2) during the response activities in five villages showed high long-lasting insecticidal net (LLIN) coverage, i.e., more than two LLINs per household. However, partners also observed that
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 7 there were still a significant number of unused LLINs. Most people within the villages reported seeking help from traditional healers for initial treatment. At fthe time o the meeting, a single Primaquine (PQ) dose was commenced but it was not fully implemented by the meeting date. Stock-outs of rapid diagnostic tests (RDTs) and antimalarial drugs were determined not to be an issue before or during the outbreak. As a result of the meeting, participants decided that the Provincial Anti-Malaria Station (PAMS) and District Anti-Malaria Nucleus (DAMN) should instruct the village malaria workers (VMWs) to apply the correct testing algorithm and communicate the need for routine use of LLIN. The meeting noted that in Nong district, only 19 of the 29 villages affected have VMWs. In response, it was decided that CMPE and the United Nations Office for Project Services (UNOPS) will discuss budget and reprogramming to ensure better coverage of VMWs. The PAMS and DAMN will also instruct the health centers to commence reporting weekly by phone to plan for response. The health centers must also start conducting Active Case Detection in villages that reported clusters of cases. Moving forward, Inform Asia will incorporate the lessons learned from the outbreak response in Nong and other districts in future trainings and mentoring of malaria program staff in Vientiane province. December 12, 2018 meeting: Inform Asia consultant, , was traveling and was unable to participate in this meeting. The COP prepared slides to update meeting participants on Inform Asia’s work, which included information on the status of the MOU between RTI and the MOH and a summary from the consultative meeting for the Vientiane work plan. Please see Activity 1.2 for further information about Inform Asia’s work in Lao PDR. Activity 1.2: Improve the quality and completeness of reporting and responses malaria cases, including the 1-3-7 strategy
Thailand
Thailand: Year 4 subactivities • Provide TA to the MIS Working Group to support their leadership and monitoring of the MIS data migration and operation To improve data migration from the hospital-based information systems and the data linkages to the MIS for 1-3-7 response, the consensus from the MIS Working Group was to create two levels of fuzzy logic. The first round of fuzzy logic will be between the weekly imported R506 data sent by the BOE and the R506 data stored from the previous week to remove duplicates. Only new cases will be merged with the BVBD-MIS. Following this round, a second round of fuzzy logic will be performed to identify and remove duplicates between the vertical program (BVBD-MIS) and general health services (R506). BIOPHICS will write the program for the fuzzy logic and the BVBD and Inform Asia will jointly review the results. BIOPHICS will be responsible for writing for writing the program for the fuzzy logic and the BVBD and Inform Asia will jointly review the results. See Figure 2 for a comparison of the current flow of malaria case information compared to the proposed workflow. The weekly R506 report provides the name of the treatment place but not the codes. Therefore, it is not currently used in the fuzzy logic algorithm. To improve the fuzzy algorithm for R506 data, the treatment place from 506 (based on the HIS-hospital code) will be matched and validated against the hospital list in the MIS database. Inform Asia will provide TA to this process.
8 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Figure 2. Current vs. proposed workflow to improve the information from the weekly R506 to the MIS
BOE = Bureau of Epidemiology; VBDU = Vector Borne Disease Unit
Lao PDR with focus on Vientiane province
In Q1, Y4, Inform Asia worked with CMPE Vientiane Province Work Planning Objectives to develop an activity plan (for Inform Asia ▪ Consult stakeholders and consolidate all activities in Lao PDR), which will be used activity plans on malaria elimination in Vientiane province, including Lao PDR as a reference document to facilitate RTI’s Government, RAI2E, RTI, WHO, and others. operational permit and MOU. The MOU ▪ Identify and define implementing/technical was submitted to DDC-MOH in October partners providing technical support on 2018, as planned. Subsequently, the DDC- malaria elimination in Vientiane province. MOH requested additional documents, ▪ Obtain consensus on the roles and which Inform Asia provided. In late responsibility in the implementation of malaria elimination strategy, including case December 2018, the MOH advised Inform investigation and 1-3-7 strategy. Asia to request a Memorandum of Agreement (MOA) instead of an MOU due to the budget level of the activity. Inform Asia is currently revising the documentation and plans to resubmit the paperwork in early January 2019. Lao PDR: Year 4 subactivities • Support CMPE to host a consultative meeting and develop an activity plan In consultation with CMPE, USAID/RDMA, and the USAID Lao Mission, it was agreed that Inform Asia could support CMPE to organize a consultative meeting in Q1 Y4. Taking advantage of the WHO-supported training in Vangvieng (November 27–30), Inform Asia assisted CMPE to host a consultative meeting on Vientiane province work planning on November 26. See text box for an outline of the meeting’s objectives. Thirty-five people participated in the meeting, including representatives from MOH, CMPE, Provincial Health Department (PHD) and PAMS, and DHOs and DAMNs from 11
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 9 districts. At the meeting, CMPE provided a status report on malaria elimination activities in Vientiane and Lao PDR as a whole, as well as shared the CMPE- and UNOPS-funded activity plans and budgets. Inform Asia presented an overview of its proposed scope of work for Vientiane province. The participants were divided into three small groups to review the activities planned under CMPE, GF RAI2E, and Inform Asia and to discuss areas of synergy and gaps. Highlights from the small group discussion are summarized below. Moving forward, Inform Asia will work closely with CMPE and partners, including WHO and GF RAI2E/UNOPS to address the issues raised and to ensure coordination of activities within Vientiane province. • All 11 districts reported less than 1% annual blood examination rates (ABER) (as of April 2018), which is well below the 3.5% national target set by the CMPE and WHO. All participants agreed that the low ABER results is concerning. The Vientiane Province Director emphasized to the DHO, PAMS, and DAMN that they need to increase malaria testing efforts. It was noted that active case detection is not part of the national malaria elimination strategy for low burden areas. However, participants agreed to emphasize screening of suspected cases and exposed cases (i.e., co-travelers or family members). As a result of this discussion, Inform Asia will work with the CMPE to agree upon an appropriate ABER target for improvement for Vientiane province and in order to mobilize sufficient RDTs. Inform Asia will work with CMPE to assist them to reinforce the importance of compliance with the testing and screening criteria at all future training and during supervisory visits. • Only one of the five malaria cases notified in 2018 was reported and investigated on time. The main reason provided was that the introductory 1-3-7 training by CMPE and WHO occurred in late 2018. The investigation concluded that it was an imported case and no further action was taken. There is no protocol to notify CMPE about a source of infection for imported cases. As a result of this experience, Vientiane participants requested additional training in the 1-3-7 approach. Further, participants agreed to notify CMPE of the suspected source of infection for imported cases. • Participants agreed that funding for the 1-3-7 activities should be available and managed at the provincial level by PAMS; however, currently there is no funding yet available including funds from GF RAI2E. The Vientiane PHD Director suggested that if funding was not available at PAMS, that the DAMN can request an advance from the DHO or PHO, subject to funding being available. • Further training for laboratory technical staff was recommended as a strategy to increase compliance to malaria testing and reporting. • It was noted that there is a need to strengthen coordination between district and health centers. Participants suggested that the DAMN should have a greater role in the coordination of malaria activities with health centers, including relaying news or updates. Inform Asia is aware that the BMGF is supporting the rollout of Emergency Operation Centers (EOCs), implemented by PSI. The program will work with all stakeholders to explore how the EOCs can help with malaria responses in Vientiane province. • Poor reporting from the police and military hospitals was noted and it was suggested that continued engagement is required to address this deficit. It was
10 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 recommended that staff from the police and military hospitals be invited to attend the monthly meetings at PHD or DHO, as well as al training and workshops. • Motorbikes were procured through a GF RAI2E grant, which should improve service coverage. • It was recommended that greater attention be paid to defining the roles and responsibilities within the 1-3-7 model. A WhatsApp group was created for Vientiane province and users report that the group is active and communication is moving freely. Participants also suggested that a consensus notification message may be easier to track and will ensure that the required information is included in the notification message. • The malaria activity plans in Vientiane from different funding sources is shown in Table 2 . Inform Asia will continue to coordinate with CMPE and WHO to create synergy in the partners’ activity plans and ensure that resources are efficiently used to address gaps in Vientiane.
Table 2. Summary of malaria activities and their sources of funding
Sources of Funding Malaria Activity WHO GF RAI2E RTI
Training Malaria elimination ✔ ✔ ✔ Malaria case management ✔ ✔ Surveillance & rapid response ✔ ✔ Supervision Central to province ✔ ✔ Province to district ✔ District to health center ✔ Case investigation a response ✔ ✔ Meeting & coordination ✔ ✔ Operation ✔
Table 3 summarizes the range of tools used for data collection, monitoring, and supervision developed by CMPE and technical partners. As a next step, Inform Asia will work with CMPE to ensure that suggestions from the field visit and consultative meeting are incorporated into the training that is planned for Q2.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 11 Table 3. Current list of tools for data collection, monitoring, and supervision for malaria elimination in Lao PDR
TA needed to adapt for File/Folder Name Description Vientiane Province (Yes/No)
F1, F2, and F3 malaria testing and treatment 1. Malaria testing and treatment registers No registers 2. Malaria Elimination Surveillance National guidelines on malaria elimination No Guideline–November 2017 implementation 3. Malaria Epi Report monthly analysis Provincial monthly DHIS2 dashboard report No template 4. Malaria Epi Report monthly elimination Provincial monthly malaria elimination report Yes template 5. Malaria Epi Report monthly outbreak Provincial monthly malaria outbreak No template response report 6. Malaria case detection and notification Job aid for malaria elimination sites Yes Job Aid developed by UCSF 7. Supervision check list national to Supervision form for CMPE to supervise No provincial level provincial level (PAMS) Supervision form for PAMS to supervise 8. Supervision check list PAMS to DAMN No DAMN 9. Supervision check list PAMS to Provincial Supervision form for PAMS to provincial No Hospital hospital 10. Supervision check list DAMN to HC Supervision form for DAMN to health center No Supervision checklist for village health or 11. Lao_SSV_malaria_VMWs_2018 V6 Yes malaria worker 12. Lao_SSV_malaria_HCs and Supervision form for provincial, district, and Yes Hospitals_2018 health center 13a. Lao_SSV_malaria_ELIM_DAMN_2018 Supervision form for DAMN in malaria Yes V6 elimination area Supervision form for DAMN in malaria 13b. Lao_SSV_malaria BR_DAMN_2018 V6 Yes reduction area
• Provide TA to CMPE, PAMS, and DAMN to establish a work flow plan for the oversight of the 1-3-7 strategy and reporting As an outcome from the consultative meeting, the work flow plan for 1-3-7 approach (see Figure 3) will serve as a road map for implementing activities. Inform Asia will continue to work with CMPE and Vientiane PAMS to include a description of the roles and responsibilities for each organizational unit. It will be used along with national case investigation and 1-3-7 guidelines during the training of Vientiane staff planned in Q2, which Inform Asia will support.
12 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Figure 3. Work flow for 1-3-7 strategy in Vientiane province
Activity 1.3: Strengthen the iDES
Thailand
Thailand: Year 4 subactivities • Provide TA to the BVBD to improve SOP and tool development for iDES Beginning in October 2018, Inform Asia along with BVBD and WHO began developing simplified SOPs for malaria case follow-up (referred to, informally, and in this report, as iDES). A finding from previous site visits was that field staff were confused as to which forms should be used because there are different forms in circulation from previous projects. To address this problem, the data collection tool was updated into a single standard form for case follow-up and reporting. The revised tool also included a work flow and new guidelines for sample collection (labeling and submission). See Figure 4 for a flowchart of malaria case follow-up. In October and November 2018, the BVBD shared the SOP tool with the Vector Borne Disease Center and VBDU in Mae Hong Son province and the PHO and VBDU in Sisaket province for their feedback. Upon receipt of their feedback, the SOP was updated accordingly. From December 25–26, a workshop on malaria case follow-up was hosted by the BVBD and funded by GF RAI2E with staff participating from 42 provinces. Inform Asia assisted in the preparation of training documents and the COP facilitated one of the small group discussions.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 13 Figure 4. Flowchart for malaria case follow-up in Thailand
• Monthly review of iDES data On November 2018, the BVBD organized an iDES meeting, which was attended by representatives from WHO’s Thailand office, from WHO’s home office, MORU, USAID, US AFRIMS, UCSF, Chemonics, and Inform Asia. Inform Asia analyzed data from the iDES pilot,1 which was presented to the group by BVBD. The data showed signs of poor drug efficacy against dihydroartemisinin- piperaquine (DHA-PIP) in Plasmodium falciparum (Pf) and chloroquine (CQ)-PQ in Plasmodium vivax (Pv) in Sisaket province compared to the seven other provinces in the pilot phase. In addition, AFRIMS shared results from their research which showed evidence of parasites from Sisaket province with mutation associated with drug resistance, i.e., increased copy numbers of the plasmepsin 2 gene, F145I mutation in Pfcrt gene, and low frequency of multiple copy numbers of the Pfmdr1 gene. MORU also shared that they observed treatment failure with DHA-PIP in a clinical trial completed in August 2017 at Phusing Hospital in Sisaket province. Their preliminary results suggested low treatment efficacy of DHA-PIP in Sisaket province. It was suggested that the same analysis should be done in every province using MIS data to see if this low DHA-PIP efficacy is limited to Sisaket province. Therefore, Inform Asia’s Epidemiologist ran an analysis on fiscal year (FY) 2018 case-based data in the MIS obtained from BVBD and determined that there were sufficient good quality data for the drug efficacy analysis. The resulting study design included malaria cases (uncomplicated Pf and Pv monoinfections) in all provinces treated according to the national treatment guidelines (previous analyses were limited the northern provinces and eight pilot
1 The eight provinces in iDES pilot included Sisaket, Ubon Ratchathani, Kanchanaburi, Chumporn, Suratthani, Maehongson, Chiangmai, and Chiangrai.
14 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 provinces). According to WHO recommendations for Therapeutic Efficacy Study, subjects with at least one visit after Day 0 can be included in the analysis. The results showed an overall DHA-PIP efficacy at 94.7%, but in Sisaket province the efficacy is reported at 81.8%. Further analyses would be needed to confirm the low efficacy observed in Sisaket province, including information on treatment compliance and molecular analysis of the parasites. This analysis will be used to support drug monitoring activities and drug policy discussion at that national level. Please note that a report from this work is proposed as a deliverable in the MEL Plan. Inform Asia will work with the BVBD and USAID to determine whether this deliverable should be a technical report or a manuscript. It is envisioned that product will involve the following as authors: BVBD, USAID, WHO, and RTI. See Annex 5 for methodology and detailed results. Activity 1.4: Conduct an MIS readiness assessment
Thailand
Thailand: Year 4 subactivities • In consultation with the BVBD and USAID, prepare a scope of work (SOW) was prepared and shared with the BVBD and USAID; feedback was received. The need for an assessment of the MIS was discussed with both the BVBD and USAID late in Year 3. Stakeholders expressed concern that the existing MIS and its associated infrastructure may not be robust enough for the long-term. As a result, it was recommended that Inform Asia assist the BVBD to conduct an MIS Readiness Assessment to: (1) gather information from users about their experiences of the MIS and identify areas for improvement; and (2) review the existing information technology infrastructure and assess its capacity to support the national malaria program for the medium- to long-term. If limitations to the current MIS are identified, the assessment will make recommendations for future action. It was proposed that the assessment take place in three stages. Stage one is focused on data collection and key informant interviews. A and a local consultant is currently leading this process and a summary report will be produced by the end of March (Q2). Stage two was designed to include an in-country visit from RTI’s Research Health Informaticist and again, a report building on the findings from the stage one report would be produced. However, this in-country visit may no longer be required. Please note that a discussion with USAID was held in January (Y4/Q 2) and it was agreed that Inform Asia may proceed with stage one of the assessment, (data collection) and following the completion of stage one, USAID, BVBD and Inform Asia will regroup to determine next steps and decide if the in-country field visit is needed. Stage three was envisaged as consensus building process based on the assessment findings and recommendations and again, the need for this stage will be determined in consultation with USAID and the BVBD.
In Q1, as part of stage one, the MIS Readiness Assessment team worked on a data collection tool that it plans to share with USAID and PMI in January 2019 (Q2) for their comments. See Table 4 for an overview of the teams’ roles and responsibilities.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 15 Table 4. MIS readiness assessment team member roles and responsibilities
Team Member Roles and Responsibilities Level of Effort Deliverables
• Provides team leadership and responsible for coordinating the 1. Data collection tools inputs of the other team 2. Assessment members and for the schedule/agenda preparation of the deliverables Up to 33 days—includes 3. Exit briefing Team Leader • Designs data collection one in-country presentation for • tools assessment. The actual USAID & BVBD number of days will be Senior Software • Oversees data analysis 4. Leads the Engineer, Research determined in preparation of draft • Supervises local consultant Health Informaticist, consultation with USAID and final report RTI • Prepares in-country and following stage-one 5. Consensus assessment schedule data collection. workshop • Serves as prime author for presentation report agenda & • Conducts consensus workshop presentations agenda & presentations • Contributes to the development of the data tool and conducts local data collection, including stakeholder interviews • Contributes to data analysis • Supports the development of Local Consultant the schedule/agenda for the in- country assessment 6. Data collection 25 days • Provides logistical support for summary report Independent the in-country assessment Consultant • Contributes to exit briefing presentation • Contributes to the draft and final report • Participates in the consensus workshop • Coordinates with Thai stakeholders and USAID on SOW • Coordinates with Thai counterparts and consultant for COP data collection 7. Consensus To be advised • Provides technical support and As needed workshop report Inform Asia perspective on Thailand malaria and action plan program, surveillance, and MIS • Provides management and logistical support • Oversees the consensus workshop Short-Term Technical • Provides technical support on Assistance (STTA) data quality and data use As needed • Provide inputs in the data Senior collection process and review Epidemiologist, Inform Asia STTA • Contributes to the development 10 days of the data collection tool
16 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Team Member Roles and Responsibilities Level of Effort Deliverables Research • Supports data analysis Note: Travel per diem Epidemiologist, RTI cost covered by RTI. • Participates in field work The need for this trip will • Contributes to report writing be discussed with USAID following the initial data collection. STTA • TA and peer review of the Up to 2 days Senior Director, report Systems Analysis & Programming, RTI STTA • TA and peer review of the Up to 2 days Research Mobile report Applications Developer, RTI
IR 2: Conducted research activities to evaluate strategies and tools for implementation and scale-up for malaria elimination Activities under IR 2 are designed to support dnational an subnational staff to evaluate strategies and/or tools for malaria elimination, including those supported under IR 1. The findings from these activities will be appliedn i IR 3 to generate SI for evidence-based decision-making when planning or implementing malaria elimination programs. Activity 2.1: Support national- and subnational-level advocacy
Thailand
Work under this activity will be undertaken in collaboration with UCSF so as to ensure coordination and to avoid duplication. A key outcome will be a case study on resource mobilization that evaluates the process and outlines lessons from Chiang Mai province. It is envisioned that this case study will be instrumental in helping other provinces advocate for funding. National-level advocacy: No high-level national meetings were organized in Q1. The next round of national-level advocacy is planned in Q2. Inform Asia will continue to support the BVBD by helping to prepare the meeting agenda and technical and advocacy materials for the meeting. Similar to Y3, a working group will be organized by BVBD to prepare for these high-level meetings. Note that as part of the National Malaria Elimination Strategy (NMES) plan and continued advocacy to ensure support of malaria elimination efforts, BVBD provides a secretariat to the two national-level committees for malaria elimination: the National Steering Committee for Malaria Elimination, chaired by the Deputy Prime Minister, and the National Administrative Committee for Malaria Elimination, chaired by the Permanent Secretary of the MOPH. The BVBD’s national-level advocacy goals are to (1) mobilize and sustain political commitment and ensure adequate resource allocation to support the implementation of the NMES and (2) create a supportive environment for multisectoral collaboration (and integration) in malaria elimination efforts. Subnational-level advocacy: Inform Asia is one of the technical partners assisting the BVBD’s subnational advocacy efforts to achieve the following goals: (1) strengthen
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 17 capacity of health staff to integrate malaria control and elimination activities into local health systems and (2) strengthen capacity of health staff (district/subdistrict and health facility level) to mobilize resources from local administrative authorities and stakeholders. Previously, Inform Asia supported the BVBD to prepare and organize workshops (e.g., training of trainers) on resource mobilization where guidelines for the LAO and malaria surveillance information from MIS were used to support subnational-level advocacy activities. In FY2019 , BVB D plans to support cascadin g workshops at the provincial/district level with funding from the national malaria program and GF RAI2E. On October 12, 2018 (Q1), Inform Asia coordinated with the Chiang Mai PHO and provided TA during the provincial-/district-level workshop on subnational advocacy at Chiang Mai Orchid Hotel. After discussion with PHO Chiang Mai, it was decided that the first activity should focus on introducing malaria elimination and local advocacy to LAOs. There were 29 participants (14 men, 15 women) representing LAOs from nine districts of Vienghang, Fang, Chai Prakan, Mae Ai, Chiang Dao, Sameong Hod, Chomthong, Om Koi, and Mae Cham. We decided to provide TA only to those LAO representatives whose roles would be relevant to public health issues in their community or who have decision- maker roles. In addition, Inform Asia’s consultant, , visited Chiang Dao district to follow-up and conduct interviews with representatives from VBDU and LAO who were part of the national training of trainer workshop in August 2018. The aim of the visit was to review progress towards resource mobilization. The information gathered will be used to develop the case study from Chiang Mai province. The case study will include an analysis of the range and appropriateness of funding sources available from the LAO and guidance for how provinces can access these funds. The case study will also discuss the rules and regulations that govern how the provinces may access LOA funding. Private sector sources of funding shall also be considered. The visit was joined by UCSF consultant, Ms. Pratin Dharmarak. Key issues identified from training in Chiang Mai and site visits in Chiang Dao include: • LAO staff were introduced to the malaria situation in their respective areas and encouraged to work closely with health staff from HPHs and VBDUs to develop a comprehensive and technically sound action plan and budget. • Key informant interviews have noted that, in the past, the provinces had made unnecessary or wrong procurements or used LAO funds to support ineffective malaria control activities. • As a way to focus attention on the malaria situation in communities, the LAO representatives suggested that the PHO send a formal letter to the LAO governing bodies with a list of A12 and A23 villages and request that the LAOs take action by supporting a proposal for malaria elimination in their respective communities. • Staff were happy with the guidelines on proposal development processes. However, some expressed concerns with financial documentation and auditing by the State Auditor since malaria activities and their costs may be unfamiliar to the Office of Government Auditor. Therefore, each auditor may interpret the allowable costs differently. This observation points to a need for continued advocacy and
2 Area stratification of malaria risk (village with malaria transmission reported in the past 1 year) 3 Area stratification of malaria risk (village with no malaria transmission reported in the last 1 year but less than 3 years)
18 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 communications between the public health sector, LAOs, and other ministries, including the Office of Government Auditor. • The LAOs’ consensus was to refer to the most recent financial regulations by the State Auditor. It was also agreed that LAO staff should provide coaching and some administrative support to HPHs or communication organizations submitting malaria elimination proposals. In November 2018, Inform Asia and UCSF updated the LAO Guidelines for Malaria Elimination4 to reflect the feedback received from health staff and LAO representatives during the August workshop in Chiangmai province and the October site visit to Chiang Dao district. These updates included • Additional descriptions to explain the malaria risk stratification. • Additional descriptions to provide distinction between the local resources from the National Health Security Office (NHSO) and LAO. The key difference is that the NHSO funds can be used for prevention and the LAO funds can be used for disease control and intervention. • Added resources, including of template of required forms and a successful proposal for LAO funds from Yala and Chachoengsao. Coordinating with the IT team, the updated LAO guidelines and workshop packages, including worksheets and unit cost for malaria commodities, were placed in the MIS resources menu. In addition to the production of the case study, Inform Asia will work with the BVBD and UCSF to track funding proposals prepared during Q2 and Q3, as proposed in the Y4 work plan. The Chiang Mai case study will include a discussion for how provinces can access LAO funding and for what purpose.
Activity 2.2: Evaluate the malaria elimination strategy, protocols, and results
Thailand
Thailand: Y4 subactivities • Document and disseminate the case investigation results Under this activity, Inform Asia provides TA to the BVBD to review the case investigation database and propose recommendations to streamline the case investigation form in support of improved data quality In Q2, additional analysis will be conducted to confirm the accuracy of the case classification and the source site determination within the case investigation database. During Y4, the following products will be produced a technical brief, PowerPoint presentation for the BVBD and a conference abstract. We will also draft a manuscript and seek publication. In Q1, Inform Asia facilitated meetings to discuss options to simplify the case investigation form, using information from the MIS data review analysis previously conducted by the Epidemiologist. At the December meeting of the MIS Working Group, Inform Asia facilitated discussion to evaluate and rank the most relevant questions of the case investigation questionnaire
4 USCF is arranging for an English translation of the Guidelines. It is anticipated that the translated guidelines will be available by the end of Q2.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 19 (i.e., the EP3 or case investigation form) to determine the most accurate source of a patient’s infection. Our preliminary analysis found that some questions included in the EP3 form were redundant to other forms, such as the current treatment regimen which is also in the Patient Registration Form (EP1). Further, for some questions, respondents could not remember or provide accurate answers, such as if they used a bednet during the time of infection, if there was residual spraying in the foci area, their use of repellent during the time of infection, their last treatment, and their last malaria episode. Questions on the date of ailment onset, if the patient had stayed overnight somewhere prior to date of ailment, and the date and camping place during infection were necessary to classify cases as indigenous or imported and to determine the source site. Other questions, such as a patient’s history of blood transfusion or repeated malaria cases aimed to determine if the case should be classified as a relapse or induced malaria and, consequently, classified as an indigenous case. However, as noted during the working group meeting, the very low frequency of the answers to these questions remained a challenge for analyzing their validity. Therefore, it was suggested that BIOPHICS extract a new set of data from the MIS (matching EP1 and EP3 data, including if there was a Pv episode during the last three months) to assess the completeness of this information on the EP3 form. After this, the Epidemiologist will assess the accuracy of the case classification, e.g., if the relapses match with indigenous status of the malaria cases. The working group raised another issue regarding the duration of incubation. It was suggested by the BVBD that as part of a quality check, the Epidemiologist build an algorithm to check if foci identification properly matched the place of overnight camping and the onset of the ailment, including an incubation period of 14 days for Pv infections. Finally, this activity was also discussed in the public sphere. Specifically, during JITMM 2018 conference held in Q1(December 2018), the poster, Malaria case investigation review in Thailand, 2012–2017, and a related turbo talk were presented. In Q2, new analyses will be conducted to confirm the accuracy of case classification and source site determination in the case investigation database. Inform Asia will develop a technical brief and facilitate meetings to provide recommendations on whether to simplify the case investigation form and procedures. • Evaluate area classification strategy and determinant factors contributing to active foci elimination To identify the most effective malaria control activities that can reverse active foci to non- active foci for malaria elimination, epidemiological and intervention data were extracted from Thailand’s MIS, which has been implemented since 2012. The analysis of foci reversion predictors co nducted between 2012 to 20 18 included the amount o f interventions and preventative measures that can rationally and successfully reach foci elimination. In previous exploratory analyses, logistic regression analyses were performed to predict the odds of successful foci elimination (conversion of active foci to non-active foci) based on the amount of interventions performed in that foci. Our hypothesis was that the higher the number of interventions would increase the likelihood of malaria elimination at an accelerated rate. • The dependent variables were the outcomes of malaria foci. − We reviewed the paths of 90,193 foci in the MIS from 2012 to 2018 and
20 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 grouped each foci to the following outcomes: ▪ persistent endemic (foci that remained active transmission), ▪ successful elimination (foci that had no active transmission by 2018), ▪ foci sustained elimination (foci that had no active transmission for at least 3 years prior to 2018), ▪ reversion (foci where malaria was reintroduced), ▪ others—those that did not fit the previous pathways. • The independent variables (malaria interventions) considered included LLIN and insecticide-treated net coverage, IRS coverage, and case detection rate (i.e., ABER). Exploratory analysis and logistic regression was then performed with foci from two provinces on the western border, Tak and Kanchanaburi. Inform Asia observed that the foci with the least number of positive cases at baseline were more likely to eliminate malaria sooner compared with foci that had a higher burden at baseline. This suggests the importance of controlling for disease burden when comparing successfully eliminated foci to persistently endemic foci. Higher coverage of interventions increased the likelihood of elimination; however, these results were not statistically significant. In Q1, in consultation with BVBD, Inform Asia reviewed and adjusted the study design methodology. The method will be a cohort analysis for foci follow-up with a start point in 2014 and endpoint in 2018. Figure 5 shows the starting cohort of 3,425 active foci in 2014 compared to 2018 where 200 foci remain active and 3,225 foci reverted to non-active foci. Figure 5. Foci reversion cohort analysis and Kaplan-Meier survival curve
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 21 Predictors of foci elimination. To understand active foci reversion, we assessed which interventions, such as the amount of interventions and preventative measures deployed, were the most successful by using a sensitivity analysis to identify the independent explanatory variables to be included in the multivariate analysis (e.g., Cox regression multivariate analysis). Population and malaria cases by foci: • Population size of the foci based on the number of people enumerated by yearly VBDU census (2012–2018) • Malaria cases per foci was based on the number of indigenous malaria cases, including − the number of indigenous cases per foci (2012–2018) − the number of imported cases per foci (2012–2018) • Malaria species (2012–2018) − Pf − Pv − Mixed infections and other species. Below are the independent identified covariates to be included in the Cox model for cohort analysis (after sensitivity analysis). Subjects’ characteristics
22 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 • A smaller foci was defined as a foci with a population of less than an average of 100 people over the last three years prior to the endpoint (measured as a binary variable). • A lower burden foci was defined as a foci with less than an average of 15 malaria cases over the last three years prior to the endpoint (measured as a binary variable). • The proportion of Pf cases per foci was based on the total number of Pf malaria cases per foci and the total number of malaria cases per foci over the last three years prior to the endpoint (measured as a continuous variable). • The proportion of indigenous cases per foci was based on the total number of indigenous malaria cases per foci and the total number of malaria cases per foci over the last three years prior to the endpoint (measured as a continuous variable). Interventions • The full investigation coverage of malaria cases by foci (100%) was based on the total cumulated number of malaria cases investigated and the total cumulated number of malaria cases in the foci over the last three years prior to the endpoint (measured as a binary variable). • The case investigation within one day was based on the number of cases investigated within one day and the total cumulated number of malaria cases in the foci over the last three years prior to the endpoint (measured as a continuous variable). • The Special Case Detection (SCD positive rate was based on the total number of positive cases found through SCD, the total number of malaria cases per foci, and the total number of malaria case per foci over the last three years prior to the endpoint (measured as a continuous variable). • The LLIN ratio was based on the total number of LLINs distributed and the average population per foci over the last three years prior to the endpoint (measured as a continuous variable). • Provinces were categorized, including Yala, Tak, and Sisaket as the provinces with the greatest number of non-reverting foci compared to other provinces at the endpoint 2018 (measured as a categorical variable). The design analysis is ongoing and other interventions conducted by the BVBD related to foci elimination were included in the model, such as the reactive case detection ratio, long- lasting insecticide treated hammock net coverage, IRS coverage, and repellent coverage. Further meetings with the BVBD, including with key partners, will be held to present the methodology and discuss the study design and review of the preliminary results. During Y4, a technical brief, conference abstract and PowerPoint for the BVBD will be produced. We will also draft a manuscript and seek publication.
Lao PDR
Lao PDR: Year 4 subactivities • Support documentation of lessons learned from the case investigation activities.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 23 No activities were undertaken in Q1. The scope of work in Lao PDR is currently being established. Please see Activity 1.3 for updates on TA support. IR 3: Strengthened capacity of national malaria programs to generate, analyze, and use SI Activities under IR 1 focus on strengthening malaria surveillance and the MIS, while IR 2 evaluates the effect of the MIS improvements on program performance and activities. Under IR 3, the focus is on strengthening the capacity of staff to generate, analyze, and use SI drawn from multiple sources, such as national databases, technical resources, and the national and global literature. Activity 3.1: Strengthen the supervisory capacity of the national programs to promote data quality and use
Thailand
Under this activity, we will support the national programs to institute a system of mentoring and gathering feedback from subnational-level staff on how to best promote evidence- based decision-making to ensure a successful malaria elimination goal. Inform Asia will assist staff in both Thailand and Lao PDR to document and communicate their successes, challenges, and lessons learned; thereby, contributing to the global knowledge base on malaria programming and strategies for elimination. Thailand: Year 4 subactivities • Develop user-friendly tools to motivate and empower staff to use the MIS • Please refer to Activity 1.3: Strengthen the iDES for a detailed discussion. • Assist the BVBD to institutionalize a system of quarterly site visits to support iDES. Please refer to Activity 1.3: Strengthen the iDES for a detailed discussion. Inform Asia has been working with staff from the BVBD, including and , to add more content to the SOPs and additional tools to streamline workflow, sample collection, and the submission processes. This included introducing a coding system for sample collection and workflow for sample processing and submission. The updated SOP for malaria case follow-up was used at the workshop organized by BVBD on December 25 and 26 in Nonthaburi. During the workshop, workflow templates were provided to participants during the group activity to draw a district-level workflow that would best fit their local context. The SOPs will serve as reference for monitoring and supervision. Please note that the SOP is being translated by the USCF team and they are now editing the English. We are advised that it will be available by the end of Q2.
Lao PDR
Lao PDR: Year 4 subactivities • Support CMPE to conduct site visits to monitor DHIS2 data quality issues Quarterly visits are proposed to start following MOU approval, which is anticipated for Q2. On November 26th (Q1), Inform Asia visited Vientiane province to conduct a consultative meeting for the province’s work planning. Please see Activity 1.2 for more information on the previous need assessment visit and recommendations from the consultative meeting.
24 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Activity 3.2: Support the national malaria programs to generate and disseminate SI Under this activity, support will be provided to the national programs in Thailand and Lao PDR to enable them to document and disseminate achievements in malaria elimination regionally and globally, thereby contributing to the global malaria knowledge base and increasing scientific stature. Inform Asia will support the national programs to develop these products, which will include research papers, presentations, and abstracts to be presented at scientific meetings and/or published in peer-reviewed journals; policy or advocacy briefs; lessons learned; and documented case studies.
Thailand and Lao PDR combined activity
• Develop a Communications Plan This activity links to Activity 2.2: Evaluate the national malaria elimination strategies, protocols, and results. In Q1, we proposed working with USAID, the BVBD, CMPE, and other stakeholders to develop a project-wide Communications Plan (covering Years 4 and 5). Unfortunately, this did not occur in Q1 as planned partly due to the resignation of the COP. All participants felt that a new COP needed to be appointed to drive this process. Going forward, the Inform Asia team acknowledges that they need to work more closely with partners and stakeholders to better map out what products should be produced and for which audiences. The Communications Officer, , commenced work on December 11, 2018. Once a new COP is appointed, the development of the Communications Plan will commence. Please see Table 5 for a status update on the SI and knowledge products that were under development in Q1, Y4. For the ASTMH 2018 meeting, Inform Asia supported the attendance of 4 delegates from Thailand (1 male and 3 female). For the JITMM 2018, Inform Asia supported the attendance of 3 delegates from Thailand (1 male and 2 female).
Table 5. SI and knowledge products under development in Q1, Y4
Status at Product Purpose Audience Key Messages End of Q1
Conference • MIS information on presentation: treatment and case follow up can be used to help • Oral presentation Disseminate (Number 1363) iDES: The the program monitor drug lessons learned given at the 67th Feasibility of Using Public health efficacy and patient on iDES in eight ASTMH meeting Routine Case professionals, outcome. provinces. presented by Dr. Management and academia, • Program can use near Contribute to the Saejeng, BVBD. Follow-Up Activities researchers, real-time information in body of to Monitor Drug and malaria MIS to improve case • Inform Asia knowledge in Efficacy and program follow-up, treatment conducted the malaria drug Resistance in managers compliance. analysis for drug resistance Thailand efficacy and surveillance. • Drug efficacy information assisted in slide in the MIS can be used to preparation. Links to Activity 1.3 support decision on and Activity 2.2. treatment policy. Conference Shared • Poster Public health • MIS is used to adjust the presentation: Thailand’s presentation professionals, location of village-based experience on (Number 1127) at academia, malaria posts (MPs) how MIS was the 67th ASTMH The Use of researchers, according to disease used to help meeting. Thailand’s Malaria and malaria burden and epidemiology. Information System improve access Presented by
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 25 Status at Product Purpose Audience Key Messages End of Q1 to Improve Access to malaria program • MPs performed 828,204 and Quality of services. managers tests and treated 68,966 BVBD. Malaria Services for patients from 2004–2017. Vulnerable • One-third of patients Communities treated at MPs were aged 14 years or younger and Links to Activity 1.2. one-third were women. Half of malaria patients treated at MPs were cross-border migrants compared with 20% treated at hospitals. • The model can successfully determine • Poster Conference Demonstrate areas of high risk four presentation presentation: use malaria weeks in advance, (LB5347) at the surveillance although with a large 67th ASTMH Public health information to margin of error (more than meeting. Development of an professionals, predict potential one-third of the total Presented by Automated Outbreak academia, outbreak or number of cases that Detection and early researchers, high-risk areas actually occurred). Next warning system for and malaria in advance for steps include exploring malaria in Thailand program • Inform Asia served preparedness other covariates, such as managers as the focal point, and/or to temperature and provided data for Links to Activity 1.1 prevent precipitation, and model building, and Activity 1.2. outbreak. understanding the spatial and reviewed the scale over which presentation. forecasts. Conference presentation: Disseminate • Poster results • Share results following A Health Public health presentation at the introduction of introduction and Communication professionals, 67th ASTMH health evaluation of a health Package to Increase academia, meeting. communication communication package Drug Adherence researchers, Presented by package to to increase treatment among Vivax and malaria increase adherence in remote malaria patients program ODPC treatment areas on the border of without G6PD managers 1, Chiang Mai adherence for Thailand and Myanmar. Deficiency on the province. International Pv patients Borders of Northern Thailand Disseminate • Oral presentation lessons learned. given at JITMM Contribute to the 2018. Scientific Conference • Surveillance data can be Session 14: presentation: body of used to detect and Current status of knowledge to confirm changes in support antimalarial Integrate Drug Public health malaria epidemiology evidence-based resistance and its Efficacy professionals, trends. advocacy and impact on clinical Surveillance: malaria decision- • Malaria surveillance practice. Implications on Drug program making. information should be Presented by Policy and Malaria managers, and used to inform and adjust Analyses of drug Elimination researchers. program activities. The efficacy from • Inform Asia demographic of risk routine case conducted the groups and patients is Links to Activity 1.3 follow-up from analysis for drug changing. and Activity 2.2. national data efficacy and from 2012 to assisted in slide 2018. preparation.
26 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Status at Product Purpose Audience Key Messages End of Q1
• Most of the respondents in a recent survey Disseminate reported using the MIS. Conference lessons learned presentation: to health • Use of MIS dashboards • Turbo talk and professionals provides timely poster presentation and malaria information and, likely (P-13) at the Malaria Case program contributed to significant JITMM 2018 Investigations in managers in Public health increase in case presented by Thailand, FY2013– other countries professionals, investigation—up to 96% , Inform FY2017: Strategic conducting case malaria in 2017 (p = 0.001). Asia Information investigations. program • Outbreaks may put a Epidemiologist. Generated from Contribute to the managers, and strain on malaria staff and • Inform Asia Thailand’s Malaria body of researchers. affect case investigation conducted the Information System knowledge to rates, as seen in Ubon analyses and Can Improve support Ratchathani and Pattani. prepared the Program evidence-based poster and turbo Effectiveness • Case investigation is now advocacy and conducted at the time of talk. Links to Activity 2.2 decision- diagnosis. As a result, making. 89% of facilities reported 100% of cases on time. • Two approaches for malaria case projection approaches, combined • Manuscript with context-specific submitted to the programmatic and Disseminate American Journal economic data, were used results CBA for of Tropical Peer-reviewed to show that malaria Thailand. Public health Medicine and publication: elimination would be cost- professionals, Hygiene on Contribute to the saving for Thailand. body of academia, November 12, The Investment • The CBA results provided knowledge to malaria 2018. Feedback Case for Malaria the Thai Government with support program received and the Elimination compelling evidence that evidence-based managers, and paper is currently Thailand: A Cost- the benefits outweigh the advocacy and researchers. being revised. Benefit Analysis costs of malaria decision- Note: the manuscript elimination and that efforts making. was accepted for to advocate for malaria publication in programming to be Q2/February. prioritized, including the full funding of the NMES, are beneficial.
2.2 Implementation Challenges COP and staff turnover: In Q4, Y3, COP resigned with a departure date of February 15, 2019, to allow for overlap and training with new COP. This has resulted in some activities scheduled for Q1 to be deferred to Q2, including the following: • Activity 1.1: Strengthen the leadership capacity of the national malaria programs in malaria surveillance and strategic information. The development of the policy agenda for the MIS Working Group and the Sustainability Plan will now take place in Q2. • Activity 1.4: MIS Readiness Assessment. was appointed as the new team leader for this activity following the departure of . A desk review and development of data collection tools for qualitative interviews of MIS users
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 27 and key informants started in Q1. The qualitative interview and in-country field assessment were moved from Q1 to Q2 (March 4–16) to enable the new COP to participate. • Activity 3.2: Support the national malaria programs to generate and use SI. The development of the Communications Plan will take place in Q2 to enable the new COP and the Communications Officer to participate. Counterpart availability: Inform Asia has experienced difficultly with accessing key counterpart staff due to the multiple demands placed on BVBD leadership and other staff, which has caused some activities to be delayed. In Q1, Y4, Inform Asia increasingly worked directly with activity focal persons (mainly mid-level technical officers, most of whom are women) within the BVBD, which has reduced some of the dependency on BVBD leadership, particularly , team leader, Malaria Elimination Group. This strategy has helped improve our work processes, however, bottlenecks at key decision points still remain. Hopefully, these bottlenecks will improve as these mid-level staff gain greater confidence and authority. Delay in national program activity: In Thailand and Lao PDR, it is often the case that there are late changes to the scheduled activities, delay in funding, and conflicting schedules of key staff, and ad-hoc requests to the BVBD from DDC leadership. These changes can affect TA support or Inform Asia’s activity timeline. Inform Asia continues to closely engage with the BVBD and CMPE to minimize changes and communicate changes as early as possible. Challenges working in Lao PDR: In Q1, Y4, Inform Asia was asked to submit an MOA instead of an MOU to the Lao PDR Government due to the size of the program’s budget. Overall, both memoranda are similar in terms of scope, however, the MOA will require annual submission and approval, whereas the MOU can cover the length of the program. In addition, in previous program years, Inform Asia had initiated the process to add a full- time program officer in Lao PDR by Q1, Y4; however, the recruitment was put on hold as directed by RTI following the Whitehouse Trafficking In Persons Report Announcement in early December 2018. The White House announcement indicated cancellation of eligible FY 2019 funds for “nonhumanitarian, nontrade-related assistance” to tier three countries included in the 2018 Trafficking in Persons report until “such governments comply with the minimum standards or make significant efforts to bring themselves into compliance with the Trafficking Victims Protection Act of 2000.” To accommodate this mandate, Inform Asia adjusted the agreement and engaged as a full-time local consultant during the waiting period. 2.3 Monitoring, Evaluation, and Learning (MEL) MEL indicators for Q1, Y4: Please see Annex 2 for a summary of the MEL project indicators for this reporting quarter. Data collection for indicator reporting: A number of activities were conducted in Q1 to support data collection needs to enable reporting under the MEL Plan. Please note the following: • Outcome Indicator 1: Improved capacity in using evidence-based decision- making to achieve malaria elimination − The development of a scorecard to measure increased capacity in evidence- based advocacy was delayed to Q2 to allow the new COP to lead this activity.
28 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 • Semiannual survey for Indicator 3.1: Percentage of individuals who report that they generated, analyzed, or used SI in their work − The data sources in Lao PDR for Indicator 3.1. Percentage of (MIS or DHIS2 users) individuals who reported that they generated, analyzed, or used strategic information (SI) in their work, is the DHIS2 users’ survey. During Q1, Inform Asia reviewed data collected via this survey, which is based on the MIS user survey used in Thailand in September 2018. The survey was adapted to Lao PDR and the DHIS2 context, and then translated to Laos. It went through a review process with CMPE before rollout. − It was decided that the electronic survey will be used, however, it was not possible to utilize the DHIS2 platform after consulting with WHO and CMPE. Inform Asia prepared an electronic survey in Google Docs, which is currently under final review with CMPE and Vientiane PHD. The link to the electronic survey will be distributed by email to DHIS2 users in Vientiane province in Q2. Data will be presented in the semiannual report. − The next semiannual survey for Thailand is planned for March 2019 (Q2). Pause and reflect sessions: Check-in conversations were conducted with BVBD to ensure Inform Asia’s TA efforts aligned with the BVBD’s objectives and work plan and to discuss issues that can influence activity timeline, including issues that cannot be addressed directly through the MIS Working Group. In support of orientation for the new COP and as part of the preparation for the semiannual report, a formal pause and reflect session with the BVBD and USAID will be scheduled. MEL and gender sensitivity: The need to address the importance of gender sensitivity in the program cycle’s MEL emerged in Q1. A meeting was held on December 21st with RDMA and their Gender Specialist to explore how Inform Asia could improve its response to gender. Per discussions with USAID, Inform Asia will review the current indicators and update the description in the Indicator Reference Sheets to describe how our gender integration efforts will translate into MEL activities. Moving forward, Inform Asia will develop a Gender Equality and Female Empowerment Checklist to systematically apply gender awareness and sensitivity dimensions to all of Inform Asia’s proposed activities, such as the MIS Readiness Assessment, and for knowledge products to be proposed in the Communications Plan for Y4 and Y5. Furthermore, the team will work with our key counterparts to promote gender equality and female empowerment. This will include, but will not be limited to, ensuring gender balanced training; conducting gender analysis in post-training impact assessments to ensure that women equally benefit from Inform Asia’s training efforts; and identifying female staff to take on more decision-making roles through advocacy, mentorship, and engagement. The MEL plan will be modified accordingly and submit to USAID for review and approval in Q2, Y4.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 29 3. Management and Administrative Issues
3.2 Staffing and Management 3.2.1 Staffing COP recruitment: Inform Asia staffing will undergo significant change early in Y4. Most notably, COP, will leave the project on February 15, 2019. Recruitment for a new COP is underway. Communications Officer appointed: In December (Q1), the new Communications Officer, , commenced with the team in Bangkok. He will support communications work for the program’s work in both Thailand and Lao PDR. Malaria Program Officer, Lao PDR: As outlined in the Y4 workplan, Inform Asia intended to transfer the local consultant position in Lao PDR to a full-time position under Inform Asia in Q1. However, for reasons discussed in Section 2.2, Implementation Challenges, the recruitment was deferred until Q2. In the meantime, to ensure uninterrupted support during the project set-up phase, Inform Asia has engaged a full-time consultant in Lao PDR. Epidemiologist position: As outlined in the Y4 work plan, RTI also intended to transfer the local epidemiologist consultant position, filled by , in Bangkok to full-time RTI employee status in Q1. However, in light of the need to recruit a new COP, the program had to adjust its staffing plan and budget to accommodate the appointment of an expatriate COP. The Y4 budget is unable to afford two expatriate full-time positions. Currently, our plan is to continue to contract as a consultant. Please see Figure 6 for an updated organogram.
30 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Figure 6. Inform Asia’s organogram, Y4 Q1
COP TBD
STTAs
Finance and Communication Officer Administration Officer
STTA: The Y4 workplan also includes an STTA pool of local and international consultants identified to support program activities. Table 6 shows consultant STTA support for Q1.
Table 6. STTA inputs named in the Year 4 work plan and their contribution by the end of Q1
Name Role Activity Link Q1 Outputs
• Conducted drug efficacy analyses for discussion with relevant partners and for presentation at national and Activity 1.3: Strengthen the international meetings. iDES • Analyzed the MIS and Activity 2.2: Evaluate the prepared data for Inform Asia malaria elimination strategy, indicators. protocols, and results Epidemiologist • Analyzed and facilitated Activity 3.2: Support the discussion on malaria case national malaria programs to investigation review in generate and disseminate SI Thailand. Provide technical inputs on • Provided technical inputs in other activities. other Inform Asia activities, including Activity1.4: MIS readiness assessment and review of technical documents. MIS readiness Activity1.4: MIS readiness Data collection tools and reporting assessment team assessment template in development. leader MIS readiness assessment local consultant Contribute to data Activity1.4: MIS readiness To begin in Q2 collection tool assessment development and support data collection and analysis Subnational-level Activity 2.1: Support Revised LAO Guidelines for advocacy local national- and subnational- Malaria Elimination with BVBD consultant level advocacy and UCSF.
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 31 Name Role Activity Link Q1 Outputs Supported Chiangmai PHO to conduct LAO workshop in Q1. • Updated the activity plan and Activity 1.1: Strengthen the supported MOU/MOA leadership capacity of the preparation and submission. national malaria programs in • Coordinated with CMPE to malaria surveillance and organize a consultative Local consultant strategic information meeting for Vientiane work (malaria) Activity 1.2: Improve the planning in November 2018. quality and completeness of reporting and responses • Worked with the COP to malaria cases, including the update and customize DHIS2 1-3-7 strategy user survey as part of data collection for Indicator 3.1. • Contributed to reporting. Program Manager All activities • Supervised the COP. Program Operations All activities Financial oversight Manager Editor & Document All activities Reporting Preparation Specialist
3.3.2 Management Relocation of the Bangkok team to a new space within the BVBD: Early in Q2, Inform Asia will be moving from its current space at the BVBD to a new space adjacent to the current room. The new space was previously a laboratory and will, therefore, need some minor renovations to make it suitable. Update on MOA for Lao PDR: In December 2018, the MOU was updated and submitted to the DDC and is now waiting for approval from the cabinet member level. A representative from t he D DC-International C ooperation unit participated in the consultative meeting in Vangvieng and expressed support for the activities and TA efforts proposed by Inform Asia. Please refer to Activity 1.2 for more details.
4. Planned Activities for Next Quarter, Including Upcoming Events and Travel
International travel proposed for Q2, Y4 is detailed in Table 7.
Table 7. International travel proposed for Q2, Y4
Link to Activities Traveler Origin Destination Trip/Days and Description
All activities; COP: To be To be determined Bangkok, One trip to work Mobilization to take up confirmed (TBD) Thailand location COP position COP orientation at COP: To be Bangkok, Jakarta, 1 trip RTI’s Asia Regional confirmed Thailand Indonesia 6 days Office Malaria elimination COP: To be Vangvieng, 1 trip training for DAMN and Bangkok, Thailand confirmed Lao PDR 6 days PAMS in Vientiane
32 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 Link to Activities Traveler Origin Destination Trip/Days and Description Malaria elimination Vangvieng, 1 trip Finance and training for DAMN and Bangkok, Thailand Lao PDR 3 days Administration Officer PAMS in Vientiane , MIS MIS assessment in- Atlanta, Georgia, Bangkok, 1 trip assessment team country field visit USA Thailand 14 days leader 1 trip , MIS 14 days MIS assessment in- Oxford, England, Bangkok, assessment, research Note: Travel costs country field visit UK Thailand epidemiologist will be covered by RTI corporate funds Management and , Brisbane, Bangkok, 1 trip orientation for new Program Manager Australia Thailand 6 days COP Financial oversight Wilmington, Jakarta, 1 trip Program Operations and orientation for Delaware, USA Indonesia 6 days Manager new COP in Jakarta
Inform Asia: USAID’s Health Research Program; Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 33 Annex 1: Y4 Milestones, Deliverables, Targets, and Timeline Against Results in Q1, Y4
Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan
IR 1: Strengthened malaria surveillance systems in Thailand and Lao PDR
Activity 1.1: Strengthen the leadership capacity of the national malaria programs in malaria surveillance and strategic information
Thailand • 3 MIS working group meetings • Up to 12 meetings of MIS Working Group • 3 MIS Working Group were held, Monthly planned, one for January, held with Inform Asia providing high-quality 12 one in October, November, and Q1–Q4 February, and March 2019, secretariat support December 2018, respectively. respectively. • Deferred to Q2 when new COP • In collaboration with the BVBD, • Sustainability plan developed 1 Q2 arrives. develop draft of plan. • No action this quarter as the • In collaboration with the BVBD, • Sustainability plan reviewed 2 Q3–Q4 plan’s development was review draft of plan. deferred. • Agenda and meeting minutes • Agenda and meeting minutes will • Agenda, minutes, and working documents Monthly 12 were summarized and shared be summarized and shared with disseminated to stakeholders Q1–Q4 with group. group. • Subworking groups established to support • No formal subworking groups • World Malaria Day 2019 on April TBD TBD specific issues (TBD, as needed) were established this quarter. 25, 2019. Lao PDR • Participated in-person for the • 3 WHO Partner meetings; Monthly two meetings in October and • Participated in the WHO partner meetings 12 planned for January, February, Q1–Q4 December. No meeting was and March 2019. organized in November. • Advocate and assist CMPE to • Contributed and participated in the DHIS2 Monthly • No meeting was organized by 12 organize at least 1 DHIS2 working group meeting organized by CMPE Q1–Q4 CMPE. working group in Q2.
34 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan
TBD by • Contributed to and participate in the USAID • No USAID partner’s meeting in • Participate in USAID partner’s 2 USAID/Lao partner’s meeting Lao PDR were organized. meeting in Lao PDR. PDR Activity 1.2: Improve the quality and completeness of reporting and responses of malaria cases, including 1-3-7 strategy Thailand • Improvement of case-based information for patients who were treated in the hospitals: • Workflow aimed at improving the • Monitor development of MIS number of malaria tests performed, malaria 1 Q1–Q3 information from weekly R506 to features to improve quality of treatment provided, and compliance with Continuous the MIS developed and agreed. R506 and MIS data. national treatment guidelines in hospital settings • Document the integration and • Documentation of the integration and 1 Q1–Q4 • Ongoing verification processes through verification processes Continuous MIS Working Group Lao PDR • MOU developed; however, MOH requested the MOU to be • Activity plan already competed in • Activity plan and MOU/MOA developed 1 Q1 changed to MOA Q1. Activity plan may be adjusted quarterly. • MOA cleared CMPE-DDC • Expect MOA approval from • MOA was summited to MOH in • MOA approved 1 Q2 Health Minister and Ministry of Q1; awaiting approval. Foreign Affairs. 1 • Activity Plan implemented Q2–Q4 • Activity plan developed in Q1. • Begin implementing activity plan Continuous • Following discussion with • Work flow mapped and agreed CMPE, a Consultative Meeting upon by CMPE, PAMS, and for Work planning was DAMN in Vientiane province. • Orientation workshop organized; meeting conducted in Q1. 1 Q2 • One 3-day training workshop notes documented and disseminated • During the Consultative Meeting, conducted with Inform Asia an orientation/training workshop support. Targeted 2 PAMS staff for malaria elimination was and 11 DAMN staff from discussed for Q2. Vientiane province (Lao PDR).
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 35 Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan
Activity 1.3: Strengthen the iDES Thailand • BVBD, WHO, and Inform Asia drafted and shared simple SOP in Q1. • SOP was updated following inputs from field staff and field observations. • The revised SOP introduced • Edit and finalize SOP for the stickers for drug package with Thai context • Updated iDES SOPs and tools developed 1 Q1 treatment instruction and follow- • Design and format SOP and disseminated up appointment information. • Translate SOP from Thai to • A refresher training was hosted English for staff from 42 provinces from December 24 to 25. Inform Asia assisted in document preparation, and participated in the meeting where the COP facilitated one of the small group discussions. • was identified as • BVBD’s iDES focal person mentored to • Use the SOP to gauge case 1 the focal person for iDES in Q1. review data and provide feedback to Q1–Q4 follow-up processes and Continuous provincial and district health staff • As above, a refresher workshop performance of health staff was held. • Provided TA to analyze drug efficacy for iDES meeting and for • Continue to provide support to two international conferences, BVBD to monitor drug efficacy Monthly ASTMH 2018 in October (1 male • Monthly review of iDES data 12 surveillance data Q1–Q4 staff, 3 female staff from BVBD and ODPC 1) and JITMM 2018 • Use the information to help in December (1 male, 2 female improve the dashboard staff) from BVBD. Activity 1.4: Conduct an MIS readiness assessment
36 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan
Thailand ailand • Activity delayed due to changes • Assessment stage 1: Desk review and data in Inform Asia staffing. collected 1 Q 1 • Activity will take place in Q2 • Desk review started to collect • In-country assessment schedule developed information on IT infrastructure. • Assessment stage 2: In-country assessment 1 Q1 conducted and exit debrief presented to USAID and BVBD • Activity delayed due to changes 1 Q1 • Activity will take place in Q2 • Draft report produced and distributed for in Inform Asia staffing. feedback 1 Q2 • Final report produced and disseminated IR 2: Conducted research activities to evaluate strategies and tools for implementation and scale-up for malaria elimination Activity 2.1: Support national and subnational-level advocacy Thailand • National Administrative Committee: Meeting agendas, presentation slides, and talking 2 scripts for Chairperson and Secretary • No meetings were organized at Q1–Q4 • Meeting is planned in Q2 • National Steering Committee: Meeting the national level. 2 agendas, presentation slides, and talking scripts for Chairperson and Secretary • Advocacy workshop conducted • Advocacy workshop conducted in in Chiangmai for 29 participants Chiangmai province with TA from Inform 1 Q2 • Completed (14 men, 15 women) from nine Asia and funding from GF RAI2E districts on October 12, 2018. • Inform Asia’s consultant, , visited Chiang • Chiang Dao district will submit • Workplan proposals to LAO developed for their respective LAO in January 165 Q2–Q3 Dao district to conduct interviews Chiangmai province with representatives from VBDU 2019. and LAO that were part of the • Document progress. national workshop in August
5 There are 20 subdistricts with A1 villages in Chiangmai province. We estimate that approximately 80% of the subdistricts will develop proposals.
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 37 Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan 2018 to document the processes for mobilizing local resources. Activity 2.2: Evaluate the national malaria elimination strategies, protocols, and results Thailand and Lao PDR (links to Activity 3.2) • Additional analysis to be done on new set of data with matching EP1 and EP3 data, including repeated episodes in previous • An algorithm for quality analysis • Consensus from stakeholders on the three months. The analysis will of foci identification will be findings and recommendations from case 1 Q1 assess the accuracy of the case developed and consulted with investigation review classification. For example, stakeholders before the analysis. classification of relapses cases, timing, and duration of incubation period.
• 2 abstracts accepted and • Discussed abstracts for ASTMH Q2 • 2 abstracts to ASTMH 2019. 2 presented at ASTMH 2018. 2019 with BVBD and USAID. (~April 2019) Please see Table 5 for details. • Prepared abstracts.
• 2 abstracts presented at JITMM • Discussed abstracts for JITMM Q3 • 2 abstracts to JITMM 2019. 2 2018. Please see Table 5 for 2019 with BVBD and USAID. (~July 2019) details. • Prepared abstracts. • Manuscript submitted to AJTMH • Revise, as needed, according to titled, The investment case for • Manuscript or report 1 Q2 reviewers’ comments for malaria elimination Thailand: A publication. cost-benefit analysis IR 3: Strengthened capacity of national malaria programs to generate, analyze, and use strategic information Activity 3.1: Strengthen the supervisory capacity of the national malaria programs to promote data quality and use Thailand and Lao PDR • Introduce tools during Malaria • User-friendly tools and checklist developed • In development by COP and 1 Lao PDR Q2 Elimination training planned for to motivate and empower staff to use MIS local consultant, . Q2.
38 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan
• No site visit for iDES this 4 Thailand Quarterly • Quarterly site visit reports quarter, as BVBD organized • Site visit. 3 Lao PDR Q1–Q4 workshop in December 2018. Activity 3.2: Support the national malaria programs to generate and disseminate strategic information Thailand and Lao PDR • Plan for Malaria Day 2019. • Tentative plans include a public event (half day) and technical seminar (half day). Possible seminar topic to be decided with • Commenced discussion with • Planning for World Malaria Day 1 Q1–Q3 stakeholders, such as subnational BVBD. 2019 will commence early in Q2. mobilization, iDES/follow-up, or malaria surveillance. • Promotional materials developed. • Provide TA to BVBD to on • Ongoing work with BVBD to • Malaria-free province verification process malaria-free province verification 1 Q2–Q3 review guide for document for 2019 completed (Thailand) and reintroduction processes. verification processes. • Document verification processes. Management, Staffing, and MEL activities Thailand and Lao PDR • Recruitment for new COP • Date of mobilization of COP • New COP recruited and in post 1 Q1 to Q2 underway. TBD. • As discussed under Section 3.2.1, this position was • Epidemiologist position appointed 1 Q1 withdrawn in light of the COP • Consultant input ongoing. appointment and will remain as STTA consultant. • Communication Officer, appointed; • Recruitment completed—no • Communications Officer appointed 1 Q2 commenced on December 11, further action. 2018
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 39 Target for Milestones and Deliverables (and Y4 Work Timeline Outputs in Q1 Plan in Q2 Personnel) Plan
• Recruitment on hold due to US • Malaria Program Officer (Lao PDR) • Consultant input ongoing. 1 Q2 Whitehouse announcement and appointed Recruitment in Q2. government shutdown. • Semiannual survey of MIS users, Indicator • To be conducted in early 2 Q2 and Q4 • Survey prepared for Lao PDR. 3.1 January. • Baseline and annual review of scorecard for • Scorecard to be updated to • Final scorecard and data increased capacity in evidence-based 1 Q1 and Q4 include gender-sensitive collection. advocacy, Outcome Indicator 1 indicators. • Team had a pause and reflect • Another team pause and reflect • Quarterly pause and reflect session held 4 Q1–Q4 meeting in October 2018 to session is planned for January with stakeholders inform work plan for Y4. 2019. • Amend/addendum to MEL to • Amend/addendum to MEL to include gender • Discussion with USAID on 1 Q2 include gender-sensitive sensitive indicator gender- sensitive indicator indicator.
40 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Annex 2: Monitoring, Evaluation, and Learning Indicator Reports (as of Q1, Y4)
o
FY 2018 FY2019 of t
ine l Indicator Data ing t ency Brief Description r Remarks Number & Name Source RDMA Target Actual Target Q1, Y4 Base equ r Repo F
This indicator measures the enhancement of the national malaria programs’ capacity in using Scorecard evidence-based decision- with making to achieve malaria Indicator 1. descriptive elimination as a result of sentences Thailand: Thailand: Improved capacity US Government (USG)- in using evidence- for each 2 2 supported Inform Asia TA. Annually TBD TBD — Collect annually based decision- indicator Lao PDR: Lao PDR: A scorecard will be used making to achieve with four 2 2 as a tool to quantify a malaria elimination numerical qualitative process of TA ratings (0– that aims at building 3) capacity in using evidence-based decision- making of the national malaria programs. This indicator aims to demonstrate improvement in the workforce’s capacity through increased knowledge in malaria Pre- and Indicator 1.1. surveillance among post-test Increased individuals after results of 0 One batch of training in Lao knowledge of completion of training individuals Quarterly 4 4 4 0 (2018) PDR planned in Q2 participants in workshop(s) conducted and malaria surveillance with TA from Inform Asia summary using either USG or non- data sheet USG funds. We will consider that the training has resulted in increased knowledge of
41 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018
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of FY 2018 FY2019 t
ine l Indicator Data ing t ency Brief Description r Remarks Number & Name Source RDMA Target Actual Target Q1, Y4 Base equ r Repo F participants when the post- test mean is higher and significantly different from the pre-test mean. The “new or improved features” refers to features Indicator 1.2. or tools in the MIS that Number of new or allow the national malaria MIS, improved features program to collect new progress 0 EP1–EP3 loop in progress and tools in the MIS types of data, conduct report, Quarterly 3 2 2 0 (2016) mHealth rollout in progress developed with TA analyses that were technical provided by Inform previously not available, report Asia enhance user interface to minimize workload, or improve data use. In Thailand, “data” MIS, Q1 90% comprising case-based 81% information for malaria patient's Q2 88% Quarterly (MIS, 85% 90% 94% See details in Annex 4 tests and results should be registration Q3 89% 2017) reported into the MIS by form, (EP1) Q4 87% the “recommended Indicator 1.3. timeline,” which is within Percentage of one day of diagnosis. reporting units that “Reporting units” in submitted data to Thailand are public the MIS according facilities that offer malaria to the DHIS, Q1 100% tests and treatment 62% recommended patient's Q2 100% services in endemic Quarterly (DHIS2 0 90% 94% See details in Annex 4 timeline registration Q3 95.8% provinces. , 2017) form, (A3) In Lao PDR, “data” Q4 100% comprises the malaria monthly report captured by the reporting units into the DHIS2.
42 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018
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of FY 2018 FY2019 t
ine l Indicator Data ing t ency Brief Description r Remarks Number & Name Source RDMA Target Actual Target Q1, Y4 Base equ r Repo F “Reporting units in Lao PDR that submitted data according to the recommended timeline” is by the 15th of the following month. In Thailand, “complete FY 2018: Treatment information” means a total information 80% complete of nine key data points (4,331/5,393 cases). must be completed: MIS, See details in Annex 5 patient’s name, date of 83% patient's 90% FY 2019 Q1: Treatment birth or current age, sex, Quarterly (MIS, 85% 80% 79% registration Thailand information 79% complete nationality, occupation, 2017) form (EP1) (1,096/1,381 cases). Among date of blood draw, lab the records with complete results by RDT or treatment information, 93% microscopy, species of complied with NTG. Indicator 1.4. infection, and malaria drug Percentage of (for patients with positive reported malaria malaria test result). cases with complete In Lao PDR, “complete information information” means a total of seven key data points No field activity in Q1 Y4. must be completed: DHIS2, 35% Monthly reporting rates are patient’s name, date of patient's 70% Quarterly (DHIS2 0 — — high. TA emphasis should be birth or current age, sex, registration Lao PDR , 2017) on data quality, malaria date of blood draw, form (A3) investigation and responses. laboratory results by RDT or microscopy, species of infection, and malaria drug (for patients with positive malaria test result). Indicator 2.1. Research activities can Project Case investigation. Number of research include pilot or documents 0 Methodology developed and Quarterly 2 1 2 — activities conducted demonstration projects, for activity (2017) data cleaned up and by program units evaluation of current tracking, analyzed. Results presented
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 43
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of FY 2018 FY2019 t
ine l Indicator Data ing t ency Brief Description r Remarks Number & Name Source RDMA Target Actual Target Q1, Y4 Base equ r Repo F with TA supported implementation activities, proposals, to BVBD. In Y4, by Inform Asia and operational research. protocols, recommendation will be They can involve synthesis and project discussed to improve case of new information reports investigation forms and/or generated from secondary processes. data analyzes, as well as Ongoing into Y4: Review of original and ongoing malaria strategy and malaria research activities. foci reduction. Activity will TA can include, but is not require longer time due to limited to, consultation, changes in foci classification preparation of proposals, definition. The latest was implementation of changed for NMES in FY research activities, 2017. BVBD agreed to have collection and verification a full year of data for FY of data, data analyses, 2018 be included in the and preparation of reports analyses. or presentations. This indicator captures the processes supported by Inform Asia’s TA for the generation of knowledge for evidence-based Indicator 2.2. advocacy and decision- Number of making that contribute to knowledge products changes in policy or Knowledge 0 developed and practices. Knowledge products Quarterly 4 3 3 — — (2016) disseminated with products will be developed produced TA supported by to capture both the Inform Asia processes supported by Inform Asia and the observed changes in policy or practices at the international, national, and subnational levels.
44 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018
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ine l Indicator Data ing t ency Brief Description r Remarks Number & Name Source RDMA Target Actual Target Q1, Y4 Base equ r Repo F They may include, but are not limited to program lessons learned, best practices, technical reports, conference abstracts, peer-reviewed publications, presentations, and policy or other briefs. A semiannual survey will be done to collect information from individual health staff on their attitudes and practices of data collection and Indicator 3.1. analysis for program 84% Percentage of planning and Not (Thailand) individuals who implementation, program applica To be Semiannual Semi- report that they monitoring, and ble collected TBD — Data collection in Q2, Y4 survey annually To be generated, evaluation. (N/A) collected in Q2, Y4 analyzed, or used “SI” can be generated from (2018) in (Lao SI in their work malaria surveillance, MIS, PDR) or DHIS2; research and evaluation; and lessons learned, and knowledge products generated with technical support from Inform Asia. Indicator 3.2. This indicator aims to The proportion of foci that Percentage of capture improvement in were responded was 77% MIS, data malaria foci that management of malaria (622/800). Among these collection Quarterly N/A 65% 88% 70% 84% were investigated foci for elimination, such 84% (527/622) were forms and managed that malaria program staff responded according to according to the properly classify foci timeline and protocol.
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 45
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ine l Indicator Data ing t ency Brief Description r Remarks Number & Name Source RDMA Target Actual Target Q1, Y4 Base equ r Repo F malaria elimination based on case notification protocol and investigation and conduct appropriate response activities. DHIS2, Under the malaria data TBD No field activity in Q1 Y4, Quarterly 65% N/A TBD — elimination strategy, collection (2018) pending MOA approval. Thailand and Lao PDR forms adopt and track the timeliness of the 1-3-7 strategy.
46 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 47 Annex 4: Timeliness of Malaria Reporting – Indicator 1.3
Timeliness of malaria reporting in the MIS and DHIS2 system is the key step to trigger essential malaria elimination activities and monitor these activities, including with the 1-3-7 strategy. This indicator aims to demonstrate whether MIS improvements and capacity building efforts, including efforts by Inform Asia’s TA, contributed to improving the timely submission of malaria reports. Indicator 1.3: Percentage of reporting units that submitted data to the MIS according to the recommended timeline, is used to monitor the timeliness of malaria reporting.
Thailand
Facility timeliness was defined by the difference between the date of diagnosis and the date the malaria case was registered into the MIS system, i.e., one day. A facility is be classified as reporting on time only when 100% of the recorded cases were reported on time. In Thailand in Q1, Y4, the total number of facilities reporting malaria cases was 788. The organizations with the greatest number of reporting units were hospitals (46%, n = 363), followed by MPs (23%, n = 184) and MCs (15%, n = 120). The mean number of cases by reporting unit was 1.7, ranging from 0.3 patients by MP to 6.9 by nongovernmental organization (NGO).6 See Table 8 for more information.
Table 8. Number, proportion, and mean number of malaria cases reported in the MIS by organization type, Q1, Y4
Number of Cases Organization type Number of Facilities Number of Cases by Reporting Unit
% No. % No. Mean MP 1.0% 8 0.15% 2 0.3 Hospital 46.1% 363 43.0% 583 1.6 HPH 4.9% 39 0.74% 10 0.3 MC 15.2% 120 35.4% 479 4.0 MP 23.4% 184 11.2% 152 0.8 NGO 1.0% 8 4.06% 55 6.9 VBDU 8.4% 66 5.46% 74 1.1 Total 100% 788 100% 1,355 1.7
*Data for October 1 to December 31, 2018 was accessed from MIS on January 4, 2019.
Monthly timeliness In Q1, Y4, the overall timeliness was 94.0%, ranging from 93.8% in October to 94.0% in December 2018. Using logistic regression multivariate analysis, Figure 7 shows that the timeliness remained steady over Q1 (adjusted odds ratio [AOR] 0.93, p = 0.574), while hospitals
6 NGOs include the malaria services delivered through the Shoklo Malaria Research Unit, a field station of the faculty of Tropical Medicine, Mahidol University and MORU.
48 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 and VBDU units were significantly less likely to report on time (AOR 0.30, p = 0 .001, AOR 0.40, p = 0.019, respectively) compared to other health facilities. Figure 7. Proportion of reporting units reporting on time, by month and organization type 100% pe ty
on 95% ati z organi 90% by
s s ne i
el 85% m i T
80% October November December
BMP Hospital HPH MC MP NGO VBDU Total
Overall, Thailand has a high proportion of reporting units that report on time. However, Inform Asia compiled the following list of program units that have consistent performance issues and shared it with the BVBD to explore the potential challenges these sites may have that contribute to their poor performance. • Tak province: MP Maeweita • Sisaket province: MC Khunhan, Kantharalak Hospital, and MP Ban Jongkor (Kanthrom district) • Ubon Ratchathani province: Fort Sunpasitthipragsong Hospital • Yasothon province: Yasothon Hospital • Yala province: VBDU 12.1.5 Yaha, Kabang Hospital, Thanto Hospital
Overall timeliness trends from Q1, Y3 to Q1, Y4 We observed that Indicator 1.3 was highest in Q1, Y4 compared to the previous quarters in Y3, ranging from 90.7% in Q1 Y3 to 94.0% in Q1 Y4 (
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 49 Figure 8).
50 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Figure 8. Percentage of reporting units that submitted data to the MIS according to the recommended timeline in Thailand
100% 94.0% 90.7% 89.3% 90.2% 88.3% 90% t i 80% un
ng 70% orti 60% ep r 50% by
s
s 40% ne i 30% el m i 20% T 10% 0% Q1, Y3 Q2, Y3 Q3, Y3 Q4, Y3 Q1, Y4
Lao PDR
Reporting units in Lao PDR that submitted data according to the recommended timeline include 56 reporting units that enter monthly malaria reports into DHIS2 by the 15th of the following month. In Q1, these included • 1 provincial hospital • 1 army hospital • 1 police hospital • 11 district hospitals • 44 health centers
Figure 9 shows the percentage of Lao PDR reporting units that submitted the monthly report according to the timeline. The DHIS2 data shows that the following four health centers do not submit at least one malaria monthly reports in Vientiane province in Q1 Y4. • Keo Outdom: District Hospital (Dec) • Kasy district: District Hospital (Oct), Health Center Banchieng (Oct), Health Center Hinnhon (Oct), Health Center Nongsan (Oct), Health Center Phontieng (Oct), Health Center Punglak (Oct) • Feuang district: Health Center Phonbeng (Dec)
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 51 Figure 9. Percentage of Lao PDR reporting units that submitted a monthly report according to the recommended timeline
100.0% 95.8% 95.2% 92.3% 90.0% 86.9%
it 80.0% n
g u 70.0% rtin
o 60.0% p e
r 50.0% y b
s 40.0%
lines 30.0% e im
T 20.0%
10.0%
0.0% Q2, Y3 Q3, Y3 Q4, Y3 Q1, Y4
52 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Annex 5: Malaria cases with complete information – Indicator 1.4
In Q1, Y4, out of the 1,381 cases recorded in Thailand by the MIS, the overall data completeness was 79%. Data completeness Subjects’ characteristics completeness • Age: 100% • Sex: 100% • Name: 100% • Occupation: 100% • Nationality: 100% Date and malaria species completeness Overall, 89% of the malaria cases data were recorded by the ODPC, 7% by BOE, and 4% by NGOs. • Draw blood date: 100% • Species: 96% (1,331/1,381; 50 cases classified as “Unknown”) Treatment characteristics completeness • Treatment place: 94% (1,300/1,381) • Treatment completeness: 79% (1,096/1,381) • Among those with treatment information, 93% followed the NTG. Treatment characteristics completeness by reporting unit type We observed that hospitals (38%) and MCs (35%) captured most of the malaria burden in Q1. Although, the treatment place information was not available for 6% of the cases. The greatest number of cases without treatment place were from Tak (n = 23), Sisaket (n = 18), and Ubon Ratchathani (n = 15). See Figure 10. Figure 10. Number of cases by reporting unit type
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 53 Table 9. Treatment completeness by reporting unit, Q1, Y4
Cases with Completeness information by reporting unit type Total Cases by Report unit Any Malaria Malaria Treatment Reporting unit type Treatment place Treatment according to NTG Information Information Information No. Distribution No. Percent No. Percent No. Percent Hospital 526 38% 526 100% 403 77% 370 92% MC 479 35% 479 100% 463 97% 435 94% MP 154 11% 154 100% 143 93% 136 95% VBDU 75 5% 75 100% 72 96% 68 94% NGO 55 4% 55 100% 4 7% 4 100% HPH 9 1% 9 100% 9 100% 8 89% BMP 2 0% 2 100% 2 100% 2 100% Unknown 81 6% 0 0% 0 0% 0 0% Total 1,381 100% 1,300 94% 1,096 79% 1,023 93%
Overall, in Q1, Y4, treatment information was available for 79% of the cases and 44 provinces reported malaria cases. In the following higher burden provinces (more than 100 cases in Q1), the treatment completeness rate was 94% (372/394) in Yala, 54% in Tak (159/296), 85% (205/240) in Sisaket, and 78% (91/116) in Ubon Ratchathani. Hospitals had the lowest number of malaria cases without treatment information (77%) with NGO (7%) while MCs, MPs, and the VBDU averaged at 95% (ranging between 93% to 97%; see Figure 11). Figure 11. Treatment information completeness by reporting unit type
Among malaria cases with treatment information, the overall NTG compliance was 93% (Figure 12). In the following higher burden provinces, the compliance rate was 93% (345/372) in Yala, 98% in Tak (155/159), 97% (198/205) in Sisaket, and 97% (88/91) in Ubon Ratchathani.
54 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Figure 12. NTG compliance by reporting unit type
The compliance rate by reporting unit type varied between hospitals (92%), MCs (94%), MPs (95%), and the VBDU (94%)(Figure). The greatest number of non- compliant malaria cases was detected in MCs and VBDU facilities from Bannang Sata, Yala Province (Table 10).
Table 10. Facility with the greatest number of non-compliant NTG treatment cases
NTG non-compliant Province Facility cases (n)
Yala MC Banangsta (MC บันนังสตา) 14 International Medical Center for Tropical Diseases under Faculty of Ratchaburi Tropical Medicine, Mahidol University 5 (ศูนยโร์ คเมองรื อนน้ านาชาต ิ ราชนครนิ ทร์) Chachoengsao Bhuddasothorn Hospital (รพ .พุทธโสธร) 4
Yala VBDU 12.1.3 Banangsta (นคม .12.1.3 บนั นังสตา) 3
Sisaket Khunhan Hospital (โรงพยาบาลขนุ หาญ) 2 Yala MC Tarntoe (MC ธารโต) 2 Tak GF RAI2E-MP Ban Laythongku (บา้ นเลตองคุ) 2 Yala Krongpinung Hospital (รพ .กรงปินัง) 2
Mae Hong Son MC Khunyuam (MC ขุนยวม) 2 Ranong MC Jorporror (MC จ .ป .ร .) 2
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 55 Annex 6: Drug Efficacy Evaluation
Drug Efficacy Evaluation Methods • Start point: Cases diagnosed from October 1, 2017 • Endpoint: Pv cases diagnosed on or before August 29, 2018 (allow for 90-days follow-up) and Pf case diagnosed on or before October 16, 2018 (allow for 42-days follow-up) • Include cases from all facilities • Malaria results based on microscopy • National Treatment Guideline (NTG) • Pf = Dihydroartemisinin-Piperaquine + Primaquine • Pv = Chloroquine + Primaquine • Follow-up schedule • Pf = Day 0, Day 3, Day 7, Day 28, Day 42 • Pv = Day 0, Day 14, Day 28, Day 60, Day 90 • Survival analysis for treatment efficacy (not PCR corrected) • Modified intent-to-treat (ITT) • Pf: Endpoint day 42 • Pv: Endpoint day 90 • A treatment recurrent failure was defined as any of the following: • Recurrent parasitemia, i.e., a conversion from a positive to a negative smear result • Recurrent Pf within 42 days • Recurrent Pv within 90 days Malaria case characteristics • 5,101 cases: 699 Pf cases (14%); 4,287 Pv cases; 115 other malaria species • Greatest number of cases found in Tak (23%) and Yala (25%) provinces • Median age: 30 years old • 20% of the cases were women • 78% of the cases were Thai nationals • 80% of cases have treatment data available
NTG treatment compliance • Overall treatment compliance to NTG: Pv = 79% and Pf = 69%
Figure 13. Drug efficacy evaluation – NTG treatment compliance
Completeness of follow-up schedule (4 visits) Overall rates for complete follow up are Pf = 32% and Pv = 40%
56 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 Figure 14. Drug efficacy evaluation – complete follow-up rate
Follow-Up (FU) Rate and Parasite Recurrence (all regimens) • Pf (n = 699), parasitological recurrence occurred between Day 7 and Day 42 • Pv (n = 4,287), parasitological recurrence occurred between Day 14 and Day 90 Figure 15. Drug efficacy evaluation – Follow-up and parasite recurrent rates
Parasite Recurrence for patients treated with NTG • Pf (n = 8 cases) treated with DHA-PIP + PQ showed parasitological recurrence between Day 7 and Day 42 in Sisaket (5 cases); Ubon Ratchathani (1 case); and Suratthani (2 cases) • Pv (n = 35 cases) treated with CQ + PQ showed parasitological recurrence between Day 14 and Day 90
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 57 Figure 16. Drug efficacy evaluation – Parasite recurrence for patients treated with NTG
Pf Drug Efficacy (Dihydroartemisinin-Piperaquine [DHA-PIP]) • Pf (n = 402) • Modified ITT analysis and Day 42 Kaplan-Meier Survival Analysis • Overall DHA-PIP efficacy at 94.7% (95%CI 89.9-98.9) • Graph (95% CI, total number of cases): • Tak: 100% (95.6-100, n = 67) • Yala: 100% (96.3-100, n = 79) • Ubon: 90.0% (71.4-100, n = 27) • Sisaket: 81.8% (78.7-84.9, n = 61) • Other: 97.6% (94.1-100, n = 103) • P = 0.003, log rank test
Figure 17. Drug efficacy evaluation – DHA-PIP
P. vivax Drug Efficacy (Chloroquine + Primaquine [CQ + PQ]) • Pv only (n = 3,386) • Modified ITT analysis and Day 90 Kaplan-Meier Survival analysis • Overall CQ + PQ efficacy at 99.1% (95% CI 98.5-99.7) • Graph (95% CI, total number of cases): • Ubon 100% (98.5-100, n = 194)
58 Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, October 1–December 31, 2018 • Other: 99.4% (98.8-100, n = 1,116) • Tak: 95.0% (91.9-98.1, n = 676) • Yala: 94.7% (86.9-100, n = 1045) • Sisaket: 55.2% (39.1-71.3, n = 355) • p=0.001, log rank test
Figure 18. Drug efficacy evaluation – CQ + PQ
Conclusion • Overall, first line treatment for Pf and Pv performed well except in Sisaket province, which is one the Cambodian border. • Patient IDs should to be used to match routine surveillance with clinical research. • Further analysis and other lines of evidence are needed, including treatment compliance information and molecular analysis of the parasites before and after treatment. • Data suggests that DHA-PIP, as a first line treatment in Thailand, should be reviewed.
Inform Asia: USAID’s Health Research Program, Associate Award 2: Year 4, Quarter 1, Oct 1–Dec 31, 2018 59