Malaria Elimination Planning for Province Notes and Activities – ForçaSaúde/USAID – September 2015 Jhpiego Malaria Team and Colleagues in Luanda1 Background Health Ministry Officials have expressed interesting in working toward elimination of malaria in the province because they have seen a major drop in cases and deaths from malaria over the years. Cases have dropped steadily from 620,300 in 2008 to 68,547 in 2014. Likewise deaths have declined from 1,559 to 17 in the same period.

An elimination effort needs to account for local epidemiology. In Huambo Province, parasitological studies of malaria show that 85% of cases are falciparum, and 15% are vivax. There is variation among municipalities in test positivity rates with , , Mungo and in the northern part of the Province having moderate rates of RDT (rapid diagnostic test at health centers) positivity, between 24-44%, and the remaining municipalities in the central and southern part of the Province (Caala, , Huambo, Cachiungo, , Chinjenje and ) having rates between 3-16%. The Province as a whole has benefitted from a reduction in cases and deaths over the past seven years, and the challenge now it to move toward the pre-elimination phase of malaria control wherein test positivity is less than 5% during the high transmission season.

With this in mind, and as part of malaria activities for Year 4 of the ForçaSaúde work plan, the malaria team and MOH counterparts planned an assessment in Huambo to determine learning and programming needs of health workers for achieving pre-elimination status of malaria. The overall aim of the assessment is to determine the extent to which municipality and frontline health center staff in Huambo Province understand and are experienced with the tools and procedures for achieving pre-elimination status for malaria in the Province and move the Province forward toward malaria elimination. To this end, Jhpiego’s Senior Malaria Specialist traveled to Huambo to work with the ForçaSaúde malaria team to conduct the malaria assessment mentioned above.

The assessment consisted of two main parts, an analysis of HMIS data on malaria testing and confirmed cases and a series of interviews with health staff at various levels of the Province. The height of the transmission season in Huambo is between November and January, and three complete years of HMIS data were available (2012-13, 2013-14, 2014-15). Using RDT testing results, which are the main form of diagnostic testing in the health centers and posts of the Province, a test positivity rate (TPR) was calculated for each municipality. There was a distinctive difference between the northern and southern parts of the Province, with come in the south approaching pre-elimination status while those in the north needed more intensified scale up of control measures. These findings are summarized below and maps mentioned within this report are appended.

1 Adolfo Sampaio, William Brieger, and Gilberto Jolomba with steadfast support from Margarita Gurdian.

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Table 1: RDT Test Positivity Rates

RDT Results Municipality Location Positive Negative Total Test Positivity Rate Bailundo North 8015 13302 21317 38% Caala S-Central 188 3238 3426 5% Ekunha S-Central 789 4209 4998 16% Huambo S-Central 3835 24586 28421 13% Cachiungo S-Central 107 3509 3616 3% Londuimbali North 3454 8602 12056 29% Longonjo S-Central 88 2901 2989 3% Mungo North 8347 10512 18859 44% Chicala North 828 2567 3395 24% Chinjenje S-Central 134 1792 1926 7% Ukuma S-Central 341 4022 4363 8% TOTAL 26126 79240 105366 25%

Since the health worker interviews were focused on a finite time period, it was decided to interview in the two highest TPR Municipalities and the two lowest. The table below shows the make-up of those to be interviewed. Interviews focused on health staff knowledge and experience with a variety of malaria elimination concepts and processes including surveillance, reactive case detection, WHO’s test, treat and track approach, working with hotspots, and use of community volunteers. A version of the interview guide is appended.

Table 2: Health Workers to Be Interviewed

Health Workers to be Interviewed: Numbers Select 4 Municipalities, two in higher and two in lower TPR (transmission) areas On Municipal Health Teams interview two people • malaria focal person 4 • one other 4 At Health Facility – select at least 3 facilities per municipality • health worker in charge 12 • health worker providing diagnosis and treatment 12 TOTAL Health Workers 32

Discussion Group Interview with Governmental and NGO 6-10 Stakeholders in Huambo (as available)

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Fie ld Work

Wednesday 2/9/15 A preliminary strategy session was held among ForçaSaúde staff to review the context and plan activities. The M&E office provided detailed maps of health facilities for each Province to facilitate interview site selection. We discussed the current context and its implications including the current lack of Global Fund grants and concern by other donors serious about serious malaria treatment commodity loss over the years.

We met with USAID staff to review processes of the assessment, including assurances that this was an assessment, not research. Armando Cotrina is the SASH/ ForçaSaúde USAID AO, and Eliane Mbounga is the PMI Malaria Program Management Specialist. Test Positivity Maps were shared and procedures explained. USAID stressed the need to involve NMCP.

National Malaria Control Program

We also met with Dr Filomeno Fortes, Director NMCP. We shared the malaria test positivity rate (TPR) with him. He explained that the malaria unit has been severely downsized due to expiration of Global Fund grant. At present a consultant from Uganda is on board to assist with developing a concept note for application to the Global Fund’s New Funding Mechanism. Work is underway to finalize the updated national malaria strategy, which much accompany the submission of concept note.

Dr Fortes had special interest in including elimination activities in the national strategy and encouraged Huambo to pilot test new approaches, especially the use of community agents to adequately extend malaria testing and treatment. He thought that they could make enough RDTs available for CHWs. Treatment coverage is only about 46% now, and CHWs could play a big role in improving this. CHW involvement in treatment is still a political issue in the MOH, and Dr Fortes is trying to resolve it. The malaria unit is including pilot case management by CHWs as part of their global Fund Concept Note. Because government is decentralized now, Provinces in theory can propose new ideas such as CHW involvement.

He was concerned about border areas and people seeking treatment on either side from health facilities close to provincial borders. This could influence statistical reports for a particular municipality. The idea of cross border meetings among provinces as has been the practice between countries in the region was raised.

Discussions are underway with one of the cell phone companies about setting up mHealth. USAID is interested, but discussions have not progressed far. This would aid overall monitoring and surveillance which is needed for entomology, epidemiology and pharmacovigilance. For diagnostics there is worry that donors may be reluctant to buy dual action RDTs that detect both falciparum and vivax, although both are present, with the latter being more difficult to control.

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Although the MOH has publicized its three approved malaria drugs, ASAL, ASAQ and ASPQ, there are still people prescribing SP for treatment. There is also concern about differential diagnosis of fevers, especially when malaria cases drop due to interventions. Also there are staff who after using RDT and finding a positive test, still request for microscopy. These issues will require intensive training and re-training.

Thursday 3/9/15 Met with Dr Juliana and his team at the Provincial Ministry of Health and shared the Test Positivity Map, concepts of elimination and plan for the assessment. He ensured that members of his staff including the officers in charge of pharmacy/laboratory and malaria, would assist. The two highest and two lowest TPR. Contact was then made with the four choses municipalities to ensure they were prepared for the visiting interview teams. Friday/Saturday 4-5/9/15 Activities included preparations for logistics, review, updating and translation of remaining materials, and continuing contact with municipalities in preparation of the visits. Note that two handouts and the basic interview guide had been translated prior to commencement of the activity while these were reviewed and additional materials were translated by the ForçaSaúde team (Dr. Sampaio and Gilberto Jolomba). Monday 7/9/15 Orientation of the team took place in a morning-long session covered the following agenda: Table 3: Orientation Schedule/Agenda

Time Topic Responsible 08.30 Check in 08.45 Introductions Dr Vida 09.10 Overview of Malaria Elimination Drs. Brieger 09.35 Purpose and Procedures of Interviews Drs. Brieger, Sampaio 10.00 Review of Interview Guide and accompanying handouts Drs. Sampaio, Brieger 10.30 Practice Session Using Interview Guide All Participants 11.30 Final Review, Planning and Questions All Participants

The session was led by four SASH/Jhpiego staff. Four interviewers were present along with three Ministry of Health staff including the provincial malaria coordinator. After review of the questionnaire several additions and modifications were made.

At the orientation the interviewers and participants were given the following Materials for Training Interviewing on Malaria Elimination: 1. Copy of Interview Guide 2. Test, Treat, Track Handout 3. Pathway to Malaria Elimination Handout

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4. Map of Huambo with Test Positivity Rates 5. Maps of Municipalities to be Visited 6. Key Elements of Malaria Elimination (briefing note) 7. Handouts from Slides Table 4: Interviewers Malaria Elimination Assessment

Name e-mail Phone Location Lucas Nhamba [email protected] 923 624 265 Medical School Cesario Sapalo [email protected] 931 251 304 Retired Fernando Sakusseia [email protected] 924 488 473 DPS/OPPM Jaime David Muehombo [email protected] 923 583 223 DPS/NFP Clementino Sacanombo [email protected] 919 641 705 DPS (Malaria)* *Clementino did not interview, but assisted in typing. Also note that our own staff, Dr Adolfo Sampaio and Gilberto Jolomba conducted and typed 5 a few interviews themselves as well as supervised and coorindated submission of work by the interviewers.

As a result of the session the translated questionnaire was revised as needed to accommodate local usage and some new questions were added based on discussions with Drs Fortes and Juliana.

The interviewers were divided into two teams of two with a supervisor from ForçaSaúde. One team covered the Municipal headquarters (blue circles on maps) plus one health center (red circles on map), while the second team covered two health centers (or health posts).

Tuesday 8/9/15: Mungo Municipality First day of interviews started about 10am and finished around 2.30pm. After meeting the municipal health director and malaria focal point, on team interviewed them and trhen went to PS Gandarinha. The second team traveled east to PS Cavili and CS Ombala Bata. Interviewers felt comfortable with the questions, though thought took a bit long. They said they should get faster with experience. They thought the respondents also understood the questions, but they did have to rephrase some to be clearer in the local usage.

The challenge of cell phone communication became apparent during this first field visit. One had to stand in a certain spot in the village of Ombala Bata to get intermittent reception. Apparently there was none in Cavili. This will affect future interventions such as mHealth reminders about elimination issues as well as rapid reporting of cases needing response from rapid case detection teams once established.

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Wednesday 9/9/15: Bailundo Municipality Bailundo community is o historical and cultural importance because it has a living traditional king in residence. After Introductions with the municipal health director and staff, also went to municipal headquarters to meet head of municipality to explain the purpose of visit. The municipal administrative staff expressed interest and support.

The Municipal Medical Officer and Malaria Coordinator accompanied one team to Luvembo Health Center. The other team interviewed health workers PS Velha Chicago and CS Monte Belo. Thursday 10/9/15: Longonjo Municipality A clear difference was seen in driving south of Huambo between Longonjo and Bailundo. The latter was experiencing rains and things looked greener. The former was still very dry. This might in part explain some of the differences in malaria epidemiology observed.

The visit started at the Municipal Healtquarters. As in Bailundo the Municipal Medical Officer and Malaria Officer followed one team to Health Center, about a 40 minute drive down an unpaved road south of Longonjo. Since phone reception was bad there it was not possible to give staff advanced warning, so only 1 of 6 was on duty. The team later found the officer in charge back in Longonjo and interviewed him there. The second team of interviewers covered Kalenganjola and Lepi health facilities. Friday 11/9/15: Cachiungo Municipality Taking in account of complexity of this municipality, interviewers were organized into 3 teams: one team handled , one at Dondi health facilities in the northern comuna of the Municipality, while the other interviewed in the central comuna at the Municipal headquarters and an MCH health center in Cachiungo town. The teams were told that roads further south were not passable. While this was a general problem in all Municipalities, it was more pronounced in Cachiungo. Dondi is a church mission facility.

Brief Summary

While translation proceeds on the interview transcripts, preliminary impressions are possible. Municipal level staff were enthusiastic about the potential of pre-elimination, but indicated they could not do this without support from the national and provincial levels in terms of training and commodities. At the health facility level there was a mixed level of

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understanding of the malaria and pre-elimination concepts about a third of staff are in definitely need of thorough updating.

Interviewers felt that some municipal malaria focal points needed refresher. The Director of Health proved to have more acceptable knowledge and skills. Overall the areas with good knowledge, skills and experience included treatment of malaria, malaria prevention measures, the RDT use. Some weakness in related responding to outbreaks of malaria transmission, monitoring and evaluation, mass drug administration, and microscopy.

Stakeholders Discussion: A stakeholders meeting was held for malaria partners in Huambo to discuss their roles at the provincial level in supporting malaria elimination at the municipal and health center levels. ForçaSaúde staff facilitated discussion. Stakeholders in attendance included 1) the Provincial Director Public Health (also representing Dr Juliana), 2) the Provincial Director of Laboratories/Medical Stores, 3) the Provincial Supervisor Malaria Program, 4) Director of Amosmid (an NGO), 5) Chief of Health Services, Huambo Municipality, 6) Director Nursing School, 7) Malaria Officer seconded to province by NMCP, and 7) Director Clinico Sagrada Esperanca, Huambo

Discussion covered readiness of the province to undertake the following in support of malaria elimination: • Procurement Supply Management • New interventions such as intensified surveillance • Reactive case detection response team potential • The pre-service and in-service training curricula • Community perceptions, beliefs and actions • Roles community health agents

The stakeholder thought malaria elimination was a good initiative for Huambo and glad Huambo could pilot the experience. The challenge is dependence on national level for basic commodities, which in turn depends largely on donor support. They were worried about uncertainties of supplies. In future there is expectation that government will decentralize finance/funding to provinces so preparation must be made. This will affect municipalities too, and it became obvious that using their own funds, municipalities must be guided to buy the appropriate commodities according to national policy.

Another concern was transportation and roads to reach villages where pre-elimination follow-up activities are needed. In terms of community work, the group mentioned the value of working with traditional birth attendants as do not need to pay them, maybe just something to help with their work. On the other hand when NGOs contact community agents they pay them which means when no money, no activity.

The group stressed the importance of involving CHWs in all aspects of pre-elimination activities ranging from diagnosis, follow-up and community mobilization/education. Health

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Worker training was another priority so that the schools prepare new health workers to undertake the tasks required for achieving elimination and in-service training for those already on the job. Communication with private clinics was also seen as important in terms of identifying cases in a timely manner and responding quickly as in reactive case detection. Saturday 12/9/15 All interviewers stopped by the ForçaSaúde office to submit their work. They were also sent a brief questionnaire to help summarize the main points that arose from their interviews as seen below. • List 3-4 main areas where the respondents were very knowledgeable and experienced. • List 3-4 main area where the respondents are weak and will need updated training.

Monday 14/9/15 We met to confirm next steps including translation of interviews, collection of handwritten transcripts, conducting for analysis after translation, planning for next stakeholder’s meeting where results will be shared and Huambo stakeholders start formulating their own malaria elimination strategy and how to incorporate follow-on activities into the next FY workplan for USAID. Report writing started.

Tuesday 15/9/15 Final meeting with USAID and PMI revolved around the important issue that malaria pre-elimination and elimination needs to be more strongly stressed in the national strategic plan as well as reflect better in the Concept Note being prepared for the Global Fund. Without clear mention, such activities may not be funded in the near future, and the call from the Municipalities and Province is that their high interest in malaria elimination needs to be matched with resources. While PMI is now shifting focus to higher burden municipalities, there is still the possibility of supporting some capacity building activities in Huambo.

There is increasing likelihood that community health workers will play a larger role, especially in case detection and prompt treatment at the village level. Unfortunately there is currently not a clearly articulated national focus on CHWs in terms of job descriptions, area to be covered, and incentives. Other countries like Rwanda and Burkina Faso have accomplished this, and hopefully Angola can learn from their experiences.

We do not want the currently hailed ‘success story’ of malaria case and death reduction in the province to reverse itself due to lack of resources. This is where a clearly articulated national strategy focus on malaria pre-elimination and elimination is needed. Efforts to use decentralized funding, which is reduced with the lower price of oil, need to be strategically allocated in Huambo. In conclusion, without a strategy, one will not be able to focus local, national and partner resources on eliminating malaria.

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Next Steps Briefly we hope to: 1. Complete transcript translation and analysis by mid-October 2. Have a final report ready by Early November 3. Hold the Stakeholders dissemination and strategic planning, meeting in mid-Novdmber

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