December3.. 194

M E MO R A N D U M

TO SEE DISTRIBUTION ,,

FROM ASIA/TR/PHN, David Ooi SUBJECT: Malaria Project Evaluation Tem Debriefing

Ea bmi1h. member of the evaluation team which recentlIvisi recntYlslted..Indonesia,

will give a debrief nq on the teamt s findings on December I, 1984 at 2:00 p.m. in Room 3318, NS. (ASIA/PD Conference Room). A summary of the recommendations is attached for your informatlin.

Attachment: a/s

DISTRIBUTION

ASIA/TR/PHN, Staff ASIA/TR, B. S'idman ASIA/EA/ISP, V. Molldrem ST/HEA, J. Erickson ST/HEA, L. Cowper DAA/ASIA, E. Staples ASIA/DP, M. Norton ASIA/DP, S. Pines MID-TERM EVALUATION OF' MALARIA CONTROL PROGRAMME October - November, 1984

EXECUTIVE SUMMARY

In general, malaria prevalance has gone down appreciably areas which have been under in those house spraying, however, the the following as major constraints team identified impeding progress towards achieving the project objectives: 1. The difficulty of recruiting and retaining adequate carry out the personnel to program in , but recognized has already made considerable that West Timor progress in overcoming this constraint. 2. The delayed release of funds which is having slowing a serious impact by down the progressive reduction of malaria and in some cases resulting in an increase of malaria.

3. The lack of the kind of entomological information necessary for planning and evaluating the program. 4. The lack of an adequate number of motor vehicles or the non-availability of malaria vehicles for field use when needed. The team report gives specific recommendations constraints for coping with these and also recommendations on examination up-grading the quality of the of the malaria slides, the development plan for both of an overall training East and West Timor, the assignment experienced of a well-qualified and malariologist to provide technical and West assistance to both East Timor, particularly in the area consideration of training, and proposes by USAID and GOI of a re-constituted with goals Timor Malaria Project and objectives revised on a realistic performance basis in light of and results obtained so far. It is the opinion of the team that a realistically extended for 2 to 3 revised project years and taking into account the made in this report recommendations would be able to achieve the project in terms objectives of the of reduction of malaria and population However, the team also feels covered. that the project objectives should considered in light of experience now be to date. It may well be that more malaria than was envisaged there is prepared at the time the project paper was and that restricting the project respectively coverage to the 40% and 30% of the population in East Timor and West Timor could lead to a quick return to the former hyper- malariometric and holo-endemicity. More surveys are needed as a basis for planning a revised and extended project. 6. IMPORTANT CONSTRAINTS IMPEDING PROGRESS TOWARDS ACHIEVING PROJECT OBJECTIVE...S

6.1. Delayed release of funds The most important constraint to the both East and West Timor success of the project malarlometric is the postponement in surveys due of spray oprations present to delays in the release and time there is a serious of funds. At the and problem in that funds malarlometric surveys for the spray cycle September-October which should have been 1984, are conducted in uot yet available for of the middle of November use in the program as accomplished until 1984, which means that late December 8 4/January the spraying cannot 1985, well after be the rainy season. the start of The delays are apparently due in information (account part to the fact that Headquarters records) sent from the is often improperly field to the Provincial corrections. prepared and muat However, in be returned for Dili several a meeting with the individuals pointed Health Officers in the required out that they had difficulty information due to lack preparing lack of a typist of a typewriter in in another case and one case, the just plain lack of cases. time in other The team further feels that this is a progress in the control very jerious constraint of Malaria in Timor and that large part on finding will be dependent in a solution to this problem. 6.2. Personnel Problems The difficulty of recruiting, number of local personnel training and retaining particularly Is a constraint In an adequate acute problem all of Timor, but is education in East Timor. Due a of most of the local to the low level of is difficult population and to recruit and the low rate of literacy in train an adequate number it all categories. Although, of temporary workers that East West Timor is better Timor, it has the added off in this respect problem of losing trained better paying jobs. workers to

"he Project Paper provides part time technical for the recruitment supervisory malaria of full time and who would be expected program staff to provide training from Java and Bali unskilled prsonnel to local Timor para-medical recruited for the and counterpart personel project. However., to work with the without local etc. there can temporary workers from be no transfer of technical Java, Bali no prospect for and management development of a self-sustaining knowledge and malaria coutrol for Timor. program Furthermore, to two the BAPPENAS dcision weeks for those experienced to restrict per diem personnel Java/Bali technical payments coming to Timor on short and supervisory term training or supervisory -2­ assignments has seriously such handicapped the project's personnel. The time ability to recruit from required for most short-term a minimum of 30 days assignemts up to 3 or more months* varies days Anything less than would not be cost effective. 30 Although this constraint particularly serious affects all of Timor, problem in East Timor* is is a largely In West Timor the problem , one of refresher training. is 6.3. Lack of Entomological Information Continued success of any control of malaria residual house spray is dependent on the program for the information including availability of entomological incrimination data on species of Anopheline of the principle vectors present, data vectors in different on each vector for each areas, susceptibility biting potential insecticide, habits of each vector breeding, resting mosquito in relation and people and bio-assay to the habits of the tests of sprayed surfaces. At the present time there being carried is virtually no out in East Timor and entomological activity surveys in West only limited species Timor. There is as and density assigned to yet no M.Sc. Medical either province (one Entomologiest stay). Although was assigned to , 3 assistant entomologists but did not Timor, both positions have been trained are again vacant. for East in West Timor need The two assistant entomology additional training entomologists program required in order to carry to provide technical out the guidance to the project. The lack status of information on of individual seasonal mosquito densities- resting species,.susceptibility vector and biting habits status of each species, of each vector species and to the future constitutes a constraint success of the program.

6.4. The Lack of Transport Transport DDT is needed in all phases and spraymen with their of the program: ourveys, to update spray equipment, to to deliver geographical reconnaissance, conduct malariometric and to provide superviion. Because of the shortages malaria vehicles of vehicles, or in are being used for some cases because becomes necessary other purposes than to use commercial transport. malaria it rented or borrowed In most cases to deliver DDT, but trucks are the spraymen must walk their own equipment. and carry With the project 4/5 completed of $ 140,000.00 in terms of time budgeted for transport only $ 72,679.00 has been spent. An insufficient number prevents the timely of vehicles and/or program conduct of the field misuse of vehicles and thus constitutes operations in the malaria a constraint to the success of the program. -3­

7. DISCUSS ON AND KEY RECOMMENDATIONS

7.1. Funding

The Team feels funds that delays in the in support of the project timely supply of adequate serious in both East and West problem which if continued Timor is a very made in could reverse the excellent reducing malaria so far. progress able to The Team does not feel pinpoint all of the causes that it has bten utilization of delays in the release of funding and therefore and recommends that: A joint GOI/AID committee of specialists in requested financial matters be to investigate all ramifications involved ii funding of of the delays the Timor Malaria Project recommendations to provide and develbp for a timely flow and the funds utilization of in support of the project. 7.2. Personnel

7.2.1. East Timor In view of turnover of the numerous vacant positions, staff, the difficulty of the high and the difficulty recruiting qualified local of obtaining short term personnel personnel from Java/Bali technical and supervisory for appropriate periods that personnel problems of time, the team constitute Lue greatest feels achievement of the objectives single obstacle to of the project aud therefore that: recommends

a. A special effort should be made to recruit, train retain local personnel and at all levels of the program. b. Assistance should be sought from health educators better understand the problem to of recruiting, training and retaining local personnel. c. A request should be made assignment to Bappenas for approval of technical and of supervisory personnel from Java/Bali on per diem to of time Timor for the actual period their services are required up to 3 months and not less than 1 month.

7.2.2. West Timor Since the outer island areas in West Timor malaria program in socio-economic started in 1975, many already been overcome. of the personnel problems There are only a few have fairly stable with vacancies and the staff comparatively little turnover. is for training of personnel. The primary need is strengthened The provincial,headquarters with sufficient priority should be given to malaria to insure -malaria program is carried that the out on a timely basis. 7.3. Training

Investment in training yields a long-range critical benefit and is a element for tbe continuation of project terminates. malaria control after the Yet only 28.9% of the total funds training budgeted for in the project paper have been used. It is the feeling of the team that the most element in the development important single of a self-sufficient malaria control for all of Timor as called program for in the project paper is training. considerable extent, the To a solution to nearly all of the constraints problems identified by the team and starts with training. This includes planning, coordination and the administration of the program at level, the completion of the the Kabupaten required financial forms, the supervision the field program, the laboratory of work in parasitology and field laboratory work in entomology. The team therefore recommends that for both East and a detailed training plan should West Timor emphasis be developed and implemented with on recruiting, training and successful retaining local personnel. The development and operations of Dili and the Sekolah Perawat Kesehatan in the one in Kupang p-ovide good evidence this approach of the feasibility of and support should be provided to possible greater the two SPK to make utilization of this resource in training c:ontrol. In view of for malaria the importance of supervision of operations which must malaria control be carried out correctly and on suggested that the time, it is plan should include trainiug on supervision. The plan how to carry out should also utilize resources available and take full advantage of in Jakarta the resources available at the Inter-Regional Malaria Training Secretariat in Kuala Lumpur sponsored by WHO for express purpose of assisting the the countries of Asia in developing their own national malaria training programs.

7.4. Entomology

7.4.1. East Timor

In view of the importance of entomological the success of any malaria control information to program and particularly those on the use of residual house relying spraying and in view of the lack information specific of such for Timor the team recommends that: a. Priority should be given for the assignment to the Timor Malaria Project of a Medical Entomology MSc graduate from Bogor. b. Priority should be given to the recruitment training and of two local assistant entomologists. team was The quite favorably impressed with the being made progress in development of the Sekolah Perawat Kesehatan and suggest that the possibility be explored of recruiting 2 graduates of this school to be trained as assistant entomologists. -5­

c' The present pattern of hiring 15 mosquito collectors per Kabupaten for 4 Kabupaten for a 10 day period each year just before the rainy provide season should be changed to for a smaller number of mosquito year collectors round or at least in a part Until an entomologist of every month. is in place, the practice hiring mosquito collectors of to coincide with the of an entomologist from vis.t Jakarta is better than nothing. 7.4.2. West Timor Although there not work full are two assistant entomologists, time on entomology as they they do work with mosquito have other duties. They collectors to collect moquitoes each Kupang and Belu only. one week each month at The only entomological activities collecting and identifying appear to be mosquitoes. The information in NTT only entomological appeared to be from a 5 day survey conducted in 1978 by provincial personnel.

Considerly more entomological provide adequate information is required technical guidance to to relying on residual any malaria control program house spraying to obtain addition to obtaining control of malaria. In information on the species present and their densities, of potential vectors which is all that is information should be being gathered now; obtained on the actual vector dissections, on the susceptibility in different areas by breeding, of each vector to insecticides, resting and biting habits on the to the habits of each vector mosquito in of the people and the results relation houses. This of bio-assay tests in sprayed information should be obtained West Timor to from representative areas include all different types in of epidemiological situations. It is recommended as a biological that a local qualified science graduate should be candidate such Entomology Course. sent to the Bogor Msc. Medical However, since the recommended that course takes 2 years it until an MSC Medical Entomologist is is available in Kupang, from the Bogor School Entomology consultants from requested on short-term assignments Jakarta should be the assistant to assist in the further entomologists and assist training of entomological them in obtaining the information needed for additional planning and technical guidance the malaria program. of

It is further it will suggested that in order be necessary for the assistant to accomplish this, entomologists to devote full to entomological work. time

7.5. Microscopy In view of the importance blood of accurate reading slides taken in the malariometric of the malaria detection particularly surveys and in passive case in relation to continuing evaluations of the

2 - 6 ­ progress of the program and in view of detected through routine the high percentage of cross-checking in mistakes both East and West Timor team recommends that: the a. A laboratory consultant from Jakarta short-term be requested for a assignment long enough refresher training to provide on-the-job to each of the field slide are examined. laboratories where The training should procedures, slide examination cover staining parasites procedures, identification and repair and maintenance of Timor the provincial of microscopes. In laboratory should West consultant work closely with the from Jakarta on the prepared first trip so as to be to take over the refresher training as needed. b. For future basic training of microscropists, assistance should be requested from the WHO Malaria Training in Kuala Lumpur which Secretariat has now prepared a training parasitology. module on

7.6. Transport

7.6.1. East Timor With the operational program 27 Kecamatans of currently being conducted motorcycles 9 Kabupaten, the provision in to the project creates of only 4 Jeeps and 7 unreastic a situation in which to expect the project it is totally called for in to maintain the schedule the project paper. It of expansion the team that is therefore the recommendation procurement and assignment of since April of the 6 vehicles 1984 plus the other 4 requested possible. It required, be expedited is the opinion of the as soon as for use in the team that the most field in Timor is the 4 suitable vehicle as this would -wheel drive, diesel provide maximum flexibility pick-up truck in transport of and equipment to men, materials the most difficult areas.

7.6.2. West Timor Although an adequate number purchased for the malaria of vehicles have available project and were been for use in the on hand, they are not malaria program. It always to hire commercial sometimes becomes necessary vehicles to carry out program. It is therefore requirements of the recommended that malaria always have first the malaria program should priority for use of the specifically motor vehicles purchased for the malaria project.

7.7. Technical Assistance There was provision in the operations consultant project paper for a contract half for the first two years malaria of the budgeted amount of the project. Only was used and since the about implementation of the project was delayed, most during the of the time of the consultant planning stages and contract was during a good part of possible that time it was not to visit the field. Since the need now for technical advisory that the program is well assistance is even greater funds remain under way and expanding in the budget, the and since adequate operations team recommends that consultant be hired a contract malaria period. full time for the The individual recruited remainder of the project of malaria should have experience control and should in all aspects and conduct be capable of assisting of the malaria training in the development the appropriate program. An Indonesian experience should national with available be recruited if possible, an international advisor but if not should be brought in. 7.8. Extension of the Project On paper the project is completing five-year program. the fourth year delayed In actual fact implementation of a 6 months to a year and of the project was than expansion has been at envisaged in the project a much slower rate including paper. There are security problems, many reasons for this retaining the difficulty of recruiting, personnel, other demands training and full-time on on personnel since malaria, delays in funding, very few are transport. and delays in In fact, taking intc obtaining team feels consideration the numerous that the project deserves problems, the accomplishing so a great deal of much in spite of tremendous credit for this lies in handicaps. the results of the malariometric The proof of nearly all areas where surveys which show schedule, the spraying has been that malaria rates have accomplished on a reasonable been drastically reduced. of the approach in Timor The feasibility has thus been demonstrated. However, given the delays and implementation of the the problems interfering in which, project plan, the team with during the remaining feels that there is no be reduced year of the project, way to the 2% or less the malaria rates can objective given in the more than a small fraction project paper for of the population covered. In view of the fact project budget that only 35.5% of has been spent the total USAID a',d GOI to arrange so far, it would theoretically for an unfunded extension be possible accomplish as much of the project in as possible with the order to of the numerous problems remaining funds. However, identified in in view implement the recommendations, this report and the time given the team suggest needed to to a two-to-three year that consideration extension of the project be targets based with more realistic on experience to date. Such an extended project kind of applied should make specific field research needed provision for the should include in support of the program. susceptibility status This incrimination of vectors and parasites, of vectors, field testing of alternative insecticides, - 8 ­

field trials of alternative methods alternative of vector control and field trials drug treatment regimes. Entomology/parasitoloy of facilities laboratory and equipment should be provided. The Health Research Institute Jakarta has facilities and p and which would be 'sonnel in providing a great assistance in p'anning technical guidance for and the kind of applied field cesearch needed in Timor. 7.9. Transmigratio n and Resettlement Areas

7.9.1. East Timor In view resettlement of the fact that the transmigration projects of East Timor and and since are located in highly malarious the people who will move into areas non-malarious these areas are from relatively areas there is considerable This is risk of malaria out breaks. particularly true in the two where the transmigration projects in Kovolima new houses will be occupied half and half by local families and families from Java or Bali. It is understanding sprayed of the team that all houses before anyone moves in, malariometric will be and malaria cases will surveys will be conducted be treated. Also that all of moving into the the families before new houses will be given special health education and training including, information on malaria. If out, it this program is carried should minimize the risk of malaria. It is recommended that the Malaria Project coordination with the Transmigration maintain close proposed anti-malaria officials to insure that the p': gram for the transmigration areas is carried out on a timely schedule.