Yangon University of Economics Master of Development Studies Programme

YANGON UNIVERSITY OF ECONOMICS MASTER OF DEVELOPMENT STUDIES PROGRAMME

A STUDY ON FACTORS CONTRIBUTING TO SUCCESS OF MALARIA PREVENTION AND CONTROL PROGRAMME IN BAGO REGION

NAY ZAR OO EMDevS - 49 (14th BATCH)

AUGUST, 2019 ABSTRACT

This study focuses on the “Factors contributing to success of Malaria Prevention and Control Programme in Bago Region". Bago Region is the one of the region of elimination area and five successful regions which has higher rate of reduction of Malaria transmission and incidence in Myanmar. The objectives of study are to analyze Malaria Prevention and Control Programme and to identify the factors contributing to success of Malaria Programme for elimination in Bago Region. Descriptive method is used in this study by qualitative approaches and quantitative analysis based on the primary and secondary data. Primary data are collected from Key Informant Interviews (KII) with focal persons of Malaria in Bago Region and implementing partners. According to the results, key activities contributing of prevention and control activities in Bago Region are Micro-Stratification, Long Lasting Insecticidal Net, Indoor Residual Spraying, Information and Health Education and Communication, Early Diagnosis Treatment, Supervision and Monitoring and Evaluation, Surveillance, Supply and Management.

ACKNOWLEDGEMENTS

There are many people to whom I am deeply indebted and whose support made a vital contribution to the completion of this study. First and foremost, I wish to extend my sincere gratitude to my Professor Dr. Tin Win, Rector, Yangon University of Economics, Professor Dr. Ni Lar Myint Htoo, Pro-Rector, Yangon University of Economics for their kind permission, to study EMDevS and support to carry out this thesis. My deep appreciation goes to Dr. Cho Cho Thein, Programme Director and Head of the Department of Economics, Master of Development Studies Programme, Yangon University of Economics and Dr. Thida Kyu, Pro-Rector of Meikhtila University of Economics, former Head of the Department of Economics, Yangon University of Economics for their valuable lecturers and other retired Professors and lecturers who gave me the guidance that I needed. This paper would not have been completed without suggestions, comments and support of my supervisor Daw Phyu Win Ei, Lecturer, Department of Economics, Yangon University of Economics. Moreover, my heartfelt thanks and appreciate to National Malaria Control Programme, Central and Bago Region and Technical Officer (Malaria), WHO which kindly took the technical guidance and data supporting on my thesis paper. And I am also very grateful to Dr Kyaw Zayar Aung (EMDevS 12th batch) who encourage me to attend this programme and supporting throughout the course and on my thesis paper as well. I would also like to thank the face to face interview participats who are from National Malaria Programme Staff and Implementing Partners. I would also like to thank my other colleagues at Master of Development Studies Programme. Also, I would like to extend my gratitude to all the people that have helped me in my research work. Furthermore, I feel that I am deeply indebted to all the people who participated in my thesis. I would like to thank my family and without their love, understanding and support, this research would not have been possible. Finally, I would like to express my deep gratitude to all persons who contribute directly or indirectly to my research paper.

TABLE OF CONTENTS

Page ABSTRACT i ACKNOWLEDGEMENTS ii TABLE OF CONTENTS iii LIST OF TABLES v LIST OF FIGURES vi LIST OF ABBREVIATIONS viii

CHAPTER I INTRODUCTION 1.1 Rationale of the Study 1 1.2 Objectives of the Study 3 1.3 Method of Study 3 1.4 Scope and Limitations of the Study 3 1.5 Organization of the Study 4

CHAPTER II LITERATURE REVIEW 2.1 Background History of Malaria 5 2.2 Regional and Global Burden of Malaria 7 2.3 Prevention and Control Strategy for Malaria Elimination 8 2.4 Factors Affecting of Malaria Prevention and Control 9 Programme 2.5 Review of Previous Studies 10

CHAPTER III OVERVIEW OF MALARIA PREVENTION AND CONTROL PROGRAMME IN BAGO REGION 3.1 Overview of Malaria Situation in Myanmar 13 3.2 National Plan for Malaria Elimination in Myanmar 19 (2016-2030) 3.3 Partner Contribution for Malaria Control Activities 27 in Myanmar 3.4 Malaria Situation in Bago Region 31

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3.5 Malaria Prevention and Control Programme 37 in Bago Region 3.6 Partner Contribution for Malaria Control Programme 42 in Bago Region 3.7 Review on Malaria Prevention and Control Activities 43 in Bago Region

CHAPTER IV SURVEY ANALYSIS 4.1 Survey Profile 48 4.2 Survey Design 48 4.3 Survey Result 49

CHAPTER V CONCLUSION 5.1 Findings 60 5.2 Suggestions 63

REFERENCES APPENDICES

LIST OF TABLES

Table No. Title Page 3.1 Malaria Cases and Death in Myanmar (2007 to 2017) 16 3.2 Malaria Case and Death in Myanmar by State and Region (2017) 17 3.3 Population of Micro-Stratification by Sub-Centre in Myanmar in 24 (2017) 3.4 Funding Figures for Malaria Prevention and Control 30 3.5 Malaria Case and Death in Bago Region from 2007 to 2018 33 3.6 Malaria Morbidity and Mortality in Bago Region by township 35 (2017) 3.7 Malaria Case by Age Group in Bago Region (2017) 37 3.8 Population of Micro-Stratification by Sub-Centre in Bago (2017) 40 3.9 Annual Parasite Incidence Rate and Annual Malaria Blood 45 Examination Rate in Bago Region from 2007 to 2018 4.1 Socio-demographic Characteristic of Respondents 49 4.2 Malaria Prevention Activities by KII Interview 52 4.3 Malaria Control Activities by KII Interview 54

LIST OF FIGURES

Figure No. Title Page 3.1 Trends of Malaria Morbidity and Mortality Rate in Myanmar 14 from 2007 to 2017 3.2 Malaria Cases and Deaths in Myanmar from 2007 to 2017 15 3.3 Confirmed Malaria Cases in States and Regions (2017) 18 3.4 Yearly Trend of Malaria Morbidity and Mortality Rate in Bago 32 Region from 2007 to 2017 3.5 Malaria Cases and Deaths in Bago Region from 2007 to 2017 33 3.6 Malaria Case by Age Group in Bago Region in 2017 37 3.7 Malaria Examination and Positive Cases in Bago Region 43 from 2007 to 2018 3.8 Malaria Annual Parasite Incidence Rate in Bago Region 47 from 2016 to 2018

LIST OF ABBREVIATIONS

3MDG Three Millennium Development Goal Fund ABER Annual Blood Examination Rate ACT Artemisinin-based Combination Therapy ANC Ante-natal Care API Annual Parasite Incidence APLMA Asia Pacific Leaders Malaria Alliance BCC Bahaviour Changed Communication BHS Basic Health Staff CBO Congressional Budget Office CFR Case fatality rate CI Confidence interval CQ Chloroquine DFID Department for International Development DMR Department of Medical Research DMS Department of Medical Services ECT Early Diagnosis and Appropriate Treatment FDA Food and Drug Administration GF Global Fund HA Health Assistant IEC Information, Education & Communication IEC Information, Education & Communication INGO International Non-Governmental Organization IP/OP In-patient/Out-patient IRS Indoor Residual Spraying JICA Japan International Cooperation Agency LLIN Long-Lasting insecticidal Net M&E Monitoring and Evaluation MDA Mass Drug Administration MDG Millennium Development Goals Med Tech Medical Technician MHAA Myanmar Health Assistant Association

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MHSCC Myanmar Health Sector Coordinating Committee MMA Myanmar Medical Association MMP Migrant and Mobile Population MOHS Ministry of Health and Sports NFM New Funding Model NGO Non-Governmental Organization NHL National Health Laboratory NMCP National Malaria Control Programme NMEC National Malaria Elimination Committee NMEP National Malaria Elimination Programme NSP National Strategic Plan OP Out-Patient P.f Plasmodium falciparum P.v Plasmodium vivax PMI President’s Malaria Initiative PQ Primaquine PSI Population Services International QA/QC Quality Assessment/ Quality Control RAI Regional Artemisinin-resistance Initiative RDT Rapid Diagnosis Test RHC Rural Health Center SC Sub-Center SME Supervision, Monitoring & Evaluation

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CHAPTER I INTRODUCTION

1.1 Rationale of the Study Malaria remains one public health problems resulting in massive morbidity particularly in developing countries. Globally, half of the world population about 3.4 billion people in 92 countries are significantly exposed to Malaria, and 1.1 billion are at high risk. Worldwide, malaria is the fifth-leading cause of death from infectious disease after infections, HIV/AIDS, diarrheal diseases and tuberculosis. There were 219 million cases of malaria globally in 2017. The malaria deaths were 435,000 representing a decrease in malaria cases and deaths rates of 18% and 28% since 2010, respectively. Globally, there are 3 to 700 million people get malaria each year, but only kills 1 to 2 million. 40% of the world’s population lives in malaria zone. Malaria zone are Africa, India, Middle East, South-east Asia, Central and South America, Eastern Europe, and South Pacific. The WHO African Region carries a disproportionately high share of the global malaria burden. Total funding for malaria control and elimination reached an estimated US$ 3.1 billion in 2017. Contributions from governments of endemic countries amounted to US$ 900 million, representing 28% of total funding. (WHO, 2018) World Health Organization stated that country development involved the systematic healthcare and human resource management to capitalize the development of individual citizens. Nations with less developed basic healthcare access is highly correlated with the less efficient economic output that strained the national development. Regionally, Southeast Asia countries went through economic miracles during twenty century period in parallel with the dramatic improvement in eradicating the major endemic diseases, especially tropical and vector borne diseases like Malaria. In Myanmar, Malaria was one of the priority diseases because of climate changes and ecological changes (Win et al., 2017). The migrant population who seek economic opportunities in forestry, mining, migration, plantations and road-building

1 were one of the vulnerable groups. For their treatment seeking behavior, they were risky for the development of multi-drug resistant P. falciparum parasite. However, these recent advances in reducing malaria morbidity and mortality, Malaria in Myanmar remains a major public health issue in the country. Out of 330 townships, 291 townships were still exposed to high cases of Malaria, Out of 330 townships in Myanmar, among them, 34 townships from Yangon Region and 5 townships from Mandalay Region (total 39 townships) were free in 2016. In 2016, Myanmar had an estimated population 51.3 million with a total of 110,146 reported cases and total number of reported malaria deaths among hospital in-patients in 2016 was 21 (VBDC, 2016). Over the decade, a remarkable progress in reducing malaria cases and deaths can be seen as there were a 79% reduction in cases and 99% reduction in deaths in 2016 compared to 2005. Malaria becomes the major constrain on regional economic development and global trade as much resources have been spent on prevention and control of Malaria much less measuring the opportunity cost of lost human resources that could instead be put in other productive means. As in many other countries, malaria primarily affects the working age group of Myanmar. It is considered as a national concern and treated as a priority (VBDC, 2016). Myanmar signed Asia Pacific Leaders Malaria Alliance (APLMA) declared to eliminate malaria by 2030 in the 9th East Asia Summit in 2014 (National Plan for Malaria Elimination in Myanmar, 2016-2030). The National Malaria Control Program has consistently putting all out efforts towards accelerate and intensify elimination and is implementing the “National Plan for Malaria Elimination in Myanmar 2016- 2030”. Transmission of P. falciparum malaria interrupted and zero incidence of indigenous cases of P. falciparum attained at least in 6 States/Regions. Among them, Bago Region was selected as one of the elimination areas. According to VBDC annual report of Bago Region, it was one of the malaria highest regions in Myanmar. The number of malaria cases in Bago Region has dropped steadily year by year. Bago is one of the five successful regions which has higher rate of reduction of Malaria transmission and incidence. In this regard, it is interested to identify factors contributing to success malaria prevention and control programme in Bago Region and challenges, lessons learnt and good practices so that this can be disseminated and replicated in other 14 states and regions to be successful too.

1.2 Objectives of the Study The objectives of this study are to study about the prevention and control program of Malaria in Bago Region and to identify factors contributing to success of the malaria prevention and control program and their inputs to elimination of Malaria in Bago Region.

1.3 Method of Study The method of the study is reviewing on secondary data and descriptive study by using mixed method . The primary data was collected from the individual face to face interviewed information from the key persons in Bago Region. Secondary data are collected from different public reports, internet websites. The main sources of data are from National Malaria Control Programme (NMCP), Ministry of Health and Sports (MOHS) and Department of Medical Research, Vector Borne Disease Control Programme in Bago Region and from World Health Organization (WHO).

1.4 Scope and Limitations of the Study The study period is from 2007 to 2017. This study only focuses on Malaria Prevention and Control activities in Bago Region implemented by Department of Health, in Bago Region. The study conducted the face to face interview with Malaria focal persons of Government Staff and Implementing partners. According to scattering place of malaria patients, it is difficult to interview directly with them for data collection. Therefore, it is conducted interview with the total respondents 50 in this study by using the individual face to face interview with malaria focal persons. Among all respondents, 39 respondents from Government Staff (Malaria project) and 11 respondents from implementing partners (stakeholder). Questionnaires are set with the four main sections. There are socioeconomic, characteristics, factors contribution of malaria prevention activities and control activities for malaria elimination and good practices, lesson learnt and issue and challenges of Malaria Control Programme. The other areas apart from Bago are not studied in this paper which are the other tropical and vector borne diseases such as Dengue, Dengue Haemorrhagic Fever, Japanese encephalitis, Chikungunya are not studied in this study.

1.5 Organization of the Study

This study is organized into five chapters. Chapter I is Introduction. It includes rationale, objectives, method, scope and limitation and organization of the study. Chapter II presents literature review and previous studies review Chapter III consists of overview of malaria prevention and control programme in Myanmar and Bago Region Chapter IV consists of Survey Analysis. Chapter V concludes with conclusion with findings and suggestions.

CHAPTER II LITERATURE REVIEW

2.1 Background History of Malaria Malaria was one of the oldest diseases in the world. In 1880, it was discovered the malaria parasite in Algiers, North Africa (Cox, Francis, 2010). Ronald Ross, discovered transmission of malaria by Anopheles mosquitoes in 1897. Malaria is a life-threatening disease caused by Plasmodium parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes, called malaria vectors, which bite mainly between dusk and dawn and it can be transmitted by a contaminated needle or transfusion. The malaria is transmitted to humans through the bite of the Anopheles mosquito. Falciparum malaria is the most deadly type. It is preventable and treatable. (WHO, 2018). The epidemiology of malaria is highly complex. There are four kinds of malaria parasites infect humans are Plasmodium falciparum (P.f), Plasmodium vivax (P.v), Plasmodium ovale (P.o), Plasmodium malariae (P.m). P.f is most likely to result in severe infection, potentially life-threatening. The cases of Plasmodium knowlesi have also been documented nowadays. The vast majority of malaria cases are caused by Plasmodium falciparum and Plasmodium vivax. The epidemiology of the disease varies greatly from location to location and from one population group or situation to another. In many cases the different situations and contexts require different malaria control strategies, adapted to suit specific risk groups and vector behaviors, and adjusted to take into consideration local infrastructure and health service coverage. Furthermore, the situation in any given area is prone to change rapidly as a result of factors such as developing drug resistance, changing ecologies, marked deforestation and large-scale population movements associated with seasonal labour, large-scale development projects, etc. Intense malaria transmission is largely restricted to hilly, forested and forest fringe areas. The most efficient vectors, members of the Anopheles dirus species complex, cannot survive without dense shade and high humidity. Deforestation therefore generally leads to substantially reduced malaria transmission,

5 although An. diruscan maintain transmission by breeding in wells. Reforestation projects such as oil palm and rubber plantations following deforestation can sometimes provide suitable habitats for vectors resulting in resurgence in malaria transmission. The next most efficient vector, which is probably the most important in terms of transmission, is Anopheles minimus (senso lato). This species is also primarily forest- based but can survive in less densely shaded forest, forest fringes and in the patchy bamboo thickets that commonly persist post-deforestation (WHO, 2018) The behavior of malaria vectors varies depending on climatic and other environmental factors. Both indoor and outdoor biting takes place, but primary vectors are characterized, at least seasonally, by their early outdoor biting habit. This is a key feature of the epidemiology of malaria throughout the Greater Mekong Sub- region (GMS), which limits to some extent the effectiveness of key interventions for vector control and personal protection. Despite a portion of the vector biting occurring early and outdoors, Long Lasting Insecticidal Nets (LLINs) continue to play a critical role in reducing malaria transmission. There is no evidence of insecticide resistance among the primary malaria vectors at present, however monitoring has been limited. Given the selection pressure being exerted by insecticide use in public health and in the agricultural sector, surveillance needs to be strengthened (WHO, 2018) The malaria causes symptoms typically include high fever with shaking chill and rigor with profuse sweating, vomiting and headaches and feeling tired. The classical but rarely observed malaria attack lasts 6-10 hours. It consists of a cold stage (sensation of cold, shivering), a hot stage (fever, headaches, vomiting; seizures in young children), finally a sweating stage (sweats, return to normal temperature, tiredness), liver and kidney failure, convulsions, and coma. Although occasionally severe, infections with P. vivax and P. ovale generally cause less serious illness, but the parasites can remain dormant in the liver for many months, causing a reappearance of symptoms months or even years later. Severe malaria is a medical emergency and should be treated urgently and aggressively. Symptoms usually begin ten to fifteen days after being bitten. If not properly treated, people may have recurrences of the disease months later. The appearances of severe malaria include cerebral malaria with abnormal behavior, impairment of consciousness, seizures, coma, or other neurologic abnormalities, severe anemia due to hemolysis (destruction of the red blood cells), hemoglobinuria (hemoglobin in the urine) due to hemolysis, acute respiratory distress syndrome (ARDS), abnormalities is blood coagulation, low

6 blood pressure, acute kidney failure, hypoglycemia (low blood glucose). Hypoglycemia may also occur in pregnant women with uncomplicated malaria, or after treatment with quinine. But malaria can be treated and controlled by the early diagnosis. The risk of disease can be reduced by preventing mosquito bites through the use of mosquito nets and insect repellents, or with mosquito control measures such as spraying insecticides and draining standing water. Several medications are available to prevent malaria in travelers to areas where the disease is common. Occasional doses of the combination medication sulfadoxine/pyrimethamine are recommended in infants and after the first trimester of pregnancy in areas with high rates of malaria. Despite a need, no effective vaccine exists, although efforts to develop one are ongoing. The World Health Organization recommended treatment for malaria is a combination of antimalarial medications that includes an artemisinin. This is called ACT (artemisinin based combination therapy). The chloroquine-resistant P. falciparum has spread to most malarial areas, and resistance has become a problem in some parts of Southeast Asia.

2.2 Regional and Global Burden of Malaria In 2017 an estimated 219 million cases of malaria in 87 countries occurred worldwide compared with 239 million cases in 2010. Although there were 20 million fewer cases in 2017 than in 2010 globally, the period 2015 to 2017. The estimated number of malaria deaths stood at 435 000 in 2017. In 2017, the region was home to 92% of malaria cases and 93% of malaria deaths. The African Region still bears the largest burden of malaria morbidity, with 200 million cases (92%) in 2017, followed by the South-East Asia Region (5%) and the Eastern Mediterranean Region (2%). Globally, 3.4% of all estimated cases were caused by P. vivax, with 56% of the vivax cases being in the South-East Asia Region. P. vivax is in the Americas (74%), and 37% of cases is in the South-East Asia Region and 31% in the Mediterranean Region. (WHO, 2018) Almost 80% of all malaria cases globally were in 15 African countries and in India. Nearly 50% of all cases globally were accounted for by Nigeria (25%), the Democratic Republic of the Congo (11%), Mozambique (5%), India (4%) and Uganda (4%). About 82% of estimated vivax malaria cases in 2017 occurred in just five countries (India, Pakistan, Ethiopia, Afghanistan and Indonesia). Of the 87

7 countries that had an indigenous malaria case in 2017, a decrease in malaria cases of more than 20% compared with 2016 was estimated in 20 countries, and an increase in malaria cases was estimated in 20 countries. Most of these changes occurred in countries with low to very low malaria burden, and in several countries the total difference was small. (WHO, 2018) The estimated deaths due to malaria globally declined from 607,000 to 435,000 cases 2010 and 2017. Estimates of malaria mortality rate compared with 2010, all regions had recorded reductions by 2017, except the Region of the Americas, mainly due to a rapid increase in malaria in Venezuela. Globally, 266 000 (61%) malaria deaths were estimated to be in children aged under 5 years. Malaria is the fourth-leading cause of death among children under 5 year of age in sub-Saharan Africa. (WHO, 2018)

2.3 Prevention and Control Strategy for Malaria Elimination The Global Technical Strategy for Malaria 2016-2030 was developed through an extensive consultation processes the began in June 2013 and culminated in the document’s adoption by the World Health Assembly at its 68th meeting in May 2015. The global strategy of malaria for elimination is built on three pillars to move closer to malaria elimination. The Pillar 1 is to ensure universal access to malaria prevention, diagnosis and treatment. The core interventions namely quality-assured vector control, prevention, diagnostic testing and treatment can dramatically reduce morbidity and mortality. In areas of moderate-to-high transmission, ensuring universal access of populations at risk to interventions should be a principal objective of national malaria programmes. Prevention strategies based on vector control, and some population groups, universal diagnosis, prompt effective treatment of malaria in public and private health facilities and at community level. Structuring programmes, stratification of malaria by disease burden, vectors control and interventions to the local context and ensure efficient use of resources. The Pillar 2 is to accelerate efforts towards elimination and attainment of malaria-free status: Countries need to reduce onward transmission of new infections in defined geographical areas, particularly in settings where transmission is low. In addition to core interventions, vectors control in well-defined transmission foci, case detection and case investigations as part of a malaria surveillance and response programme. The Pillar 3 to transform malaria surveillance into a core intervention. Strengthening malaria surveillance is important

8 to programme planning and implementation which is a key factor for accelerating progress. All countries where malaria is endemic and those vulnerable to the re- establishment of malaria should have an effective health management and information system, helping national malaria programmes to direct resources to the most affected populations, identify gaps in programme coverage, detect outbreaks, and assess the impact of interventions in order to guide changes in programme orientation (WHO, 2015). There all above activities are key factors for malaria elimination program. The global malaria elimination efforts are conducted by governments under malaria endemic countries and international partners. An estimated US$ 3.1 billion was invested in malaria control in 2017. Approximately three quarters (US$ 2.2 billion) of investments in 2017 were spent in the African Region, followed by the regions of South-East Asia (US$ 300 million), the Eastern Mediterranean, the Americas (US$ 200 million) and the Western Pacific (US$ 100 million each). In 2017, US$ 1.4 billion was invested in low-income countries, US$ 1.2 billion in lower-middle income countries and US$ 300 million in upper-middle-income countries. International funding represented the major source of funding in low-income and lower-middle- income countries, at 87% and 70%, respectively. Globally, insecticide-treated mosquito nets were delivered between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs), mainly long-lasting insecticidal nets (LLINs), were reported by manufacturers. (WHO, 2015).

2.4 Factors Affecting of Malaria Prevention and Control Programme The factors affecting the prevention and control of malaria are the community preventive measures integrated with the health care system such as using ITN/LLIN, drainage of stagnant water, mosquito spray, indoor residual, home spray/use of repellant and health care seeking for fever as designed by the government are on practice. The socio-economic difference and educational status, wealth index, type of house, presence of ITN distribution program from the health center and involvement of the community in prevention campaigns were independently and significantly determined implementation of malaria prevention measures in the community. The LLIN/ITN using is more effective for malaria prevention and further affects malaria prevention practice. The malaria prevention programs implemented at the health care

9 system also highly determines malaria prevention measure, involved in malaria prevention campaigns were more likely to practice malaria prevention.

2.5 Review of Previous Studies As per success stories from other countries that a study conducted in 2006 which reviewed the case studies from Vietnam, Brazil and India stated that the common success factors for malaria reduction were conducive country conditions, targeted technical approach using a package of effective tools (using of LLIN, Case Investigation and Case management by treated with treatment guideline), data-driven decision-making, active leadership at all levels of government, involvement of communities, community awareness, decentralized implementation and control of finances, skilled technical and managerial capacity at national and sub-national level, hands-on technical and programmatic support from partner agencies, and sufficient and flexible financing. Promoting malaria control activities is an important role in reducing malaria burden. World Malaria Report stated that 11 countries have shown decreases in malaria cases after widescale implementation of malaria control activities in the population at high risk (Barat, 2016). The role of community service officer and international organizations played an important role in providing financial and technical support on government efforts to reduce the impact of malaria. National budget for Malaria control activities can improve malaria control activities. For the middle and low income countries, funding availability is also a successful factor to reduce malaria burden (Kesteman et al., 2017). Myo Myo Zin (2009) explored about the Malaria Prevention and Control Programme in Rakhine State to study malaria prevention and control activities and examine social, culture and economic factors affecting of health and delivery of services in Rakhine. He found that Rakhine State is the highest malaria prevalence area in Myanmar. In Northern Rakhine State, religion influenced culture negatively to women’s health. High illiteracy rate in females leads women unable to prevent malaria and other disease. Construction of prawn breeding ponds, uncontrolled population migration and forestry works lead to re-emergence of malaria in Northern Rakhine State. Lack of access to adequate health services is a major contributing the highest malaria prevalence rate. LLIN was used in many townships and village to prevent and control malaria in Rakhine. Selected Indoors Residual Spray was not covered the whole population in Rakhine.

Aye Thet Htar Kywe (2014) studied about the Malaria Prevention and Control Programme of WHO in Mon State. The objectives of the study were to study prevention and control programme of Malaria in Mon State and to identify the prevention and control activities of National Malaria Control Programme in Myanmar from 1978 to 2013. Her study found that Mon State is high illiteracy rate in female leads women unable to prevent malaria and other diseases. Involuntary health workers should be assumed as a good approach for community mobilization in malaria control program in Mon State. Win Bo (2016)analyzed the Malaria Prevention and Control Programme in Myanmar. The objective of the study was to access national malaria control programme on outcomes of malaria control in Myanmar. He found that incidence and deaths due to malaria in Myanmar is decreasing due to improved access to diagnosis and treatment services. The number of malaria outbreaks decreasing. Population migration is identified as most frequent cause of malaria outbreaks in Myanmar. Resources are limited in malaria prevention, diagnosis and treatment of Myanmar. Access to diagnosis and treatment facilities is limited in some areas of Myanmar such as conflict-effected areas, borders, and hard-to reach area. Majority of Partners of National Malaria Control Programme is international NGOs. There is a lack of effective coordination among partners of malaria control and overlapping of implementation area is identified. The funding in malaria control of Myanmar is increasing but sustainable funding is needed to strengthen malaria control. Lwin Lwin Mar (2018) explored about the knowledge, attitude and practice towards malaria in Saltawgyi village, Madaya Township, Mandalay Region. The aim of this study was KAP of community towards malariato find out the barriers of the community for taking malaria services at public health sectors and the last one is to find out the challenges of malaria health staff from Saltawgyi for providing malaria services. Descriptive method was used for analysis and 200 households were randomly selected. This study found that the community well known about diagnosis methods and signs/symptoms but knowledge regarding cause of malaria and biting habit of malaria mosquito were simi-informed. Sleeping under insecticide bed nets is main malaria preventive measures frequently reported by the study participants but only 59% practically used it. Most of the respondents had positive attitude on malaria. Upon reviewing the previous thesis related to three pillars set by WHO for global malaria elimination, one may come to conclusion that Rakhine, Mon and other

11 regions in Myanmar has face critical challenges in health education (Myo Myo Zin, 2009, Aye Thet Htar Kywe, 2014) and inability to mobilize the community for coordinated malaria control program (Win Bo, 2016), and the reliance of involuntary healthcare workers (Aye Thet Htar Kywe, 2014) was found to be not effective factor in preventing malaria in Mon state. All previous studies in general point out that a new approach is needed to increase health education, better access by healthcare workers to community for Rapid Diagnostic Treatment (RDT), surveillance to control Annual Parasite Incidents (API), to decrease Morbidity and Mortality rate for Bago region.

CHAPTER III OVERVIEW OF MALARIA PREVENTION AND CONTROL PROGRAMME IN BAGO REGION

3.1 Overview of Malaria Situation in Myanmar Malaria is a re-emerging public health problem in Myanmar due to climate change, migration, ecological changes, emergence of multi-drug resistance, artemisinin resistant malaria parasite and change behavior of vector. The National Malaria Control Programme figures presented below are based mostly on data from public sector health services as well as other implementing partners. It should be noted that some vulnerable groups living in endemic communities are not currently served by public sector community-based case management services. NMCP figures include limited data from the private sector at present, and the private sector plays a very significant role in malaria case management in Myanmar. Although initiatives managed by NMCP partners are now promoting parasitological diagnosis in the private sector, coverage is currently limited but growing. The reported malaria statistics therefore underestimate the true burden of disease. Nevertheless, they do give the most robust measure available of progress towards malaria control/elimination goals over time. (MOHS 2015). In 2016, Myanmar had an estimated population of 51.3 million with a total of 110,146 reported malaria cases. The total number of reported malaria deaths among hospital in-patients in 2017 was 21. Malaria morbidity rate /case rate in 2016 was 0.04 per 100,000 population. A total of 21 malaria deaths was reported. Out of 330 townships in Myanmar, 34 townships from Yangon Region and 5 townships from Mandalay Region (total 39 townships) were malaria free in 2016. In 2015, a total of 138 townships had Annual Parasite Index (API) of less than 1 per 1000 at-risk population compared to 69 townships in 2006. (VBDC, 2016)

3.1.1 Trends of Malaria Morbidity and Mortality from 2007 to 2017 The reduction in malaria caseload is less clear due to a combination of factors, including gradual expansion of health-care coverage in recent years (most especially as a result of the rollout of community-based malaria case management services) and the introduction of Rapid Diagnosis Test (RDT) for point of care diagnosis throughout the health system. As a result of these advances, almost all cases are now parasitological confirmed. Data from 2012 onwards are relatively strong and demonstrate a steady and impressive reduction in caseload year by year. Over the last decade, a remarkable progress in reducing malaria cases and deaths can be seen as there was a 79% reduction in cases and 99% reduction in deaths in 2016 compared to 2007 despite improved case detection resulting from the recent roll-out of RDTs. Trends of Malaria Morbidity and Mortality Rate in Myanmar (2007-2017) are shown in Figure (3.1). Figure (3.1) Trends of Malaria Morbidity and Mortality Rate in Myanmar from 2007 to 2017

14.0 11.7 12.0 10.7 10.9 10.0 10.0 9.0 8.1 8.0 6.8

6.0

Rate 4.1 3.6 4.0 2.2 2.1 1.8 1.6 1.6 2.0 1.3 1.2 0.8 0.5 0.2 0.1 0.0 0.1 0.0

Malaria Morbidity and Mortality and Mortality Morbidity Malaria 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

Morbidity rate Motality rate

Source: National Malaria Control Programme According to figure (3.1), the malaria morbidity rate was 1.6 per 1,000 population and malaria mortality rate was 0.1 per 100,000 population respectively in 2017. The malaria morbidity rate and mortality rate of malaria in Myanmar were 9.0 per 1000 population and 2.2 per 100,000 population respectively in 2007. Over the

14 last decade, the malaria case and death are very drastic fall in decrease from 2007 to 2017. Table (3.1) shows malaria cases and deaths in Myanmar from 2007 to 2017.

Malaria Cases and Deaths in Myanmar from 2007 to 2017 are shown in Figure (3.2). Figure (3.2) Malaria Cases and Deaths in Myanmar from 2007 to 2017

1,400 800,000 1,261 1,200 700,000 1,087 600,000

1,000 972 252,916 252,916

187,207 187,207 500,000

800 788

206,961 206,961 108,124 108,124

149,275 149,275 400,000 600

564 300,000

Malaria Deaths Malaria Cases 400 403

200,000

447,073 447,073

440,208 440,208

421,903 421,903

391,679 391,679 384,531 384,531 371,612 371,612 236 200 333,871 100,000

205,658 205,658 92

182,616 182,616 37 30 110,146 110,146 - 21 85,612 - 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Confirmed Probable Malaria Malaria Death Malarila

Source: National Malaria Control Programme Figure (3.2) Myanmar had an estimated population of 54.4 million with a total of 85,612 reported malaria cases. Total number of reported malaria deaths among hospital inpatients in was 30. Over the decade, a remarkable progress in reducing malaria cases and deaths can be there was a 79% reduction in case and 99% reduction in deaths in 2017 compared to 2007.

Table (3.1) Malaria Cases and Deaths in Myanmar (2007 to 2017) Out-Patient (OP) In-Patient (IP) Total Case Cerebral/ Malaria Malaria Total Total Malaria Fatality Year Population Confirmed Probable Confirmed Severe Malaria Morbidity Morbidity Patient Patient Case Rate Malaria Malaria Malaria Complicated Death Rate Rate Attended Attended (OP+IP) (CFR) Malaria 2007 57,860,566 6,354,467 318,392 149,275 719,779 53,220 9,054 1,261 520,887 9.0 2.2 0.4 2008 59,017,777 6,828,384 399,559 187,207 740,615 47,514 10,160 1,087 634,280 10.7 1.8 0.3 2009 59,147,616 6,986,664 336,759 206,961 795,420 47,772 8,739 972 591,492 10.0 1.6 0.3 2010 59,265,912 7,425,040 396,606 252,916 863,367 43,602 6,939 788 693,124 11.7 1.3 0.2 2011 48,582,481 7,503,372 387,860 108,124 823,945 34,043 6,053 564 530,027 10.9 1.2 0.1 2012 48,387,643 7,265,777 364,265 0 962,033 27,414 4,160 403 391,679 8.1 0.8 0.1 2013 49,010,861 9,841,975 315,509 0 1,074,728 18,362 2,085 236 333,871 6.8 0.5 0.1 2014 49,717,494 12,136,627 195,214 0 1,198,149 10,444 1,090 92 205,658 4.1 0.2 0.0 2015 50,787,727 12,704,940 175,138 0 1,182,172 7,478 660 37 182,616 3.6 0.1 0.0 2016 51,300,683 14,494,066 105,874 0 1,385,899 4,272 510 21 110,146 2.1 0.0 0.0 2017 54,473,738 14,660,323 82,665 0 1,537,143 2,947 260 30 85,612 1.6 0.1 0.0

Source: National Malaria Control Programme TPA, Total patient attended Morbidity rate = (Total malaria deaths/population) x 100,000 Mortality rate = (Total malaria cases/population) x 1,000 CFR, Case fatality rate = (no. of malaria deaths/no. of in-patient confirmed malaria cases) x 100

Table (3.2) shown the malaria cases and deaths by State and Region in Myanmar (2017). Table (3.2) Malaria Cases and Deaths by State and Region in Myanmar (2017)

In-patient Out-patient Total Morbidity Mortality Sr.No Township Population Severe Confirmed Confirmed Confirmed Cerebral Malaria Rate Rate Complicated CFR Malaria Malaria Malaria Malaria Death Malaria

1 Ayeyarwady 6,365,061 1,625 250 2 - 1 0.40 1,875 0.29 0.02 2 Bago 5,113,206 202 115 3 1 1 0.87 317 0.06 0.02 3 Chin 508,359 4,804 201 20 87 13 6.47 5,005 9.85 2.56 4 Kachin 1,829,848 1,440 191 4 1 5 2.62 1,631 0.89 0.27 5 Kayah 310,214 297 40 1 0 0 - 337 1.09 - 6 Kayin 1,613,849 1,051 259 16 17 0 - 1,310 0.81 - 7 Magway 3,941,237 229 73 2 2 1 1.37 302 0.08 0.03 8 Mandalay 6,389,390 510 96 0 0 1 1.04 606 0.09 0.02 9 Mon 2,251,873 166 42 1 3 1 2.38 208 0.09 0.04 10 Naypyitaw 1,238,039 86 60 0 0 0 - 146 0.12 - 11 Rakhine 3,359,337 8,697 317 14 2 6 1.89 9,014 2.68 0.18 12 Sagaing 5,463,672 6,254 706 19 40 1 0.14 6,960 1.27 0.02 13 Shan (East) 2,062,896 880 65 0 0 0 - 945 0.46 - 14 Shan (North) 2,262,426 1,022 217 4 0 0 - 1,239 0.55 - 15 Shan (South) 2,367,742 782 184 5 2 0 - 966 0.41 - 16 Tanintharyi 1,459,952 1,022 126 3 11 0 - 1,148 0.79 - 17 Yangon 7,936,637 31 5 0 0 0 - 36 0.00 - Grand Total 54,473,738 29,098 2,947 94 166 30 1.02 32,045 0.59 0.06 Source: National Malaria Control Programme

Figure (3.3) shows confirmed malaria cases in States and Regions (2017)

Figure (3.3) Confirmed Malaria Cases in States and Regions (2017)

Rakhine 9014 Sagaing 6960 Chin 5005 Ayeyarwady 1875 Kachin 1631 Kayin 1310 Shan (North) 1239 Tanintharyi 1148 Shan (South) 966 Shan (East) 945 Mandalay 606 Kayah 337

State/Region Bago 317 Magway 302 Mon 208 Naypyitaw 146 Yangon 36 0 2000 4000 6000 8000 10000 Malaria Confirmed Cases No. of Malaria Cases (OP+IP)

Source: National Malaria Control Programme

The State/ Region wise malaria cases and deaths are illustrated in Table (3.2) and Figure (3.3). According to table, malaria morbidity was highest in Rakhine State followed by Sagaing Region, Chin State and Shan State in 2017. The lowest malaria morbidity was observed in Yangon region followed by Naypyitaw and Mon State. Bago Region was also fifth lowest malaria morbidity in 2017. The in-patients are those who came to hospitals and later diagnosed with Malaria and out-patients are those who have been treated in community-level healthcare providers such as village- level and township-level healthcare providers who are mostly operated by implementing partners, healthcare volunteers, and healthcare officers. Most malaria cases happened among people residing or temporarily located in villages, houses or shelters near (1-3 km) or in forest area. Persons generally living in such conditions are poor minority ethnic groups, forest worker, such as cutting bamboo or rattan or charcoal production, gold panning and other occupations related to forest activities. Migrant and mobile population is other major risk groups for malaria. For economic reasons, they have to go for farming, logging or mining in forest area, and to work for dam and road construction and agricultural worker, such

18 as rice cultivation, rubber plantation and palm oil plantations. Internally displaced population (IDPs) caused by dam construction, agricultural works and political conflicts (new settlement camps) are also more exposed to the disease. The government and UN, INGOs, NGOs are activitely involved in Long-Lasting insecticidal Net LLINs distribution and to some extent indoor residual spray (IRS) targeting IDPs in nongovernment townships.

3.2 National Plan for Malaria Elimination in Myanmar (2016-2030) The national plan for malaria elimination in Myanmar 2016-2030 has been developed in line with WHO Global Strategy (GTS) for Malaria 2016-2030. Ministry of Health and Sports aims to achieve malaria elimination by ensuring equitable and universal access to effective curative and preventive services to everyone at risk of malaria. MNCP is working closely coordination with all communities, national and international non-government organizations, private sector stakeholders, United Nations agencies and financial partners. Achieving the vision of “A Malaria free Myanmar by 2030” will contribute significantly to poverty alleviation as malaria is mostly prevalent in the poorest segment of the population: those living or spending time in remote forested areas including mobile and migrant populations. The goals of National Malaria Control Programme are: (1) Interrupt transmission of and eliminate indigenous malaria throughout the entire country by 2030 and (2) Maintain malaria-free status in areas where malaria transmission has been interrupted and prevent re-establishment of local transmission.

The objective of National Malaria Control Programme are: (1) Reducing the incidence of malaria to less than 1 case per 1000 population at risk in all States/Regions by 2020 (2) Interrupting transmission of and eliminating indigenous P. falciparum malaria at least in 6 states/regions (Yangon, Bago, Magway, Mandalay, Nay Pyi Taw Union Territory & Mon) by 2020 and throughout the entire country by 2025, considering the urgent action required against multi-drug including artemisinin resistance in the country and the Greater Mekong Sub-Region (GMS) as well;

(3) Interrupting transmission of and eliminating indigenous malaria in a phased, progressing manner across the country by 2030; and (4) Preventing the re-establishment of local malaria transmission due to importation in all areas where it has been eliminated before and beyond 2030. (MOHS, 2015)

3.2.1 National Malaria Prevention and Control Programme (NMCP) in Myanmar The National Malaria Control Programme (NMCP) located within the National Vector-Borne Diseases Control (VBDC) programme has a robust infrastructure and is staffed with people possessing a wide range of technical competencies at the central level, and a few staff positions at the state/regional level where malaria control is integrated into the general health services. At the township and village levels, basic health staff such as midwives and health assistants (HA), and Integrated Community Malaria Volunteer (ICMV) deliver malaria services with technical assistance and guidance from the state/regional NMCP staff. The NMCP is partnered by over 37 international and local nongovernment organizations (NGOs) which have received international financial support for malaria control. International nongovernment organizations (INGOs) operate in endemic areas defined by the Government and all NGOs work through their own ICMVs in scaling up malaria control interventions. The activities of these implementation partners have been very helpful in rapidly scaling up antimalarial services in their areas of operation. However, a very large part of the service delivery for malaria control operations are being carried out by the public sector health services. Over the years, the NMCP at the central level has suffered from continuing reduction in manpower due to their inability to replace posts vacated by retired malaria staff (budget constraints, and a hiring freeze) contributing to poor implementation of the programme. The state/region level is also under-staffed and under-resourced, with many critical NMCP positions still vacant weakened facilities and poor support for field operations also. In contrast, malaria intervention delivery at the township level has been greatly strengthened over the past six years – mainly at the rural health centre (RHC) and sub-centre and lower levels staffed by midwives, HAs and INTEGRATED COMMUNITY MALARIA VOLUNTEER (ICMV)s resulting in high coverage of antimalarial interventions. The field malaria programme

20 staff and the basic health staff were consistently found to be highly motivated, delivering malaria control services including in some very difficult environments in spite of many constraints. However, states/regions are geographically large, the few NMCP staff and limited financial resources are inadequate to support these operations with malaria expertise on the ground or able to deal with emerging issues.

3.2.2 Health System and Resources for Malaria Prevention and Control Activities in Myanmar National Malaria Control Programme is the key actor for Malaria Control activities in Myanmar. The role of National Malaria Control Program called NMCP plays the leading role in setting up framework of strategy, action plan and roadmap in coordinating all the important stakeholders in the efforts to control Malaria from states and divisions in Myanmar. NMCP is under the VBDC Programme headed by two Deputy Directors; one for Malaria and one for Dengue, Lymphatic Filariasis and other vector borne diseases. The organization chart of Vector Borne Disease Control (central) shown in Appendix (1). Most of the staff and resources of VBDC at all levels, except in the bigger cities, are focused on malaria. The NMCP works closely with the Department of Medical Services, the National Health Laboratory and the Food and Drug Administration Department in order to implement key activities. (VBDC, 2016) The State/Region VBDC office is headed by the State/Region VBDC Assistant Director and/or VBDC Team Leader who, with the team, manages the malaria programme at the State/Region level Organograms of VBDC office at district and township levels are also mentioned. The National Malaria Control Programme (NMCP) located within the National Vector-Borne Diseases Control (VBDC) programme has a strong infrastructure and is staffed with people possessing a wide range of technical competencies at the central level, and a few staff positions at the state/regional level where malaria control is integrated into the general health services. At the township and village levels, basic health staff such as midwives and health assistants (HA), and Integrated Community Malaria Volunteer (ICMV)delivers malaria services with technical assistance and guidance from the state/regional NMCP staff. National Malaria Control Programme Manpower and organization chart show in Appendix 1. One of the strategies in integrating malaria prevention and treatment

21 activities in primary health care. Therefore the brief review of Primary Health Care and Community Healthcare Systems are discussed in the following sections. Headed by Township Public Health Department (TPHD), 4 Public Health Officers in township-level hospital has two Medical Officers (one for Disease Control/ Public Health and one for Medical Care) and one Administrative Officer assist for township-level malaria control and treatment activities. At village levels, those similar activities are conducted by the basic health staff such as midwives and health assistants (HA), and Integrated Community Malaria Volunteer (ICMV)delivers malaria services with technical assistance and guidance from the state/regional NMCP staff. Under each Rural Healthcare Center (RHC), there are four to five Sub-RHCs (each managed by a Midwife with a Public Health Supervisor - level II). Microscopy for blood-testing services is available at Public Township Hospitals. Township Hospitals (25 to 50 beds) are the basic unit for medical and surgical care for rural and urban communities. All Township Hospitals in the country are managed by a Township Medical Officer. Under each Township Hospital, there are 1 or 2 Station Hospitals (16 beds) managed by Medical Officer. All basic health staff, Medical Officers and Township Medical Officers have received relevant training on malaria case management, recording and reporting, and supply chain management during the past 5 years. (VBDC, 2016). Although community-level health staffs are working on various aspects of community health sectors, it is worth mentioned about their roles in observing the success factors controlling Malaria as village-level health staff such as basic health staff, midwives play critical roles by collaborating with healthcare volunteers, public healthcare officers and having the direct communication with hard-to-reach community. Integrated Community Malaria Volunteer (ICMV) are key service providers at the community level in Myanmar and form the foundation of malaria control activities at village/community level. Substantial investments have been made in community based health services by Global Fund, 3MDG, USAID-PMI and JICA and Integrated Community Malaria Volunteer (ICMV)s involved in malaria case management nationwide. Integrated Community Malaria Volunteer (ICMV)s working under the programme and I/NGOs are provided with five-day modular training on malaria diagnosis and treatment. They provide malaria diagnosis and treatment at community level using RDT, ACT, CQ and PQ according to national malaria treatment guidelines. Some are also engaged in prevention activities such as LLIN

22 distribution, health education and community awareness raising activities depending on the organization that supports and supervises them. Just over 50% of the malaria cases diagnosed in 2015, were diagnosed and treated by s and their involvement grew larger since then. (VBDC, 2016).

3.2.3 Malaria Prevention and Control Activities The National Malaria Control Programme of Myanmar has two main activities. Those are prevention and control of malaria. Preventive activities reply on the following key factors: - Stratification of areas for Malaria Control/Micro-stratification - Distribution Long Lasting Insecticidal nets (LLIN) - Indoor Residual Spaying (IRS) - Information, Health Education and Communication Control activities reply on the following key factors: - Early Diagnosis and Appropriate Treatment - Supervision and Quality Control of Malaria Microscopy, Community Based Malaria Control Programme - Malaria Surveillance, Monitoring, Supervision and Evaluation - Data Management and Supplies Management

Preventive activities Dissemination of messages on malaria is carried out through various media channels with the emphasis on regular use of bed nets (if possible appropriate use of insecticide treated nets) and early seeking of quality diagnosis and appropriate treatment (as soon as possible within 24 hours after onset of fever). Production and distribution of Information, Education and Communication (IEC) materials is also carried out in different local languages for various ethnic groups and different target groups such as forest related travelers, pregnant women and general population. Advocacy activities are conducted to public and private sectors, NGOs, religious organizations and local authorities at different levels. In Myanmar, Micro-stratification was completed in 180 Townships in 2012, 51 Townships in 2014 and 2015. However, criteria for microstratification have been revised because the previous criteria used were subjective rather than objective. Now

23 some of the Townships already have village-wise parasitological data that can be used to stratify villages so as to be in line with changing strategic direction from control to elimination. The unit of micro-stratification is “village” and that stratification is determined using API instead of using risk factors alone. Risk factors are still used to evaluate the receptivity and vulnerability in potential transmission areas where malaria data is incomplete Due to limitation on the availability of population by village, sub-centres have been considered as the unit of measurement for calculating population at risk under each setting Stratum Transmission levels N. of Sub-centres Population at risk % of Population at risk (VBDC, 2015). The areas had been stratified as described below. Population of micro-stratification by Sub-centre in Myanmar are shown in Table (3.3).

Table (3.3) Population of Micro-Stratification by Sub-Centre in Myanmar (2017) Stratum Transmission Status Sub-centers Population % of Population 3a High 1026 3,542,647 7% 3b Moderate 1,461 6,328,845 12% 3c Low 2,062 12,664,333 24% 2 Potential 4,439 21,354,063 41% 1 Malaria free 1,531 8,116,373 16% Source: National Malaria Control Programme

Table (3.3) illustrates Malaria high area (Stratum 3a) was 7% of total population, Moderate risk area (Stratum 3b) was 12%, Low risk area (Stratum 3c) was 24% and Potential area (Stratum 2) was 41%. According to national malaria program contribution of prevention and control activities, the malaria free area becomes 16% of total population, 1,531 subcenter respectively in 2016. According to the ecological changes, distribution of malaria morbidity patterns and results from the micro-stratification, the highest risk areas for the malaria was about 38.9% in the 1990 was reduced to 7% in 2016. Thus the malaria free areas in the country were increased from 16% to 40% from 1990 to 2016. Package of malaria control activity has been given according to the result of risk area stratification that ensures the effective resource allocation. Validation on micro-stratification process was done by malariometric survey in some targeted townships. Selective and sustainable preventive measures are carried out emphasizing on personal protection

24 and environmental management. With limited resources, areas were prioritized for either distribution of long lasting insecticidal nets (LLIN) or impregnation of existing nets (ITN). At present, LLINs are a core intervention that is widely used to reduce transmission and prevent malaria in local communities and high-risk areas migrant mobile populations. Universal coverage with LLINs to ensure that (a) each household has sufficient nets and (b) every inhabitant at risk sleeps under a LLIN every night is critical to reduce transmission in high-transmission settings. Distribution of LLINs with locally appropriate and gender sensitive Information, Education & Communication (IEC) is important for Behavior Change Communication (BCC) to ensure community participation and correct LLIN usage. In 2016, a total of 3046,008 LLINs were distributed by the NMCP with the support from Global Fund and Presidents’ Malaria Initiative /USAID. LLINs were distributed in States and Regions. (VBDC, 2016). Indoor residual spraying (IRS) can reduce malaria transmission in plains to low-level areas but has only a limited impact in hilly and forested areas, and now is mostly restricted to the control of outbreaks and addressing migrant mobile populations (MMPs) in some situations. In Myanmar focal IRS in the event of outbreaks, addressing MMPs in some situation, and active foci of malaria in areas eligible for elimination where case and foci investigations are in place, and entomological evidence and other factors indicate that interruption of transmission can be expected. During 2016, selective indoor residual sprarying (IRS was done in 3 State, Kachin State, Kayah and Rakhine State. Fendona was used IRS and covered a total of 10,252 building. (VBDC, 2016). Information, Education and Communication and Behaviour Change Communication (IEC/BCC) are IEC/BCC is one of the main strategies to educate and raise awareness of target populations for malaria prevention and control. IEC interventions target high-risk populations and mobile migrant populations. They also pay special attention to boost interventions related to artemisinin resistance containment operations as well as LLIN distribution, improved utilization of nets in different settings, population screening, and compliance with the full treatment regimen (including low dose primaquine in P. falciparum infections). BCC mechanisms and tools strengthened to improve treatment seeking behaviours and adherence to treatment. Various channels are mentioned, such as interpersonal communication, mass media, schools, mobile teams, etc. Within the VBDC, some

25 staff should be trained in IEC/BCC, taking stock of innovative communication approaches and modern BCC packages. (WHO, 2016)

Control Activities Early Diagnosis and appropriate treatment is important strategy in malaria control programs. Malaria mobile teams and malaria voluntary health workers reached up to rural areas, hard-to reach and hardest to reach areas for improving access. Community based malaria control program is important in controlling malaria. According to the new anti-malarial treatment policy, case management with ACT (Artemisinin based combination therapy) was practiced in all 330 townships. In 2016, 3.1 million population was tested for malaria either by microscopy of malaria Rapid Diagnosis Test, annual blood examination (ABER) was 6.12%. As guided by the National Plan for Malaria Elimination in Myanmar, the ABER for populations at risk in active and non-active residual foci should be kept of above 5%, and preferably increased to 10% or event higher. Major of malaria cases in Myanmar were diagnosed by RDTs. Out of 3.1 million population tested for malaria in 2016, 3 million was tested by RDT. Number of positive cases diagnosed by RDT in 2016 was 103,349 and RDT positive rate was 3.38%. On the contrary, total number of population tested by both microscopy and RDT was 3,367,541 out of which 85,019 were diagnosed positive with malaria. Slide positively rate was 2.52%. (VBDC, 2016). Supervision and quality control of malaria microscopy was done in 103 malaria microscopic centers by laboratory technicians from Central and State/Regional VBDC team And Department of Medical Research in 2014. Currently there are 752 of microscopy centers under Department of Public health (DOPH) and Department of Medical Services (DOMS). In 2016, altogether 127 laboratories were supervised by the Malaria Programme (VBDC), two news training and seven refresher trainings to 104 malaria microscopics and conducted 5 competency training to 76 microscopists as well. The estimated participants (miscroscopists) were 280 who are from all state/region level VBDC team. For the capacity building and quality assurance for microscopy and RDT use monitoring and supervision of diagnostic centers, production of laboratory guidelines, training materials, standard operating procedures and building networks with international laboratories for research by funding supported from WHO, JICA and other funding agencies.

The training for entomological monitoring conducted in 2016 in Yangon. This training focused on vector bionomics, vector sampling method, vector indentification and monitoring of insecticide resistance. The trainees included assistant entomologist, entomological assistance, and insect collectors. Training of VBDC staff on Basic Entomology was also conducted in all States/Regions. Monitoring and supportive supervision can improve the quality of the service. Monitoring is the regular assessment of activities applied to assess resources invested (inputs), and service delivered (output) by the programme. Monitoring and supervision of the programme includes: - Data recording, data collection, data compilation and data analysis - Drug and logistic supply - Skill on diagnosis (malaria microscopy and RDT) - Adherence to treatment guideline (by checking register) Monitoring and Evaluation (M&E) is non-routine assessment which will be concerned with the outcome of the programme, end result and impact on malaria control programme. Supervision and quality control of malaria microscopy was done in 103 malaria microscopic centers by laboratory technicians from Central and State/Regional VBDC team. The purpose of the national M& E plan is to provide guidance on programmatic, logistics and financial M&E plan within and across different.

3.3 Partner Contribution for Malaria Control Programme in Myanmar The ‘Myanmar Health Sector Coordinating Committee’ (M-HSCC) (an expansion of the Global Fund specific ‘Myanmar-Country Coordinating Mechanism’) was established in 2013 and takes a leading role in coordination of both governmental and non-governmental sectors. The M-HSCC has a Technical Strategy Group (TSG) for malaria, which is led by the Department of Disease Control, with WHO serving as technical secretariat. The mandate of the TSG Malaria is to provide technical guidance in the development of national strategies, to provide coordination among partners, and to provide clarity on major technical and policy issues. The TSG meets periodically to discuss, review and endorse certain proposals, reports and other documents and carry out the assignments given to them. It also provides broad oversight of the implementation of grants and projects as required. The TSG-Malaria

27 appoints a working group (the Core Group for TSG-Malaria) to deal with specific tasks as necessary. The various funding sources from International Donors and implementation partners, Malaria prevention efforts are gaining momentum since 2007 according to the evidences observed above. Therefore it is critical to understand how the whole Myanmar has gone through Malaria prevention effort with the Malaria prevention funding. The Government of Myanmar budget provision for malaria was increased from US$ 1 million in 2014 to US$ 6.4 million in 2016 for Myanmar. The Government of Myanmar’s budget provision for malaria (the NMCP budget) was US$ 261 million in 2010-2015 and was estimated to US$ 468 million in 2016-2020. Government fund are allocated on a year-to-year basis, and therefore exact budgets for future years cannot be predicted with certainty. Other partners are providing technical assistance, complementing the financial contributions committed by the government and the funding partners. WHO provides technical assistance through its country office and through the Emergency Response to Artemisinin Resistance (ERAR) program for coordination and strategy and policy development, norms and guidelines, SoPs, surveillance and response systems, information on migrant and mobile populations as well as operational research. Several INGOs are providing technical assistance to NMCP in the areas of planning, financing, malaria elimination, case-based data reporting system, and surveillance, among others. The National Malaria Control Programme had also co-operated with 37 implementing partners, which are 5 donor organizations, 4 UN agencies, 20 International INGOs, 8 NGOs collaborated funding agency was GF and other donors. 3MDG and Global Fund has started its Malaria prevention activities since 2014 and their activities included malaria prevention, control and treatment (in collaboration with the other 4 implementing partners: PSI, CPI, MAM, MHAA) focusing on hard to reach, conflict affected and implementing areas. Malaria testing and treatment, community awareness raising sessions, other vector control activities, and LLIN distribution were done. Provided integrated malaria RDT testing and treatment service to risk population and their family members in some of their clinics starting from 2017). 3MDG also supported 2 pilot studies in 2017 mapping of private medical doctors (in partnership with PSI), and pilot study for strengthening and integrated in partnership with Malaria Consortium. The key achievement is reported to be in 2017 in which 366,002 cases examined, 7,205 Pf cases treated with ACT+PQ,

3616 Pv cases treated with CQ+PQ. 3MDG fund is initially planned to close out by the end of 2017 but uncertainty in one-year extension that effects on partners’ planning and programming of the malaria activities. However, the transition was going well with no funding gap in between. JICA has mainly supported for the prevention and control activities are: (1) developing the support system such as surveillance, monitoring system (2) information management system including GIS, (3) Micro-stratification by ecological factors (3) Capacity building and human resource development to health workers from central to community level, support VBDC laboratory and various types of training (4) analysis and disseminate of the project outcomes. JICA has spent USD 850,000 since the initial project launching till 2018, contributing to 27,551 cases examined, 66 positive cases detected (Pf 36, Pv 26, Mix 4). JICA has done tremendous work and achievement in sustaining community health worker’s activities under low endemic situation; operationalization inter-sectoral collaboration in teak plantation sites as a malaria high transmission risk area with Forest Department. Medical Action Myanmar (MAM) started working in Myanmar in June 2009 with the opening of a clinic in Yangon. Then with the support from 3MDG and Global Fund, it then expanded the total coverage to a total of 28 townships (1,683 villages) in 2017. Factors contributing to the Malaria prevention in Bago included training and supply of Village Health Volunteers (VHV), diagnosis and treatment of malaria, regular monitoring and supervision visits to VHW and provide on-the-job training, referral of severe malaria patients, mobile clinics by MAM field teams led by Medical Doctors, LLINs distribution, reporting to NMCP. MAM has progressed with 196,030 people tested with RDTs, 9,248 malaria positive patients (7,344 P.f/mixed and 2,053 P.v patients) treated according to the national treatment guideline, 63,390 LLIN distributed, more than 750,000 patient consultations were done by MAM through fixed clinics, mobile clinics and the Integrated Community Malaria Volunteers (ICMV). Almost all INGOs mainly provide effective community-based malaria diagnosis and treatment services through trained community volunteer network. They recruit community volunteer with the guidance of township medical officer and NMCP. And then recruited volunteers are provided training according to the national guideline. All malaria products and IEC materials are supplied with free of charges free of charges (FOC) and volunteers also have to provide malaria services to the

29 community with FOC too. Volunteers are also responsible to provide health education and to assist in LLIN distribution activities. Field supervisors of respective organizations visit to volunteers monthly generally in order to provide technical support and necessary product and IEC supply. Volunteers are also responsible to provide patients information with NMCP recommended report format. Field supervisors collect patients record from volunteer and submit it to NMCP monthly, quarterly and annually. Table (3.4) shows the number of INGOs, NGOs and their respective funding availability for Malaria prevention and control in Myanmar.

Table (3.4) Funding Figures for Malaria Prevention and Control Sr. No Funding Source Malaria Budget in 2016 (USD) 1 Government 6,437,430

2 Global Fund (including all PRs) 55,302,769

3 USAID/PMI 9,000,000

4 Other bilateral (DFID, JICA, etc.) 6,607,886

5 WHO 25,000 Total 77,373,085 Source: National Malaria Control Programme

The national malaria control programme is collaborating with 37 organizations. Majority of the partners of national malaria control programme is international NGOs followed by national NGOs, CBOs, faith-based organizations, donor organizations and UN agencies. Malaria control efforts led by National Malaria Control Programme have been technically supported by UN agencies, WHO, UNICEF and JICA. They have been financially supported by the donor community, and complemented by the work of implementing partners.

3.4 Malaria Situation in Bago Region Malaria is one of the major public health problems in the country as well as Bago Region in the past decade (VBDC, 2018). However, the number of malaria deaths has dropped steadily year by year from (46) in 2007 to just one in 2017 (about 97.8 % reductions over 10 years). The yearly trend of malaria morbidity and mortality from 2000 to 2010 gradually by substantially decreases year after year. Both yearly morbidity and mortality rate are now in the decreasing trend as described below. There is only one township Shwekyin, among the 28 townships for annual parasite incidence (API) more than one and the remaining township are API less than one and Zeegone township is API value zero in 2017. Bago is one of the epidemiology of malaria in Myanmar, due to climatic and ecological changes, population migration, mobile population who seek economic opportunities in rural economic frontier area and the economic development. In Bago region, migration is one of the problem for malaria elimination, especially is Shwegyin township, there is gold mining and rubber plantation. Most of people in Bago region move to other state and region especially Mon, Tanantharyi and also within the region. Migrants are found to be working mostly on gold mining, rubber plantation, and the infrastructure development projects for dam, electricity etc. All for species of human plasmodium are present in the country but there are 3 species in Bago region and mostly P.falciparum and P.vivax. The major primary vectors in Bago Region are An. Minimus and An. Dirus and the secondary vector are An.culicifacies, An.annularies, An.phillipinensis, An.aconitus, An.maculatus and An.hyrcanus. There is reduction of malaria case compare with the previous year (2007), the total number of malaria cases in 2017 (1,188 cases) compared to that of 2007 (11,685) cases. Shwegyin Township still ranks number one in the most malarious townships in Bago region while Nyaunglaybin Township is second. Nowadays Zeegone Township has no reported malaria case in 2017. Figure (3.4) shows the yearly trends of malaria morbidity and mortality rate in Bago Region (2007 – 2017).

Figure (3.4) Yearly Trends of Malaria Morbidity and Mortality Rate in Bago Region from 2007 to 2017

14.00 11.56 12.00 10.74 9.95 10.00 8.03 8.00 6.65 5.52 6.00

4.00 2.66 1.44 1.65 1.65 2.00 0.84 0.94 0.78 0.73 0.16 0.08 0.27 0.11 0.06 0.02 Malaria Morbidty and Motality Rate Motality and Morbidty Malaria 0.00 0.08 0.02 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

Morbidity rate Mortality rate

Source: National Malaria Control Programme

In figure (3.4) illustrated, the malaria morbidity rate reduced from per 1000 populations 6.65 in 2007 to 0.06 patients in 2017. The current malaria mortality rate in Myanmar in 2017 is 0.02 per 1000 populations and is 1.44 per 1000 populations in 2007. Malaria morbidity rate and malaria mortality rate are dramatically decreased from 2007 to 2017. Table (3.4) shows the yearly trend of malaria morbidity and mortality rate in Bago Region from 2007 to 2017.

Figure (3.5) shows malaria cases and deaths in Bago Region from 2007 to 2017 Figure (3.5) Malaria Cases and Deaths in Bago Regionfrom 2007 to 2017

40,000 90 85

35,000 81 81 35,435 80 30,459 30,000 70 60 25,000 23,536 50

20,000 46 19,021 16,038 15,728 41 40 15,000 36

11,582 30

Malaria Case Malaria Death

10,000 20 5,193

5,000 3,247 10 8 1,569 4 4 317 0 1 1 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Malaria Case Malaria Death

Source: National Malaria Control Programme

In figure (3.5) illustrated, the malaria cases were reduced from per 1000 populations 11,582 in 2007 to 317 patients in 2017. The malaria death in 2007 were 85 and 1 of malaria death in 2017 respectively. In the past decade, the malaria cases and deaths were dramatically decreased from 2007 to 2017. Table (3.5) also shows the data of malaria cases and deaths in Bago Region from 2007 to 2017. Table (3.5) Malaria Cases and Deaths in Bago Region from 2007 to 2017

Malaria Malaria Morbidity Mortality Year Examine Case Death Rate Rate 2007 26,126 11,582 85 6.65 1.44 2008 32,218 15,728 81 11.56 1.65 2009 34,134 16,038 81 10.74 1.65 2010 69,797 35,435 41 9.95 0.84 2011 76,345 30,459 46 8.03 0.94 2012 63,787 23,536 36 5.52 0.78 2013 118,485 19,021 8 2.66 0.16 2014 140,360 5,193 4 0.73 0.08 2015 194,151 3,247 4 0.27 0.08 2016 235,471 1,569 1 0.11 0.02 2017 284,835 317 1 0.06 0.02

Source: National Malaria Control Programme

Table (3.5) shows the examined malaria case in 2007 was 26,126 and found the positivity case was 11,582 and malaria death was 85. Although the blood test examined in 2017 was more than the previous years, the malaria positive case was 542, the malaria death was only 1, intensely decrease compare with 2007 to 2017 respectively. Figure (3.5) shows Malaria Case by Age Group in Bago Region in 2017.

Table (3.6) Malaria Morbidity and Mortality in Bago Region by township (2017) Total Morbidity Mortality Out-Patient Department In-Patient Department Confirmed Rate Rate Malaria Sr.No Township Population Severe Confirmed Confirme Cerebral Compli Malaria TPA TPA CFR Malaria d Malaria Malaria cated Death Malaria 1 Bago 462,719 110,574 7 31,644 5 1 - - - 17 0.04 - 2 Thanatpin 163,150 41,562 - 4,050 ------3 Kawa 227,074 117,387 2 6,300 - - - - - 2 0.01 -

4 Waw 216,183 74,648 2 5,054 1 - - - - 3 0.01 - 5 Daik-U 217,977 50,226 12 5,829 1 - - - - 13 0.06 - 6 Nyaunglebin 220,651 52,065 18 14,050 17 - - - - 35 0.16 - 7 Kyauktagar 279,493 79,529 13 18,352 7 - - - - 20 0.07 - 8 Shwegyin 111,158 33,888 47 8,280 23 - - - - 70 0.63 - 9 Taungoo 255,800 91,326 13 22,863 6 - - - - 19 0.07 - 10 Yedashae 218,180 43,852 8 6,784 3 - - - - 11 0.05 - 11 Htantabin 126,333 37,133 10 11,258 6 - - - - 16 0.13 - 12 Oaktwin 172,638 39,524 4 6,278 4 - - - - 8 0.05 - 13 Phyu 294,014 79,002 5 17,944 2 - - - - 7 0.02 - 14 Kyaukkyi 121,493 24,051 13 5,979 9 2 - 1 11.11 22 0.18 0.82 15 Gyobingauk 19,185 31,469 - 6,549 2 - - - - 2 0.00 - 16 Letpadan 193,927 62,732 2 6,656 1 - - - - 3 0.00 - 17 Minhla 127,255 28,945 2 4,556 1 - - - - 3 0.00 - 18 Moenyo 135,340 13,831 1 1,671 1 - - - - 2 0.00 - 19 Nattalin 172,549 61,126 2 7,165 2 - - - - 4 0.00 -

Total Morbidity Mortality Out-Patient Department In-Patient Department Confirmed Rate Rate Malaria Sr.No Township Population Severe Confirmed Confirmed Cerebral Malaria TPA TPA Complicat CFR Malaria Malaria Malaria Death ed Malaria 20 Oakpho 134,897 41,223 2 5,684 1 - - - - 3 0.00 - 21 Padaung 147,546 34,730 12 6,297 14 - - - - 26 0.02 - 22 Paukkhaung 125,267 33,642 8 5,310 2 - - - - 10 0.01 - 23 Paungde 142,361 37,783 1 6,012 - - - - - 1 0.00 - 24 Pyay 233,405 44,621 7 2,652 4 - - - - 11 0.00 - 25 Shwedaung 130,830 37,986 1 4,627 1 - - - - 2 0.00 - 26 Thayarwady 158,251 42,930 5 9,616 2 - 1 - - 7 0.00 - 27 Thegone 133,211 35,331 - 7,176 ------28 Zegone 72,319 24,743 - 2,768 ------Total 5,113,206 1,405,85 197 241,4 115 3 1 1 0.87 317 0.06 0.02 Source: National Malaria Control Programme9 04 0.02

Table (3.6) shows malaria morbidity and mortality in Bago Region township wise in 2017. Shwegyin township is the highest malaria cases in Bago Region and the lowest malaria case was in Paungde township. The malaria death was 1 person in kyaukkyi township only in Bago Region.

Figure (3.6) illustrates malaria cases by age group in Bago Region in 2017 Figure (3.6) Malaria Cases by Age Group in Bago Region in 2017

Malaria Case

968 1000

800

600

400 Malaria Cases Malaria 200 50 87 75 8 0 < 1 Year 1 - 4 year 5 - 9 year 10-14 year > 15 year Age Group

Source: National Malaria Control Programme

Table (3.7) shows Malaria case by age group in Bago Region (2017).

Table (3.7) Malaria Cases by Age Group in Bago Region (2017) Sr. No Age Group No. of Malaria Case 1 Under 1 8 2 1-4 50 3 5-9 87 4 10-14 75 5 15 above 968 Source: National Malaria Control Programme

Figure (3.6) and Table (3.7) demonstrates cases of malaria by age group. Malaria case of 15 above year old was slightly higher than other age group in 2017. Most of the malaria patient are in working age group.

3.5 Malaria Prevention and Control Programme in Bago Region The National Malaria Control Programme, Department of Health and Sport within the National Vector-Borne Diseases Control (VBDC) programme has a strong

37 infrastructure and is staffed with people possessing a wide range of technical competencies at the central level, and a few staff positions at the state/regional level where malaria control is integrated into the general health services. The Bago Region VBDC office is headed by the Bago Region VBDC Assistant Director and/or VBDC Team Leader who, with the team, manages the malaria programme at the Bago Regional Office. The Regional Malariologist (RO) is directly managed to VBDC team and district and township levels VBDC team as well. The Bago VBDC team manage to all RHC, SC of VBDC staff and volunteer at the township and village levels, basic health staff such as midwives and health assistants (HA), and village health volunteers (VHV) deliver malaria services with technical assistance and guidance from the Bago Region NMCP staff. The total number of Bago Region, VBDC staff are about 75 staffs which is included Field Staffs of VBDC of township levels in Bago Region. It is organized by Regional Malariologist, Team leader, Malaria Assistant (Head Quarter and Zone), Malaria Inspector, Laboratory Technician Grade (1), Assistant Entomologist, Insect Collector, Spray Man and driver etc. In Bago Region, there are increase health facilities Rural Healthn Center (RHC), Sub-rural health center (SC), number of basic health staff (BHS) and number of village health volunteers (VHV) in Bago Region. There are 159 Rural Health Center (RHC), 838 Sub-Center (SC), 3,014 Basic Health Staff (BHS) and 2,096 Village Health Volunteer (VHV) in 2017 according to VBDC Annual Report. Appendix (3) shows the detailed manpower of Vector Borne Disease Control of Bago Region. The prevention and control activities for malaria are being implemented in Bago region in accordance with the National Malaria Elimination Strategies. The goal of the previous National Strategic Plan (2010-2020) was to reduce malaria morbidity and mortality by at least 60% by 2016 relative to 2007 figures. By 2016 morbidity and mortality were down by 97.9% (in 2007, 39179 cases and in 2016, 1569 cases) and 96 % (in 2007 there was 46 deaths and one death in 2016) respectively. Therefore, Bago region was achieved the goal of previous National Strategic Plan (2010-2020) and now Bago region is assigned as to get malaria elimination (‘zero indigenous transmission’ and ‘zero malaria death’) in 2020 in updated National Strategic Plan (2016-2020). To achieve the malaria elimination in 2020 in Bago region, the following four main objectives were: (1) To eliminate the locally contracted malaria in Bago Region in 2020.

(2) To interrupt transmission of falciparum malaria in Bago Region. (3) To prevent the emergence of multi-ACT resistant P. falciparum in Bago Region. (4) To prevent the re-establishment of malaria in areas where transmission has been interrupted. The malaria prevention and control activities of Bago Region are following key factors and three supporting factors: Prevention activities are (1) Stratification of areas for Malaria Control/Micro-stratification (2) Distribution Long Lasting Insecticidal nets (LLIN) (3) Indoor Residual Spaying (IRS) (4) Information, Health Education and Communication Control activities are (1) Early Diagnosis and Appropriate Treatment (2) Supervision and Quality Control of Malaria Microscopy, Community Based Malaria Control Programme (3) Malaria Surveillance, Monitoring, Supervision and Evaluation (4) Data Management and Supplies Management

The two supporting elements are: (1) Expending research for innovation and improved delivery of services (2) Strengthening the enabling environment Malaria transmission intensity varies from one locality to another depending on the different epidemiological factors prevailing in each locality. Good epidemiological stratification of the malaria problem by locality or village is essential for better targeting of interventions of malaria prevention and country. The malaria risk population is the result of malaria micro-stratification. Village base micro- stratification started in 3 townships of Bago region in 2008 by the support of UNICEF. At 2011, NMCP revised the micro-stratification guideline and updated malaria situation and produce the risk map for 19 townships in 2015. The Stratification area for Malaria risk area is shown in Table (3.6) Population of Micro-Stratification by Sub-Centre in Bago in 2017.

Table (3.8) Population of Micro-Stratification by Sub-Centre in Bago (2017) Transmission % of Stratum Ward Village Population Status Population 3a High 0 151 71,922 1%

3b Moderate 0 335 209,688 4% 3c Low 0 306 274,750 5% 2 Potential 9 1,678 1,190,546 23%

1 Malaria free 210 4,211 3,366,300 66%

Source: Vector Borne Disease Control Programme, Bago Region

In Table (3.8) illustrates Bago region revised 4 townships in Bago East and five townships in Bago West in 2016 according to the updated micro-stratification 2015 guideline. Therefore total (14) townships were revised in Bago region with new micro-stratification guideline. According to area micro-stratification results, (1)% of total populations form (151) villages reside in malaria high risk area, (4)% of total populations form (335) villages reside in malaria moderate risk area, (5)% of total populations from (306) villages in malaria low risk area, (9) wards and (1678) village reside in potential area and (66)% of total populations (4211) villages and (210) wards reside in non-malarious area (malaria free area). Bago has various initiations in prevention of Malaria and the results are categorized for the successful prevention are training of BHS for malaria elimination existing Integrated Community Malaria Volunteer (ICMV)s, Supervision visit (Microscopist, health facilities and Integrated Community Malaria Volunteer (ICMV)s), Quarterly evaluation and planning meeting with Integrated Community Malaria Volunteer (ICMV) and BHS at township level that are under surveillance, Continuous LLIN distribution, Surveys (community base survey, health facilities base survey, migrants survey for LLIN utilization) that are later found to be valuable in determining the feedback mechanism of patients and health care personnel, Active case detection together with case notification, case investigation, foci investigation, foci classification and response including Entomological monitoring and Micro- stratification. The risk areas is the important for each township and the micro-plan is prepared at village level which include a logistic plan for diagnosis, treatment,

40 prevention equipment for vector control LLINs, IRS activities, training plan for basic health staff and village health volunteer. In 2007, NMCP changed the target from control phase to malaria elimination and this micro-stratification revised again and updated malaria map. LLIN distribution was done in 10 townships in 2017, the number of LLIN was 2,438 and the total number of LLIN distribution was 858,579 nets from 2012 to 2018. Detail distribution of LLIN in Bago Region shown in Appendix (6). Indoor residual spray was down in 5 townships of Bago East by showing in Appendix (7). The case management, and surveillance that are factors in successful prevention of Malaria in Bago region. The most Malaria infected areas, the distribution of Special Mosquito Nets (LLINs) are received equally, showing that patients are actually using and applying to prevent Malaria infection. The next adjacent figure also proved the same townships have been distributed with Spray equipment’s for the total population of 19,213 from 56 villages, 4,151 houses with total 4,223 households. See in Appendix (7). In Bago region, case detection was done both method of active case finding and passive case finding. Information, Education and Communication/ Behaviour Change Communication (IEC/BCC) is one of the main strategies to educate and raise awareness of target populations for malaria prevention and control. IEC interventions target high-risk populations and mobile migrant populations. Such as interpersonal communication, mass media, schools, mobile teams, etc with various channels. The updated information with IEC/BCC have advocated to community, schools, mass media and mobile team. Early Diagnosis and appropriate treatment is important strategy in malaria control programs. Malaria mobile teams and malaria voluntary health workers reached up to rural areas, hard-to reach and hardest to reach areas for improving access. Community based malaria control program is important in controlling malaria. Case management with ACT (Artemisinin based combination therapy) was practiced after testing by Rapid Diagnostic Test (RDT).

Monitoring and supportive supervision can improve the quality of the service. Monitoring is the regular assessment of activities applied to assess resources invested (inputs),and service delivered (output) by the programme. Monitoring and supervision

41 of the programme includes data recording, data collection, data compilation and data analysis, drug and logistic supply, skill on diagnosis (malaria microscopy and RDT) adherence to treatment guideline (by checking register). Evaluation is non-routine assessment which will be concerned with the outcome of the programme, end result and impact on malaria control programme. Supervision and quality control of malaria microscopy was done in 103 malaria microscopic centers by laboratory technicians from Central and State/Regional VBDC team in 2014.

3.6 Partner Contribution for Malaria Control Programme in Bago Region VBDC team, Bago Region had also co-operated with UN agencies, International Organizations, NGOs and INGOs. Making collaborated funding agency was GF. There are 3 INGOs (ARC, URC and PSI) and 3 NGOs (MMA, MHAA and KMSS) in Bago Region. In 2015, Global Fund supported (28) township providing the routine malaria control activities and capacity building training to various service provider, monitoring and quality strategy. PSI provided the volunteer activities in (19) townships. Moreover, Myanmar Health Assistance Association (MHAA) is also included in Malaria control activities with community volunteer program in Shwekyin Township. WHO participated as a main body of technical assistance and partnership with NMCP in handling the management of technical issues, coordination, data management, monitoring and evaluation. Major contributions for the prevention of Malaria in Bago region are from implementing partners such as JICA, 3MDG, MAM, URC, PSI and Global Fund. Following individual milestones and profiles are mentioned to understand better about their individual contributions for the successful outcome of Malaria prevention and control. JICA has mainly strived for the four success factors – (1) actual operational scale implementation in validating the effectiveness of the Malaria controlling model, (2) developing the support system such as surveillance, monitoring system and information management system including GIS, (3) human resource development to different levels of health workers from central to community level, (4) analysis and disseminate of the project outcomes for all the 28 townships in Bago region. Those activities are insightful in identifying the success factors and comparing each element of success factor as Case management, prevention, management and support for CHW activities, entomological surveillance (Geographical Information System), micro stratification by ecological factors and so on. The support VBDC laboratory

42 and various types of training are non-determinant factors JICA has done. All in all, JICA has spent USD 850,000 since the initial project launching till 2018, contributing to 27,551 cases examined, 66 positive cases detected (Pf 36, Pv 26, Mix 4). JICA has done tremendous work and achievement in sustaining community health worker’s activities under low endemic situation; operationalization inter-sectoral collaboration in teak plantation sites as a malaria high transmission risk arbea with Forest Department.

3.7 Review on Malaria Prevention and Control Activities in Bago Region The evidences from the analysis of this given graph shown in (Figure 3.5) Malaria Morbidity and Mortality rate in Bago region indicate that throughout the twelve years horizon from 2007 to 2018, rate of malaria morbidity and mortality gradually went down during 2008-2018 period and then completely zeroed out of malaria death at 2018 January to October. Figure (3.7) shows of Malaria Examination and Positive Cases in Bago Region from 2007 to 2018.

Figure (3.7) Malaria Examination and Positive Cases in Bago Region from 2007 to 2018

300000 284835

250000 235471

JICA 194151

200000 179757

150000 140360 118485

100000 76345

69797

63787

35435

34134

32218 30459

50000 26126

23536

19021

16038

15728

11582

5193

3247

1569

1188 542

2016 2007 2008 2009 2010 2011 2012 2013 2014 2015 2017 2018

Exam Positive

Source: National Malaria Control Programme

Shown in figure (3.7) Malaria examination and positive case from 2007 to 2018 October data. Although, in 2007 the examined was 26,126, found malaria

43 positive cases was 11582 in Bago Region, 179,757 was tested with RDT, the positive case was 542 cases in 2018 January to October. In the initial years of this studies, the Examination for the present of Malaria are gradually increasing together with the number of Malaria positive cases found. With the controlling efforts such as distributing LLIN, prompt treatments and health educations, the number of Malaria positive cases shown in (Figure 3.5). The same pattern can be seen with rather less slope for the number of reported deaths caused by Malaria infection for the same observable period. Throughout this twelve years period, the reverse trend of Malaria examination cases are then found in the adjacent figure proving the efforts of implementing partners and public health department working together in coordination for the prevention of Malaria in Bago region form 2007 to up till now. Being the fund itself, Global Fund (PRs) is passively assisting the INGOs and NGOs that are working towards the prevention and controlling Malaria in Myanmar. Main funding beneficiaries then carry out their Malaria prevention activities through the overview of UNOPS. CPI and other partners covered 728 villages in 19 townships and reached approximately 260,000 vulnerable populations in conflict affected areas in Myanmar in 2017. 3MDG-GF has provided to Malaria prevention activities since 2014 in Myanmar the activities included malaria prevention, control and treatment (in collaboration with the other 4 implementing partners: PSI, CPI, MAM, MHAA) focusing on hard to reach, conflict affected and implementing areas. Malaria testing and treatment, community awareness raising sessions, other vector control activities, and LLIN distribution were done. Provided integrated malaria RDT testing and treatment service to migrant and mobile population and their family members in some of their clinics starting from 2017. The challenge would be delay in reporting that resulted from various reasons, ranging from the hard to reach geographies, to the lacking of standardized reporting system and treatment guideline among the ethnic health organizations. 3MDG fund is initially planned to close out by the end of 2017 but uncertainty in one-year extension that effects on partners’ planning and programming of the malaria activities. However, the transition was going well with no funding gap in between. Table (3.9) shows in Annual malaria blood examination rate and annual parasite incidence rate in Bago Region (from 2007 to 2018).

Table (3.9) Annual Parasite Incidence Rate and Annual Malaria Blood Examination Rate in Bago Region from 2007 to 2018

Year API ABER Positivity rate 2007 4.29 1.23 34.97 2008 13.09 1.62 81.05 2009 8.68 1.83 47.34 2010 5.80 1.42 40.71 2011 5.51 1.56 35.31 2012 5.72 1.59 36.06 2013 2.66 1.18 22.50 2014 0.73 0.89 8.20 2015 0.65 3.90 1.67 2016 0.31 4.63 0.66 2017 0.23 5.57 0.42 2018 0.10 3.47 0.00 Source: National Malaria Control Programme

API, annual parasite incidence = Total confirmed malaria/Population) x 1000 ABER, annual blood examination rate (Total examined/Population) x 100 Positivity rate = Total confirmed malaria/Total examined) x 100

Table (3.9) shows in 2008, Annual Parasite Incidence (API) in the Bago Region was 13.09 per 1,000 population and in 2018, API was 0.10 per population. In 2008, Annual Blood Examination Rate (API) was 1.62% and 3.47 % was in 2018 respectively. Figure (3.8) shown the Annual Parasite Incidence (API) in Bago Region by township wise from 2016 to 2018. Figure (3.9) showing the malaria annual parasite rate was dramatically decrease year by year in each township. Only Shwegyin township of Bago Region had API (0-1) in 2018 and other townships of Bago Region has API (Less than 0 and 0) respectively. As per studied of secondary data of Malaria indicators which are reported malaria case OP and IP, Malaria Morbidity and Mortality Rate, Under 5 and Pregnant Woman Malaria case and death, Annual parasite incidence rate, proportion of LLIN utilization data of Bago Region has dropped steadily year by year. According to WHO instructions, if the country or State/Region that have achieved at least 3 consecutive

45 years of zero indigenous cases are eligible to apply for a WHO certification of malaria-free status. In the past decade, Bago Region was one of the malaria highest region in Myanmar. Now Bago region of malaria case and death has slightly going down year by year. Bago is one of the five successful regions which has higher rate of reduction of Malaria transmission and incidence. Due to the factors contributing of malaria prevention and control programme in Bago Region and cooperation and collaboration with public, private and implementing partners contribution and funding supporting of Donor such as 3 MDG, GF, JICA and other I/NGOs in Bago Region which will be very soon to Malaria Elimination Region. As per National Malaria Elimination Plan 2016-2030 ‘Ready to beat malaria’ ‘Malaria Elimination by 2030’.

Figure (3.8) Malaria Annual Parasite Incidence Rate in Bago Region from 2016 to 2018

Source: National Malaria Control Programme

CHAPTER IV SURVEY ANALYSIS

4.1 Survey Profile Bago region is situated in the southern part of the central plain region of Myanmar. It is bordered with Magway region and Mandalay region to the north, Kayin state, Mon state to the east, Yangon Region to the south, Ayeyarwaddy Region and Rakhine State to the west. Two main rivers of Myanmar Ayeyarwaddy, Sittaung are passing through Bago region from the North of South. Bago Region divided into the four districts of Bago, Pyay, Tharrawaddy and Taungoo. It consists of (28) township, (322) wards, (1,555) village tracts and (4,653) villages. Bago is the regional capital and the fourth largest city of Myanmar. Other major cities include Taungoo and Pyay. It seems that Bago mountain range divide the region into east and west. There are (14) township in Bago east and west each which are Bago Division has 28 townships. The population is estimated (5,154,539) census data. The urban population is estimated (907,582) and rural population is estimated (4,246,957) as per national malaria control program data in Bago Region. The growth rate of (1.0698) percent. The population density is (336) persons per square kilometer. It contains mainly Myanmar. (VBDC Bago, 2017). The study area is located in Bago Township, Bago Region. This chapter is composed of the comprehensive layout of the survey structure, interviewing 50 respondents who are 40 respondents from Public Healthcare Staff, Malaria Field Staff and 10 respondents from implementing partners (stakeholders) that sufficiently cover the existing capacity for Malaria Control and Prevention Program in Bago Region.

4.2 Survey Design This study was conducted by asking individual face to face interview through structured questionnaries. The survey questionnaire was designed with five part. Part I is related socio-demographic characteristics Part II is key factors contribution of Malaria Prevention Activities, Part III consists of key factors contribution of Malaria

Control Activities for Elimination and Part IV is good practices, lesson learnt, issue and challenges of Malaria Control Programme.

4.3 Survey Result 4.3.1 Socio-Demographic Characteristics Key Informant interview with Government Healthcare Staff In descriptive analysis on socio-demographic factors of (50) respondents of Governmental Healthcare Department and implementing partners in the survey number from percentage distribution on gender, age, education, position were included with public healthcare staff under NMCP and partner agencies.

Table (4.1) Socio-demographic Characteristic of Respondents Characteristics Frequency Percentage Male 37 74% Gender Female 13 26% Total 50 100% 21-30 4 8% 31-40 25 50% 41-50 17 34% Age 51-60 1 2% Over 60 3 6% Total 50 100% Secondary level 0 0% High School Level 1 2% Education Level Graduate 14 28% Post Graduate 35 70% Total 50 100%

Table (4.1) Socio-demographic Characteristic of Respondents (Continued)

Characteristics Frequency Percentage Medical Officer 32 64% Field Officer 1 2% Malaria Inspector 5 10% Data Assistant 10 20% Position Health Assistant/Malaria 1 2% Assistant Volunteer 1 2% Total 50 100% Government Officer/Staff 11 22% Organization Implementing Partner 39 78% Total 50 100% >1 year 1 2% 1-3 year 13 26% 4-6 year 14 28% Experiences in 7-10 year 15 30% Malaria Project 11-20 year 2 4% More than 20 year 5 10% Total 50 100% Source: Key Informant Interview (2019)

As illustrated in Table (4.1), a total of 50 people participated in the study and of those studied, 37 (74%) were female and 13 (26%) were male. The maximum age range was between (31-40) years with the percentage of 25 (50%). The second highest was between (41-50) years with the percentage of 17 (34%). The third highest was between (21-30) years with the percentage of 4 (8%). The age range (51-60) was 2% respectively. Age more than 60 years was 6%. Regarding with distribution of educational level by respondents, most of the respondent are medical doctor with post graduate 35 (70%) and 14 (28%) was Graduate. The high education was 1 person (2%) of the respondents respectively. As shown in table (4.1) the position of 50 respondents were also mentioned. Approximately 32 (64%) of Medical Officer and Malaria Inspector was 5 (10%),

Malaria Assistant was 1 (2%), Data Assistant was 10 (20%), Integrated Community Malaria Volunteer 1 (2%) and it was followed by 1 (2%) Field Officer. Regarding the table (4.1), 50 in 39 (78%) of respondent were Government Officer/Staff from Malaria and Implementing partner respondents were 11 (22%) respectively. In Table (4.1) the working experience in malaria project distribution, the most of the respondents experience of More than 20 year experience was 5 (10%), 11-20 year experience was 2 (4%), 7-10 year experience was 15 (30%), 4-6 year is 14 (28%), followed by 1-3 year experience was 13 (26%), less than 1 year and 1 year experience of respondents was 1 (2%) respectively.

4.3.2 Supporting Factors of Malaria Prevention Activities

Table (4.2) Malaria Prevention Activities by KII Interview Sr. Key Factors of Malaria Preventive Activities Yes No Total No. 1. Stratification of areas for Malaria Control/ Micro- 39 (78%) 11 (22%) 50 stratification 2. Distribution Long Lasting Insecticidal nets (LLIN) 45 (90%) 5 (10%) 50 3. Indoor Residual Spaying (IRS) 27 (54%) 23 (46%) 50 4. Information, Health Education and Communication 42 (84%) 3 (6%) 50

Source: Survey data (2019)

Stratification of areas for Malaria Control/Micro-stratification Preventative measure described in the survey are shown in Table (4.2). Respondents were asked the key activities of malaria prevention and control activities. According to the information from Government Officer (Malaria), that microstratification is the one of the important prevention activities of Malaria Prevention and Control Program to move closer to Malaria Elimination. As per respondent’s information, in 2010, the United Nations Children’s Fund (UNICEF) has supported micro-stratification in 80 townships. Furthermore, re-stratification of micro-stratification were conducted collaboration with MOHS, UNICEF and WHO as well as all township level and village level in Myanmar. As per national malaria control programme strategy, a malaria risk micro-stratification is strategic risk mapping tool used to identify the most vulnerable communities and families within townships so that malaria control intervention can be highly focused. A malaria risk micro-stratification was undertaken in order to identify high-risk malaria villages and communities so that malaria control interventions can be highly targeted population area for prevention and control activities. The control activities are such as the distribution of LLIN, Case Management and Vector Control and Surveillance activities can be prioritized. Insecticide Treated mosquito Nets (ITN) and Long Lasting Insecticidal Nets (LLIN).

Distribution Long Lasting Insecticidal nets (LLIN) According the information form Malaria Control Programmme, the LLINs utilization is recommended of WHO to prevent mosquito bite, not only for the prevention Malaria disease but also for other vector borne disease such as Dengue Hemorrhagic Fever, Lymphatic Filariasis, Japanese encephalitis, Chikungunya. In according with National Malaria Control Programme policy, the LLIN distribution and utilization is the one of the most imperative activities of Malaria Prevention and Control activity. The National Malaria Control Programme is distributed of the LLINs as per criteria. Malaria Programme were provided LLIN to forest goers, migrant worker, formers, seasonal workers, new settlement sites, disaster and outbreak areas transmission, in malaria risk areas should be protected by distributing of LLINs. LLIN distribution was done in 10 townships in 2017 by the NMCP with the support from Global Fund. Since 2012, National Malaria Program implemented only LLIN, VBDC has not recommended ITN. In Myanmar, LLINs were provided through the Integrated Community Malaria Volunteer (ICMV) network by VBDC and different organizations. In Myanmar, LLINs were provided through the Integrated Community Malaria Volunteer (ICMV) network by VBDC and different organizations. As discussed with Malaria Assistant (Field Staff) of Bago Region (the respondent) information together with secondary research analysis, it is concluded that Bago is concentrated with large-land company and small businesses related to natural resource extraction. Therefore, the number of migrants coming from other states and divisions are considerably significant. The commonest reason for migration was to work followed by coming to find job. Malaria can then be transmitted to other region by migrants of infected Malaria although the infected migrants might not show symptoms immediately. The timely distribution of LLIN/ITN for malaria prevention should be emphasized.

Indoor Residual Spaying (IRS) According to respondents experiences, as Indoor residual spraying (IRS) can reduce malaria transmission in plains to low-level areas but has only a limited impact in hilly and forested areas, and now is mostly restricted to the control of outbreaks and addressing migrant mobile population (MMPs) in some situations. In Myanmar focal IRS in the event of outbreaks, addressing MMPs in some situation, and active foci of malaria in areas eligible for elimination where case and foci investigations are in

53 place, and entomological evidence and other factors indicate that interruption of transmission can be expected.

Information, Health Education and Communication (IEC) Most of the respondent said that Information, Education and Communication/ Behaviour Change Communication (IEC/BCC) is one of the main strategies to educate and raise awareness of target populations for malaria prevention and control. Production and distribution of Information, Education and communication (IEC) materials is also carried out in community level, village level. The advocacy, health talk, social media are more effective for community awareness and health knowledge. Malaria Program was advocated yearly for health education not only for Malaria but also for Dengue and Filariasis in township as well as village level with collaboration local authority, Healthcare staff, Malaria Program Staff and INGOs. IEC interventions target high-risk populations and mobile migrant populations. Such as interpersonal communication, mass media, schools, mobile teams, etc with various channels.

4.3.3 Supporting Factors of Malaria Control Activities

Table (4.3) Malaria Control Activities by KII interviews Sr. Control Activities Yes No Total No. 1 Early Diagnosis and Appropriate Treatment 45 (90%) 5 (10%) 100 2 Supervision and Quality Control of Malaria 100 21 (42%) 29 (58%) Microscopy, Community 3 Malaria Surveillance, Monitoring, Supervision 100 19 (38%) 31 (62%) and Evaluation 4 Data Management and Supplies Management 32 (64%) 18 (36%) 100 Source: Survey data (2019)

Early Diagnostic and Appropriated Treatment (EDAT) Control malaria measures described in the survey data are shown in Table (4.3). According to respondent’s information, Early Diagnostic and Appropriated Treatment (EDAT) is the most important factor for malaria prevention and control activities. The findings support the evidence that Early Diagnostic becomes critical factor. The answers reveal that the officers commonly agree on certain points on the need to train Basic Health Staff (BHS) for malaria elimination, Quarterly evaluation and planning meeting with Integrated Community Malaria Volunteer (ICMV)and BHS at township-level. The officers are generally intending all migrant people to meet with respective BHS (Basic Health Staff) or Integrated Community Malaria Volunteer (ICMV) need provide the refresher training. Not only these volunteers need capacity building for active case detection, process for case notification and case investigation with Rapid Diagnosis Test (RDT).

Supervision and Quality Control of Malaria Microscopy As per respondent of National Malaria Control Programme’s information, the quality-assurance diagnostics needed in public health facilities as well as private health care providers and NGO operated health facilities. Quality assurances of RDT were also done in collaboration with DMR (Lower Myanmar). Malaria mobile teams and malaria voluntary health workers reached up to rural areas, hard-to reach and hardest to reach areas for improving access. Currently there are 752 of microscopy centers under Department of Public health (DOPH) and Department of Medical Services (DOMS). The NMCP conducts cross checking of the slides to the laboratories under the DOPH based on the quality assurance and quality control. According to respondents information, the community based malaria control program has been introduced and implemented in some selected townships. The community-level health staffs are working on various aspects of community health sectors. The volunteer roles in observing the controlling Malaria as village-level health staff such as basic health staff, midwives play critical roles by collaborating with healthcare volunteers, public healthcare officers and having the direct communication with hard-to-reach community. Integrated Community Malaria Volunteer (ICMV) ice providers at the community level in Myanmar and form the foundation of malaria control activities at village/community level. In Bago Region,

55 the estimated Integrated Community Malaria Volunteer (ICMV) is 900 volunteers were trained by NMCP, 910 volunteers were trained by INGOs (MHAA, JICA, ARC and PSI). Substantial investments have been made in community based health services by INGOs and JICA and Integrated Community Malaria Volunteer (ICMV) involved in malaria case management nationwide. Integrated Community Malaria Volunteer (ICMV)s working under the programme and I/NGOs are provided modular training and database training for data entry. Their responsibility are to investigate the malaria patient and to give early diagnosis and treatment at community level using RDT, ACT, CQ and PQ according to national malaria treatment guidelines. Their other duty are data encoding with tablet in data system and data reporting to NMCP. They engaged also in national malaria prevention activities such as LLIN distribution, health education and community awareness raising activities depending on the organization that supports and supervises them. They have got only incentive not with salary. Malaria program provided to them the mobile phone, tablet and other facilities by funding supporting from JICA, WHO and other INGOs as in project area.

Surveillance followed by Monitoring and Evaluation Most of the respondent’s information, although three activities such as surveillance, monitoring and awareness activities are different in nature, Integrated Community Malaria Volunteer (ICMV) are working on all of the activities and working under public healthcare service point out that their current work expands to 1-hour walking distance from the healthcare facility. Together with real time data from case reporting, common issues presented by Implementing Partners such as stock supply chain can be improved. Surveillance, Monitoring & Evaluation (M&E) and database system shall need to be improved as well as their role plays significantly in public administration of Malaria Control. Their other feedbacks are to conduct more health education (HE) activities, to improve data quality and standard such as validity, timeliness, completeness, accountability, coverage and more international trainings for public health officers to gain more international exposure. Although M&E still is not what volunteers expected to become, the role of surveillance, supervision has inevitably the successful factor influencing the prevention of Malaria in Bago region. As discussed with national malaria control programme, for the vector control activities are included in malaria prevention field activities such as monitoring of insecticide resistance, vector bionomics study. These field activities were

56 conducted in the respective States and Regions. Laboratory activities include mosquito rearing in insectary, susceptibility test and bio-assay test for evaluation on efficacy of LLINs. Training on Entomology was also conducted in Gyogone VBDC office in Yangon.

Data Management and Supplied Management The data management has improved in all states by supported from the Global Fund the overall planning and monitoring of malaria interventions, including data management, is still far from perfect in the majority of townships in Myanmar. The Vector-Borne Disease Control (VBDC) Programme at central and state levels is managing the malaria programme and in charge of strategy and policy guidance (central level). It is also in charge of monitoring and consolidating reports from all townships activities. The central level team is expected to provide feedback to township teams, but this is happening with delay. As per Data Assistant and Malaria Field Project Coordinator answered, in the past decade the data management system was poor. The data record was recorded with carbonless by hand writing such as data record book, they did not record with computerized system. There was faced some problems such as data uncompletedness, sometime damage of hard copy data (carbonless). Data Management team was trained the malaria government staff such as Malaria Assistant, Malaria Inspectors, Spray Man, Data Assistant (WHO) and Integrated Community Malaria Volunteer (ICMV) with new database system. The National Malaria Control Programme is strengthened the data management system, for developing the data reporting system such as Malaria Case Base Survey (MCBS), Mobile Case Based Reporting (MCBR), District Health Information System (DHIS).

Collaboration with Public, Private and Implementing Partners The personnel from Ministry of Health and Sports and non-governmental organizations who have extensive experience in malaria control were interviewed. The followings reflect opinion of respondents on malaria. The Ministry of Health and Sports plays a leading role in implementing malaria control programme in collaboration with other sectors such as public and private sectors and UN, INGOs. Basic Health Staff are critical to implement malaria prevention and control activities. Village Health Volunteers are contributing significantly to the Basic Health Staff in malaria prevention and control. UN agencies, non-governmental organizations and

57 donor agencies provide funding for malaria prevention and control’s equipment tools, such as medical supplies to national malaria control programme. The people receive diagnosis and treatment from a variety of sources such as government health facilities, non-governmental organization clinics, volunteers and private health care facilities. Preventive measures including distribution of long lasting insecticide treated nets and community awareness raising sessions as well as using rapid diagnostic test kits are also important factors to reduction of malaria morbidity and deaths. Monitoring and supervision visit of the MoHS officials to the field level ensure high quality care for malaria. Information management system including data collection and data analysis also facilitates quick response to malaria outbreaks. Capacity building of Basic Health Staff and volunteers is critical to sustain the achievement of national malaria control programme. Furthermore, commitment of Ministry of Health and Sports and WHO towards elimination of malaria in Myanmar by 2030 is a very important step to improve wellbeing of the people in Myanmar.

4.3.4 Good Practices, Issue and Challenges of Malaria Control Programme National Malaria Control Program’s good practices are the microscopist training, refresher training to laboratory technician, data management training to VBDC field staff and Integrated Community Malaria Volunteer (ICMV), Case investigation and management with national standard treatment guideline, LLIN distribution to targeted populations, good data management with strengthen database system, social behavior changed, good malaria knowledge and practice, advocacy and awareness to community and hard to reach are for health education. IEC has developed of new updated document and awareness to communities. The National Malaria Control Programme is organized regularly the annual staff meeting, Data Management training, quarterly implementation meeting and planning meeting with implementing partners for moving forward to elimination of malaria (2030) in Myanmar. The discussions exposed the following issues and challenges weakness of supply and management system, such as stock outage control, drug and LLIN expire date control system in some township level and RHC/SC level. The standard operation procedure to prevent stock outage needs to be critically reviewed and modified to take into account the actual ground challenges such as changes in township level authority, township level approval process. As staff turnover of

58 volunteer is more frequent in the ground-level staff, their knowledge sharing, prompt response to sudden changes in their operational setting needs to be standardized. Regarding the respondent’s information from Malaria Control Programme that the issue and challenges are orientation the programme staff to elimination mode, addressing malaria in conflict area, hard to reach area, malaria among mobile and migrant population. The another issues and challenges are limited budget, luck of technical capacity in BHS staff and field malaria staff, limited human resources, volunteer turnover, case management, surveillance in some area and luck of LLIN utilization in some peoples and migrant and mobile worker in Myanmar. Expending the roles of Integrated Community Malaria Volunteer (ICMV) in declining malaria incidence and transforming to ICMV. The reporting system is also weakness, it is difficult to get in time, due to lack of human resource, weak management, lack of data management system, lack of capacity as well as delay administrative procedure, transportation and communication for remove area, conflict area and hard to reach area. The supervision and monitoring team could not go regularly for the quality assurance and quality control of malaria microscopy to all the laboratories at RHC/SC level all State/Region. Sometimes coordination and cooperation are poor with senior management and ground level (operational level) such as administrative process and supply and management system. The technical staff and basic health staff still weak of capacity. Need data accuracy and completeness reporting from township level to State and Region level through Central VBDC data team for data compilation. As per information of respondents from implementing partner, the issue and challenges are project funding for the sustainability of program operation, staff turnover, technical capacity, international staff such as consultant, long procedure of staff recruitment in administrative process, weak of capacity building training of international, weak management and administrative procedure. There is difficult to dealing with administrative process with MOHS, Donor and partners. Sometime a bit difficult to get concurrence for travel authorizations for international technical staff such as consultant to visit hard to reach area, conflict area and disaster area from MOHS and local authority. Resources are limited overall coverage of activities, supervision and monitoring in malaria control. As malaria is one of the public diseases in Bago Region, especially in Shwekyin Township of Bago Region remains a few the malaria case.

CHAPTER V CONCLUSION

5.1 Findings The incidence of malaria has reduced significantly from 450,229 cases in 2007 to 82,695 cases in 2017. Long-term trend shows decreasing malaria morbidity and mortality in Myanmar. In 2017, malaria morbidity is highest Chin State followed by Rakhine State and Sagaing Region and malaria mortality rate is highest in Chin State followed by Rakhine State. Malaria deaths have declined steadily from 1,265 reported deaths in 2007 to 30 reported deaths in 2017. Furthermore, there is a reduction in the malaria case fatality rate in Myanmar as well. It has decreased from 2.37 percent in 2005 to 1.29 percent in 2018. In 2016, as per micro-stratification, the malaria free areas in Myanmar hosted 16% of total population. In the past decade, Bago is the malaria highest region in Myanmar. According to study of secondary data from Malaria Prevention and Control Program in Bago Region, the malaria morbidity and mortality rate have declined steadily. The malaria morbidity rate has declined in Bago Region from 6.65 percent in 2007 to 0.06 percent in 2017 respectively and the malaria mortality rate has also declined from 1.44 percent in 2007 to 0.02 percent in 2017. Total malaria case in Bago Region was 11,582 in 2007, and it declined to 1,188 cases in 2017. The total malaria deaths was 85 in 2007, and it declined to1 in 2017. Malaria case and deaths of under 5 year children and pregnant women in Bago Region are also slightly decreased. Migrant and mobile populations include a major risk group for malaria (e.g., mining, forest related activities, construction, rubber tapping, etc.) that exposes them to malaria. National Malaria Prevention and Control Programme is the leader in malaria elimination and it provides strategic guidance to the state level. It also conducts monitoring of malaria prevention and control activities by collecting reports from state levels and regular communication with the focal persons. Delayed reporting and feedback mechanism between the township, state or region and central level is observed. The programme has truly promoted and scaled up full coverage of LLINs

60 starting in high endemic townships and has substantially increased countrywide access to and use of free-of charge malaria RDTs and highly effective ACTs. the total number of LLIN distribution was increased from 2,438 in 2012 to 858,579 in 2018. Indoor residual spray was conducted in 5 townships of Bago East, to cover the total population of 19,213 from 56 villages. Information, Education and Communication interventions such as interpersonal communication, mass media, schools, mobile teams, etc with various channels, target high-risk populations and mobile migrant populations.. The updated information with IEC/BCC have advocated to community, schools, mass media and mobile team. The malaria control activities including malaria case investigation, early diagnosis, treatment, community awareness raising sessions, vector control activities, and LLIN distribution were successfully implemented. The active case detection was conducted with case notification, case investigation, foci investigation, foci classification and response including entomological monitoring and micro- stratification. The risk areas are the important for each township and the micro-plan is prepared at village level which include a logistic plan for diagnosis, treatment, prevention equipment for vector control LLINs, IRS activities, training plan for basic health staff and village health volunteers. The case management, vector control and surveillance are critical factors in successful prevention of malaria in Bago Region. Supervision and quality control of malaria microscopy was done in 103 malaria microscopic centers by laboratory technicians from Central and State/Regional VBDC team and Department of Medical Research in 2014. Currently there are 752 of microscopy centers under Department of Public health (DOPH) and Department of Medical Services (DOMS). In 2016, 127 laboratories were supervised by the Malaria Programme (VBDC), two news training and seven refresher trainings to 104 malaria microscopists and conducted 5 competency training to 76 microscopists. 280 staff from VBDC were trained on quality assurance for microscopy, RDT usage, monitoring and supervision and laboratory guidelines in all States and Regions . . Quarterly meetings are organized between National Malaria Control Programme and implementing partners to discuss on difficulties and challenges as well as to review the progress and to formulate the work plan. Lack of data reporting system, supply and management system, stock tracking are observed at township level. To address that, the National Malaria Control Programme organized trainings for the Malaria Assistant, Malaria Inspectors, Spray Man, data assistant and

Integrated Community Malaria Volunteer (ICMV) with the support of WHO and other partners. The National Malaria Control Programme strengthened the data management system, for developing the data reporting system such as Malaria Case Base Survey (MCBS), Mobile Case Based Reporting (MCBR), District Health Information System (DHIS). Malaria control activities is carried out in collaboration with public sectors and private sectors. The Ministry of Health and Sports plays a leading role in implementing malaria control programme in collaboration with other sectors and nongovernment organizations/Implementing Partners in scaling up malaria control intervention in malaria risk areas. The role of implementing partners is crucial in the sustaining success of malaria control in Bago Region. Basic Health Staff and Integrated Community Malaria Volunteer (ICMV) are critical to implement malaria prevention and control activities. UN agencies, non-governmental organizations and donor agencies provide funding and medical supplies to national malaria control programme. The negative sides are lack of data reporting system, lack of standard operation procedure, limited human resources and limited capacity of government staff. The staff from national malaria control program of all levels (township, state/region and central) should receive more international exposure by participating in trainings, meetings and workshops to ensure international networking and improved capacity. According to the interview with Malaria Programmme and Implementing Partners that malaria cases and deaths has dropped steadily in Bago Region from 2007 to 2017 as per study of secondary data of Malaria Control Program . The malaria indicators which included reported malaria case OP and IP, Malaria Morbidity and Mortality Rate, Under 5 and Pregnant Woman Malaria case and death, Annual parasite incidence rate, proportion of LLIN utilization data were dramatically decreased in Bago Region. According to WHO rules, if the country or State/Region that have achieved at least 3 consecutive years of zero indigenous cases are eligible to apply for a WHO certification of malaria-free status. Even though, Bago Region was one of the malaria highest region in Myanmar in the past decade. Currently, malaria cases and deaths of Bago Region are in the downward trend. Bago is one of the five successful regions on malaria elimination due to the huge efforts of national malaria control programme, multisectoral cooperation and political commitment.

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Appendix (1)

Department of Public Health Vector Borne Disease Control (Central) Organization chart

Source: Vector Borne Disease Control Programme

Appendix (2)

Township level malaria micro-stratification map of Myanmar

Source: National Malaria Control Programme (NMCP) data

Appendix (3)

Bago Region VBDC Manpower (2017)

Sr. No Staff Category Unit

1 Regional Malariologist 1

2 Team Leader 1

3 Malaria Assistant (Head Quarter ) 1

4 Malaria Assistant (Zone) 2

5 Assistant Entomologist 1

6 V.B.D.C Malaria Supervisor (Health Assistant 4) 32

7 Permeant Spray Man 27

8 Malaria Inspector 6

9 Insect Collector 2

10 Teach, Grade 1 2

Source: VBDC annual report of Bago Region (2017)

Appendix (4) Distribution of Long Lasting Insecticide Nets (LLINs) Activities in Bago Region in 2017 No.of No. of population No. of Population LLINa Covered Sr.No Township Village House Total LLINs Total Remark <5 >5 AN <5 >5 AN Hold Pop: Pop: 1 Bago 59 10569 4170 40751 302 44921 27688 4170 40751 302 44921 GF 2 Daik-U 25 1885 843 7756 92 8599 3807 843 7756 92 8599 GF 3 Kyauktagar 53 8701 3713 40880 358 44593 21962 3713 40880 358 44593 GF 4 Shwegyin 35 6687 3157 29265 218 32422 15509 3157 29265 218 32422 GF 5 Taungoo 39 4920 2158 16319 222 18477 18477 2158 16319 222 18477 GF 6 Yedashae 90 9731 3647 39729 315 43416 25025 3647 39729 315 43416 GF 7 Htantabin 24 5295 2281 22591 209 24872 12604 2281 22591 209 24872 GF 8 Oaktwin 42 5789 2560 22889 327 25449 9951 2560 22889 327 25449 GF 9 Phyu 14 5765 602 7091 39 7693 4304 602 7091 39 7693 GF 10 Kyaukkyi 54 8637 3991 39978 381 43969 19059 3991 39978 381 43969 GF (10) Township 435 67979 27122 267289 2463 296874 158386 27122 267289 2463 296874

Sr.No Township Village No.of No. of population LLINs No. of Population LLINa Covered Remark House <5 >5 AN Total <5 >5 AN Total Hold Pop: Pop: 1 Kyauktagar 59 1549 6573 6573 3330 6573 6573 GF 2 Shwegyin 33 911 4017 4017 2600 4017 4017 GF 3 Taungoo 37 645 2568 2568 1500 2568 2568 GF 4 Yedashae 30 881 3336 3336 2000 3336 3336 GF 5 Oaktwin 8 391 1231 1231 700 1231 1231 GF 6 Phyu 25 1089 4182 4182 2375 4182 4182 GF 7 Kyaukkyi 4 1143 4000 4000 2200 4000 4000 GF (7) Township 196 6654 0 25907 0 25907 14705 0 25907 0 25907 Army+KNU+PWS Sr.No Township Village No.of No. of population LLINs No. of Population LLINa Covered Remark House Hole <5 >5 AN Total Pop: <5 >5 AN Total Pop: 1 Bago 1 161 26 366 1 392 250 26 366 1 92 2 Daik-U 1 114 24 358 382 400 24 358 382 3 Shwegyin 9 1422 3260 49 2600 399 3260 49 3659 4 Taungoo 1 0 0 0 0 0 350 0 5 Htantabin 4 351 149 1300 6 1449 1500 149 1300 6 1449 6 Kyaukkyi 2 0 3000 0 (6) Township 18 2048 199 5284 56 5539 8100 598 5284 56 5882 Appendix (5)

Indoor Residual Spray Activities in Bago Region (2017)

Indoor Residual Spray (IRS) No. Township Village House Other Total Building Population

1 Shwegyin 13 563 2 565 1,842

2 Taungoo 11 771 22 793 3,622

3 Yedashae 8 1,103 34 1,137 5,007

4 Oaktwin 14 837 8 845 3,471

5 Kyaukkyi 10 877 6 883 5,271

Total 56 4,151 72 4,223 19,213

Source: VBDC annual report of Bago Region (2017)

Appendix (6)

Key Informant Interview Questions to Public Healthcare Staff /Implementing Partners

Qualitative Question form Part I: Socioeconomic and Characteristics 1. Name _ ………………………………… 2. Gender ………………………………… 3. Age ………………………………… 4. Occupation/Position ………………………………… Officer (Gover:) Officer (UN) Malaria Staff Non-Malaria Staff Other …………………………………. 5. Organization …………………………………… Government Non-Government UN INGO 6. Education Level ………………………………… 7. Income …………………………………..

Part II: Malaria Prevention and Control 8. What is your responsible in your Department? ………………………………. 9. Do you have experience in Public Health? …...... …… Yes No

If yes, How many year experience do you have in Public Health/total experience? 1. Less than 1 year 2. 1 year 3. 2 year 4. 3 year 5. 4 year 6. More than 5 year

9. Do you have experience of Malaria Project? Yes No If yes, How many year experience do you have? …………………………………

10. How many staffs for Malaria Control Program in your Department.? ………………

11. How many projects are operating under your Department? ….………………………

12. Which geographical areas are covered under malaria project?

Population Duration of Funding State Township covered Project Source (Villages/persons)

13. How do you think, are there factors influencing for the Malaria Prevention and Control? Yes No 14. What are the factors influencing for the Malaria Prevention and Control? 1. Poverty, Poor living 2. Education 3. Malaria knowledge 4. Malaria practice 5. Malaria Attitude 6. Awareness 7. Funding 8. Government policies 9. Human resource 10. Supply and management Other …..…………………..………………………………………………

15. What are the key activities/ key factors of your project? For prevention activities 1. Stratification of areas for Malaria Control/Micro-stratification 2. Distribution Long Lasting Insecticidal nets (LLIN) 3. Indoor Residual Spaying (IRS) 4. Information, Health Education and Communication /Health Talk For control activities 5. Early Diagnosis and Appropriate Treatment 6. Supervision and Quality Control of Malaria Microscopy, Community Based Malaria Control Programme 7. Surveillance, Monitoring, Supervision and Evaluation 8. Data Management and Supplies Management

Other …..…………………………………………………………………

16. What do you think, which key activity is the more important for Malaria Prevention? and Control? 1 to 8, pls mention …………..……………………. 17. What is your project support for Micro-stratification activities? How? …………………………………………………………………………………… Who are the contributing partners for Micro-stratification activities? …………………………………………………………………………………… How many townships did the program done in Myanmar for micro-stratification? All State/Region? …………………………………………………………………………………… 18. Is there conduct the advocacy, health talk for community awareness in Bago Region in this year/last year? Yes No …………………………………………………………………………………… 19. Do you feel that current participatory approaches (relaying IEC, distributing LLIN etc.) are relevant, observing equity, efficient and effective as linked to local needs? Yes No ….………….…………………………………………………………………… 20. What do you think, are the migrant people’s/the community awareness of malaria prevention? behavior as well as to sleep under bed-nets every night? Why? Yes No ….………….…………………………………………………………………… 21. What do you think, is it easy or difficult to motivate villagers/community to use ITN/LLIN? Please specify. Yes No ……………….……………………………………………………………….. 22. How many LLIN distribution in your project townships in this year/last year /total? …………………………………………………………………………………… How many township and population coverage? Which township? …………………………………………………………………………………… 23. How many coverage house-hold of Indoor residual spray in this year/last year /total? …………………………………………………………………………..………… How many township and population coverage? Which township? …………………………………………………………………………………… 24. How many microscopy training to microscopists in all State/Regon Bago Region/ Bago Region in this year? What is the quality assurance and control of microscopy? …………………………………………………………………………………… 25. How many time supervisions and monitoring to RHC/Sub-center per year? …………………………………………………………………………………… 26. How many volunteers do your project have in Bago Region (East and West)? NMCP volunteer/ other INGOs supported volunteer? …………………………………………………………………………………… 27. What is the responsibility of volunteer for case management for Malaria? ……………………………………………………………………………… 28. What do you think, BHS staff/Volunteer follow service delivery/apply national treatment guidelines for malaria treatment? Please specify.

Yes No ……………………………………………………………………………………

29. How could you prioritize the needs of villagers/communities in prevention, early diagnosis and prompt treatment (EDPT)of malaria? ……………………………………………………………………………………… 30. What is the data management system and data assurance? ……………………………………………………………………………………

31. What is the role of volunteer for data reporting system? …………………………………………………………………………………… 32. Do you think, any difficulty for Data Reporting System? Why? Yes No ………………………………………………………………………………… 33. Is there any tacking system for supply and management at RHC/Sub Center/ground level? Stock management system? Yes No ……………………………………………………………………………… 34. Who are your partners and how do your co-ordinate with them? ……………………………………………………………………………………… What do you think about the trend of malaria from the last 10 year to current year? Why? ………………………………………………………………………………. 36. Do you think, it will be eliminated at Bago Region in 2020? regarding of National Programme’s goals? (6 Region: Mon,Bago,Yangon,Mandalay,Naypitaw & Magway)

Yes No Don’t know

If Yes, Why? ……………………………………………………………………… If No, Why? ……………………………………………………………………… 37. Asia Pacific Leaders Malaria Alliance (APLMA) declaration to eliminate malaria by 2030, do you think Myanmar can make it? And why?

Yes No If Yes, why? …………………………………………………………..……..…… If No, why? …………………………………………………………..……..……

Part III: Good practices, Lesson learnt and Issue and Challenges

38. What are the lessons learnt and good practices of Malaria Project of your organization? ……………………………………………………………………………………… 39. What are the biggest Issue & Challenges do you face during the implementation of project?  Funding  Human Resource  Technical capacity  Sustainability & Consistency of project

Other …….……………………………………………………………………

40. Any suggestion please, which are the important things for elimination of Malaria in malaria prevention and control program and other partners? …………………………………………………………………………………… The slogan of National Malaria Elimination Plan 2016-2030, is ‘Ready to beat malaria’ ‘Malaria Elimination by 2030’. Malaria elimination is expected in Bago Region at some point before 2030 acknowledging significant outcomes of malaria prevention and control by all stakeholders.

5.2 Suggestions Bago region has successfully eradicated the threat of malaria over the last decade and the success factors need to be duplicated in other states and regions to have scale up the successful process of prevention and control of malaria across Myanmar. In this thesis, the success factors mainly such as the good practices of Malaria Staff, Basic Health Staff and Integrated Community Malaria Volunteer (ICMV) in case investigation, case notification and cage management /early diagnosis appropriate treatment with National Treatment Guideline, utilization of LLIN and vector control surveillance were carefully researched to understand how each factor contributes to the overall malaria prevention and control in Bago Region. If adequate funding support is available, it is recommended to strengthen following areas- the capacity of malaria staff, human resources management, manpower, technical support, database system, development of Integrated Community Malaria Volunteer (ICMV)’s capacity. VBDC central team and State/Region team should be frequently go to field visit for the supervision and monitoring including supply chain management system, such as manage for stock expired. The time-plan for each phase of the strategy namely case investigation, management and response to control was followed, and response action was taken in nearly all malaria cases for the available case information for surveillance. Strengthening of health information and monitoring system is needed to avoid missing information and duplicated information. Future research on feasibility of mobile/tablet database system, data recording system, surveillance and providing response to all cases including imported malaria can be further studied to reinforce the monitoring and evaluation process.