Completion Report

Project Number: 48446-001 Technical Assistance Number: 8959 June 2019

Malaria and Communicable Diseases Control in the

Greater Mekong Subregion

This document is being disclosed to the public in accordance with ADB’s Access to Information Policy.

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area. TA Number, Country, and Name: Amount Approved: US$ 4,500,000 TA 8959-REG: Malaria and Communicable Diseases Control in the Greater Revised Amount: Not Applicable Mekong Subregion Executing Agency: Source of Funding: Regional Malaria and Other Amount Undisbursed: Amount Utilized: Asian Development Bank Communicable Disease Threats Trust Fund $327,879.04 $4,172,120.96 TA Approval Date: TA Signing Date: Fielding of First Consultants: TA Completion Date 23 September 2015 30 October 2015 Original: 30 June 2017 Actual: 25 June 2018 Account Closing Date Original: Actual: 30 June 2017 19 December 2018 Description. The spread of multiresistant-drug malaria is jeopardizing the remarkable progress made in malaria control in the Greater Mekong Subregion (GMS) since 2000. The Asian Development Bank (ADB) designed the TA at the request of the governments of , Lao People’s Democratic Republic (Lao PDR), and (CLM), to address the following binding constraints for malaria elimination in the region: (i) inadequate malaria and communicable disease control strategy in Myanmar where malaria incidence is highest and malaria care in the region is least-developed; (ii) lack of services addressing specific needs of the migrant and mobile population (MMP), a key risk group for malaria given their exposure to disease vectors and inaccessibility to the health system; and (iii) insufficient coordination for malaria control in the region. Expected Impact, Outcome, and Outputs. The impact of the TA was to eliminate malaria across Cambodia by 2025, and Lao PDR and Myanmar by 2030, as stated in the countries’ national malaria elimination strategies. The outcome of the TA was national malaria and communicable diseases control (CDC) programs strengthened and better coordinated in CLM. The outputs were (i) Myanmar malaria surveillance and diagnostic systems improved, (ii) MMP’s specific needs for malaria prevention and treatment addressed, and (iii) regional coordination on malaria and CDC among GMS countries strengthened. The TA is rated relevant. The TA is aligned with GMS countries’ respective plans for malaria elimination, which in turn was based on the agreement at the Ninth Summit in 2014 towards the goal of an Asia and the Pacific region free of malaria by 2030. The TA is also aligned with ADB’s Operational Plan for Health 2015–2020, Regional Cooperation and Integration Strategy, and Strategy 2020 midterm review (2014) which recommended expanding health sector operations. At completion, the TA continued to align with country plans and government strategies, and ADB’s Strategy 2030, particularly in fostering regional cooperation and integration. The TA was designed in dialogues with major development institutions, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) under World Health Organization (WHO) technical leadership. The TA design was well articulated, particularly on malaria elimination which is high on the government agenda. The TA targeted the most at-risk groups and helped the countries to address the following critical constraints under their respective malaria elimination programs (i) undeveloped disease surveillance systems; (ii) inadequate quality assurance systems for malaria diagnosis in laboratories; and (iii) weak public health systems unable to serve large populations. The risk of shifting governments’ focus from malaria and CDC towards other issues was mitigated through a continuous dialogue with the countries, and coordination with international non-governmental organizations (NGO), GFATM, and WHO leadership. The TA deliverables were well received by the countries and incorporated in their national policies. The TA aligns with current ADB interventions (see overall assessment and major lessons). The TA developed innovative activities, such as use of information technology based on mobile phone in malaria surveillance, quality assurance system for malaria diagnostic, and private sector involvement in malaria control and prevention. These innovations have good demonstration value for CLM governments and future ADB engagement. Delivery of Inputs and Conduct of Activities. Under Output 1, the TA mobilized University Research Co. (URC), an international NGO. URC worked closely with the National Malaria Control Program (NMCP) and the National Health Laboratory (NHL). Originally, two NGO packages were planned, but a minor change in implementation arrangements to combine services under one package proved to be more efficient and significantly reduced recruitment processing times. The TA brought together NMCP and NHL and several development institutions such as WHO, Save the Children, and International Cooperation Agency. The TA developed with NMCP, a mobile data management system (mDMS) which allows basic health services staff and village malaria workers to report malaria cases to the central level using mobile phone technology. It (i) provided guidelines for mDMS usage; (ii) trained 179 health staff (of which 116 female); (iii) provided IT hardware (servers and laptops) and 168 mobile phones to staff (102 to female staff); and (iv) piloted the mDMS in five townships in two states. The TA reviewed the laboratory quality assurance malaria diagnostic capacities and training of relevant health staff, and developed the National Guidelines on Microscopy and the Manual on Laboratory Quality Assurance. The TA distributed (i) 1,500 national guidelines to hospitals nationwide; and (ii) 500 manuals to Myanmar State/Region Vector Borne Disease Control staff. The TA (i) trained about 61 health staff (of which 45 female) in targeted hospitals; (ii) equipped 27 facilities in 10 targeted townships with laboratory diagnostic equipment and medical supplies; and (iii) conducted staff supervision in collaboration with NMCP and NHL. Output 2 activities were carried out by the International Organization on Migration (IOM) which supported MMP-focused interventions in selected districts in CLM. This output consisted of field-based activities in selected CLM districts to assess MMP malaria risks and develop pilot models to address MMP needs linked to worksites along forest areas. The TA conducted situation analysis of the malaria risks faced by MMPs in CLM, including in private sector enterprises. The TA provided information, education, and communications materials to address these. The TA trained 75 volunteers and peer educators (of 2

which 15 female) to improve access to malaria prevention and testing for MMP groups. The low percentage of women in the private enterprise (mining) explain the low proportion of female in trainings. The TA conducted worksite interventions in more than 60 sites where MMPs were at risk of malaria infection. A regional MMP workshop presented the implementation of the pilot models and their achievements. Under Output 3, the TA implemented cross-border information sharing procedures including malaria data and communicable diseases outbreaks in 27 CLM provinces. CLM national malaria programs designed and developed specific malaria-targeted action plans in border areas. CLM countries shared information and experiences on MMP interventions during regional meetings and issued recommendations for further activities targeting MMPs. The TA also conducted regional meetings to support regional health cooperation improvement of infection prevention and control in hospitals and in laboratory services in the GMS (including and the People’s Republic of ). TA activities were relevant to achieve TA outputs, and the governments were satisfied with inputs received from the TA. The Government of Myanmar endorsed guidelines and manuals prepared by the TA for nationwide use. At governments’ request, ADB allowed a one year, no-cost TA extension to allow more time for monitoring results, completing activities (including additional training and delivery of durable insecticide impregnated bed nets), and planning for eventual take-over of the TA under the countries’ respective national malaria programs. The minor changes in implementation arrangements described in previous paragraphs were processed not out of design deficiencies but to facilitate implementation of activities. The design and monitoring framework remained unchanged. TA savings were realized because existing national programs and GFATM financed the consumables for the implementation of pilot interventions under outputs 1 and 2. Studies were incorporated in the consulting firms’ contracts. The TA hired five individual national and international consultants for a total of 124 person months. This was more than the envisaged 78 person-months at design, as longer inputs were needed to advise governments on multiple and complex issues such as those related to the malaria program in Myanmar. The performance of all individual consultants, URC, and IOM for the duration of the TA is rated satisfactory. They all delivered their respective outputs and collaborated well with ADB, countries’ central and local health offices, and other partners. As executing agency, ADB provided specialist and analyst inputs for overall TA management, consultants’ contract management, facilitating regional workshops, coordinating functions of the regional coordination unit, and maintaining effective and functional relations with its government counterparts in CLM. The governments were fully cooperative, and provided timely and relevant inputs, necessary internal approvals, and in-kind contributions. The performance of ADB and the governments is rated satisfactory. Evaluation of Outputs and Achievement of Outcome. Output 1 was achieved. The TA (i) refined an mDMS for malaria diagnosis and treatment; (ii) improved the laboratory quality assurance practices; and (iii) enhanced malaria microscopy diagnostic standard operating procedure. The refined mDMS was tested in two regions and five townships in Myanmar, based on the mDMS manual for basic health services staff and village malaria workers. The TA also provided equipment and capacity building for 27 public health centers in 2 states, achieving compliance with the national guidelines on malaria diagnostic quality in 20 of those. By the end of the TA, NMCP checked the quality of the malaria tests performed in the health facilities and reported that the accuracy of malaria diagnostic in the health facilities increased from 80% (baseline) to 100%.a Output 2 was achieved. The TA produced (i) a mapping report of private projects employing mobile population in the TA targeted areas; and (ii) 60 worksite gender responsive interventions focusing on MMPs, including provision of consumables, training of volunteers, and information, education, and communication campaigns to improve awareness on malaria issues. The outputs were achieved with delay, due to the slow recruitment procedures of the consultants and the longer than expected time required to receive governments guidance on implementation sites’ choices. Output 3 was achieved. Myanmar was included in the regional exchange networks established under the ADB-supported Second GMS Regional CDC Project.b By December 2017, emerging epidemic reporting through IHR/WHO procedures within 48 hours were observed in 84% of cases and in 48 hours in 100%. The TA held three regional meetings participated by representatives of CLM Ministries of Health, which issued recommendations for regional malaria surveillance system and activities focusing on MMP. The regional meetings resulted in a working definition for MMP, and CLM representatives’ commitment to integrate the MMP activities piloted in the TA into their national malaria programs. The TA considered gender dimensions in implementation. Under outputs 1 and 2, (i) microscopy and quality assurance trainings ensured inclusion of all relevant female and male clinic staff; (ii) surveillance equipment distribution and training ensured women’s participation; (iii) surveillance systems provided sex-disaggregated data; (iv) interventions took into account specific needs of female MMPs working in private sector enterprises; and (v) recipients of awareness raising outreach in local communities targeted women as the first point of contact. The TA expected outcome was achieved. The TA strengthened the national malaria and CDC programs. The Myanmar Ministry of Health and Sports endorsed the laboratory guidelines and quality assurance manuals for dissemination and nationwide use. The Myanmar NMCP integrated eMDS into the malaria national reporting system. The CLM national malaria control programs endorsed the regional workshops’ recommendations on interventions focusing on MMP in private sector projects and cross- border areas: (i) continued training and mobilization of village volunteers and mobile/itinerant traders as peer educators/outreach volunteers; and (ii) broadening of volunteers’ skills to include disease prevention and health promotion. 3

The CLM malaria control programs established in 27 provinces, cross-border periodic information sharing procedures including data on malaria cases. All three countries strengthened the capacity of their CDC systems to rapidly assess the emergence of epidemics. CLM national malaria control programs designed and developed annual plans for cross-border activities in border areas. The TA is rated effective. The mDMS in Myanmar is now improved and tested and improved diagnostic systems are in place with better equipment and training for health centers adequately provided. MMP awareness was increased with sufficient interventions provided focusing on malaria prevention, diagnosis, and treatment. Regional cooperation on CDC was improved across the GMS with cross-border information sharing mechanisms on malaria and communicable diseases outbreak now strengthened. Cross-border action plans for MMP care are also prepared. TA outputs contributed directly to outcome achievement. Dialogue with other donors (GFATM, WHO) and the governments ensured that malaria elimination receive sufficient attention and funding in CLM. The TA is rated efficient. While the TA extended by one year, it delivered within its budget, and funds were used as expected. Coordination with other donors, particularly the GFATM allowed savings on consumables and insecticide impregnated bed nets purchase. Studies were incorporated in the consulting companies’ contracts. The TA mobilized teams that satisfactorily implemented project activities and provided results within a limited timeframe. The TA additionally contributed to the production and dissemination of knowledge products on laboratory diagnostic guidelines, quality assurance protocols, and working with MMP in worksites. Overall Assessment and Rating. The TA is rated successful. The TA design was sound, and the regional capacity development TA modality was appropriate. The TA remains aligned with ADB and government development priorities. Its outcome and outputs were largely achieved and within budget. Governments endorsed for national use TA outputs and recommendations. The CLM countries, together with Viet Nam, have been implementing since 2015 an ADB-supported project aimed at improving regional health security (including the malaria control) through the strengthening of health services.b The countries are committed to allocate sufficient resources in the future for malaria elimination and health security strengthening. Development partners are also continuing their support toward malaria elimination. As TA benefits are expected to continue after TA completion, the TA is likely sustainable. A short intervention period and the complex dynamics of malaria control and elimination strategies make the TA’s impact on malaria elimination difficult to measure at this stage. However, provincial health offices annual reports from areas supported by the TA indicate an overall reduction of malaria incidence: (i) 20.2 cases per 1,000 population in 2013 to 4.4 in 2017 (Cambodia); (ii) 10.2 cases per 1,000 population in 2013 to 0.85 case per 1,000 population in 2017 (Champassak province, Lao PDR); and (iii) 26.5 cases per 1,000 population in 2013 to 2.88 cases per 1,000 population in 2017 (Attapeu province, Lao PDR). Major Lessons. Designing and monitoring high quality malaria interventions that improve health staff capacity and create effective strategies for reaching MMP is a slow process and requires time to verify results. Key lessons learned from the TA serve as essential inputs for the ongoing GMS Health Security Projectc and the development and implementation of the GMS Health Cooperation Strategy. These include: (i) parallel health agencies such as Myanmar’s NMCP and NHL could work well together with clear and well-defined roles and outputs, and would serve to strengthen and make the country’s health system more efficient; (ii) sustainability particularly related to digital health information systems is assured when governments and other development partners take part in the design and review of project implementation; in this case, GFATM has committed to support the work done by IOM; (iii) MMPs can be effectively reached through customized service delivery mechanisms; (iv) worksite interventions are possible utilizing appropriate cooperation mechanisms; (v) village volunteers and peer educators are a crucial component of prevention and treatment programs addressing multiple disease threats among migrants and mobile people, ethnic minorities, and other vulnerable groups; involving NGOs is beneficial given their flexible systems to engage volunteer health workers outside the public health system; and (vi) regional and cross-border activities result to the development of relevant policies and action plans. Recommendations and Follow-Up Actions. Ministry of Health and Sports should (i) cause NHL and NMCP to jointly and regularly supervise and monitor state, region, and/or township hospital laboratories. This is vital to maintain laboratory quality assurance including corrective action. NMCP should advocate with partners/ donors for continuation of activities; (ii) encourage hospitals to use microscopy for malaria testing, apply the national malaria microscopy guidelines, and adopt the quality assurance manual. NHL and NMCP should sustain the momentum of cross-checking and panel testing for quality control. Timely feedback on results of cross-checking slides is necessary (state and/or region); and (iii) use the TA’s experiences for other communicable diseases. MMP intervention design and framework can be scaled up by the ongoing GMS Health Security Project. Lessons in private sector engagement should be shared and discussed in various GMS health platforms, particularly as they relate to migrant health. Review of regional and cross-border initiatives should be conducted, and gaps addressed to strengthen regional cooperation under the GMS Health Security Project. TA = Technical Assistance. a ADB. 2018. Malaria Surveillance and Laboratory Quality Assurance in Myanmar: Final Report. Manila. b ADB. Regional: Second Greater Mekong Subregion Regional Communicable Diseases Control Project. c ADB. Regional: Greater Mekong Subregion Health Security Project.

Prepared by: Gerard Servais Designation and Division: Senior Health Specialist, SEHS