ELIMINATION 8 STRATEGY: ACCELERATION PLAN

Transcription

1 ELIMINATION 8 STRATEGY: ACCELERATION PLAN

2 INTRODUCTION 4 Elimination 8 Acceleration Plan impact 7 TABLE OF CONTENTS BACKGROUND 8 About the Elimination 8 8 Progress Towards E malaria targets 9 Acronyms and Abbreviations 2 Executive Summary 3

3 A FRAMEWORK FOR ACCELERATING MALARIA ELIMINATION IN THE E8 12 Integrated vector management 14 Universal integrated patient and parasite management 16 Enhanced case-based and epidemic preparedness and response 18 Programme management and health systems 20 GETTING TO ZERO 22 Enhanced malaria workforce 24 Commodity security and supply 25 Regional strategic priority areas 26 Regional 28 Entomological 29 Epidemic preparedness and response 30 Advocacy 31 RESOURCE MOBILISATION 32 MONITORING AND EVALUATION 34 National malaria outcome and impact indicators 34 Quality assurance & accountability 35 APPENDICES 36 Comprehensive monitoring and evaluation plan 36 References 39 ELIMINATION 8 STRATEGY: Acceleration Plan

4 ACRONYMS AND ABBREVIATIONS Acceleration Plan AIDS CHW E8 E8S ECAMM EPR Eswatini Frontline countries Global Fund HIV IRS LLIN M&E MMPs MOSASWA NMCP NMEP QA RDT Regional Strategy SADC The Elimination 8 Acceleration Plan Acquired immunodeficiency syndrome Community health workers Elimination 8 Regional Initiative Elimination 8 Secretariat External Competency Assessment in Malaria Microscopy Emergency preparedness and response Formerly Kingdom of Swaziland Botswana, Eswatini, Namibia and South Africa The Global Fund to Fight AIDS, TB, and Malaria Human immunodeficiency virus Indoor residual spraying Long lasting insecticidal nets Monitoring and evaluation Mobile and migrant populations Mozambique, South Africa, and Eswatini National Malaria Control Programme National Malaria Elimination Programme Quality assurance Rapid diagnostic test E8 Malaria Elimination Regional Strategy Southern African Development Community Second line countries Angola, Mozambique, Zambia and Zimbabwe TWG WHO Technical Working Group World Health Organization 2

5 EXECUTIVE SUMMARY IN 2007, DURING THE THIRD SESSION OF THE AFRICAN UNION CONFERENCE OF MINISTERS OF HEALTH, MEMBER STATES LAUNCHED THE AFRICA MALARIA ELIMINATION CAMPAIGN, COMMITTING TO TRANSITION ELIGIBLE COUNTRIES FROM MALARIA CONTROL TO ELIMINATION. LATER THAT YEAR, THE SOUTHERN AFRICAN DEVELOPMENT COMMUNITY (SADC) REAFFIRMED THIS COMMITMENT, SIMILARLY PLEDGING TO ELIMINATE MALARIA FROM SOUTHERN AFRICA. SADC identified six countries as having the greatest potential to eliminate malaria by 2015: Botswana, Namibia, South Africa and Eswatini, as well as the island states of Zanzibar and Madagascar. Recognising the fact that malaria transmission patterns are highly interconnected across this region, and that the success of elimination was dependent on regional collaboration and engagement, the four eliminating countries (Botswana, Eswatini, Namibia and South Africa) also called the frontline four formed a partnership with their northern neighbours (Angola, Mozambique, Zambia and Zimbabwe) the second line four to form the Malaria Elimination 8 Initiative, or the E8. The border of malaria in southern Africa currently runs through the northern provinces of the frontline countries. Recently, the E8 member states experienced significant setbacks to reaching their elimination goals. In response, the E8 joined forces to create the E8 Acceleration Plan (the Acceleration Plan) an enhanced regional implementation plan modelled after the World Health Organization s (WHO) Malaria Global Technical Strategy and informed by national and regional review processes to complement existing regional and national strategic plans. It prioritises a focused set of approaches and activities that, with adequate funding, capacity and leadership, will support the E8 in addressing challenges to achieving malaria elimination in southern Africa. 1 ENHANCED 2 COMMODITY 3 REGIONAL 4 REGIONAL 5 ENTOMOLOGICAL 6 EPIDEMIC Guided by the Acceleration Plan framework, cross-cutting initiatives or accelerators will be implemented, in collaboration with national and regional strategies. ACCELERATION PLAN INITIATIVES MALARIA WORKFORCE: SECURITY AND SUPPLY: STRATEGIC PRIORITY AREAS: SURVEILLANCE: SURVEILLANCE: PREPAREDNESS AND RESPONSE: Ensure adequately skilled staffing for technical and programmatic coordination, supervision and implementation. Achieve universal coverage by ensuring quality-assured prevention and treatment commodities are available. Mobilise resources and enhance evidence-based delivery of malaria prevention and treatment in underserved areas of regional relevance. Improve regional data and information sharing to inform decision making and resource allocation. Robust monitoring of abundance, distribution, and behaviour of vector species and insecticide resistance. Provide incidence management support for rapid response at regional, national, and sub-national levels. 7 ADVOCACY: Reinvigorate and maintain commitment for malaria elimination from national governments and partners. ELIMINATION 8 STRATEGY: Acceleration Plan

6 INTRODUCTION The Elimination 8 Regional Initiative (E8) was formed in 2009 by the Ministers of Health of Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe to call attention to and support the malaria elimination goals declared by the countries in SADC. Between 2000 and 2012 the E8 four frontline countries (Botswana, Eswatini, Namibia, and South Africa) achieved rapid declines in malaria incidence (Figure 1) while the second line four (Angola, Mozambique, Zambia, and Zimbabwe) made noticeable progress in malaria control. However, the progress achieved in the frontline and second line countries was not furthered or maintained; instead, malaria elimination efforts have stagnated. During the implementation of the Elimination 8 Strategic Plan ( ), the E8 member states the frontline four in particular experienced significant setbacks, including major malaria outbreaks, during the last three malaria transmission seasons. In response, the E8 commissioned an effort, led by member states and supported by a wide range of malaria experts, to identify strategic initiatives and activities that will support the E8 to accelerate towards elimination by THE RESULT IS THE ACCELERATION PLAN: an enhanced regional implementation plan that complements the existing regional and national strategic plans. 4

7 Namibia Botswana FIGURE 1. MALARIA TRENDS IN FRONTLINE COUNTRIES Eswatini South Africa THOUSANDS _ TOTAL CASES IN E8 FRONTLINE COUNTRIES ( ) THOUSANDS _ World Malaria Report, ; E8 Scorecard, 2017 ELIMINATION 8 STRATEGY: Acceleration Plan

8 1 INTRODUCTION THE ACCELERATION PLAN outlines what is needed to support each E8 country to achieve their elimination targets and proposes key regional priority initiatives to bridge gaps and reach underserved populations and locations. GLOBAL TARGETS Acceleration Plan REGIONAL STRATEGIC PLANS Acceleration Plan NATIONAL STRATEGIC PLANS FIGURE 2. THE ACCELERATION PLAN AIMS TO: Review progress towards malaria elimination in the E8 region Present the E8 approach towards malaria elimination programmes for the southern African context, using its malaria elimination framework Identify current challenges faced by the E8 countries, focusing on areas with connected malaria ecologies Develop crosscutting activities, or accelerators that will address key challenges throughout the E8 region, accompanied by a costed implementation plan 6

9 ELIMINATION 8 ACCELERATION PLAN IMPACT The expected impact of the Acceleration Plan on malaria within the E8 is depicted below. These targets have been set by the E8 countries in a review of current trends and areas of proposed activities as part of the Acceleration Plan. FIGURE 3. MALARIA ELIMINATION TRANSITION IN THE E8: Angola Zambia Zimbabwe Namibia Mozambique Botswana Eswatini South Africa 2021 Malaria transmission Malaria free Low transmission Eliminated Medium transmission Very low transmission High transmission Angola Zambia Zimbabwe Mozambique Namibia Botswana Eswatini South Africa ELIMINATION 8 STRATEGY: Acceleration Plan

10 BACKGROUND ABOUT THE ELIMINATION 8 Malaria elimination will not be achieved without cross-border and regional collaboration. The E8 was formed as part of a collaborative regional approach to coordinate inter-country and cross-border malaria elimination initiatives. The E8 is a subsidiary agency of SADC and serves as the inter-governmental organisation s malaria elimination coordinating entity. The E8 Ministerial Committee is the main decisionmaking body of the E8 and leads strategic and diplomatic dialogue. The position of E8 Chairperson rotates between member states every three years. The Ministerial Commitee is supported by an E8 Technical Committee, whose mandate is to oversee, advise, and recommend technical interventions to be implemented across the region. The Technical Committee is supported by five Technical Working Groups (TWG) including Diagnosis and Case Management, Surveillance, Monitoring and Evaluation (M&E), Vector Control, Community Engagement, and Research Sub-Committee. FIGURE 4. E8 GOVERNANCE STRUCTURE SADC JOINT COUNCIL OF MINISTERS OF HEALTH AND MINISTERS RESPONSIBLE FOR HIV/AIDS The Elimination 8 Secretariat (E8S) is a non-profit organisation responsible for actioning Elimination 8 resolutions and strategic plans, facilitating the execution of the E8 Strategy for malaria elimination (Regional Strategy) and convening partnerships between member states and technical experts to deliver regional collaboration. The E8S also serves as a funds administrator on behalf of the E8 partnership. Governance of the E8S is supported by a Board, which oversees the programmatic, financial and other administrative functions. E8 AMBASSADOR E8 TECHNICAL COMMITTEE DIAGNOSIS & CASE MANAGEMENT SURVEILLANCE, MONITORING & EVALUATION E8 MINISTERIAL SUB-COMMITTEE E8 SECRETARIAT BOARD VECTOR CONTROL E8 SECRETARIAT RESEARCH SUB- COMMITTEE report directly advisory capacity 8

11 PROGRESS TOWARDS E MALARIA TARGETS In 2000, a period of decline in malaria transmission in the frontline four countries began, and thereafter a brief period of relative stagnation or plateau followed. Over the last three malaria seasons, however, there has been a resurgence of malaria. Figure 6 provides an overview of the three phases of malaria transmission in the region since Frontline countries THOUSANDS Botswana South Africa Eswatini Namibia* THOUSANDS* Second line countries 10 FIGURE 5. PROBABLE AND CONFIRMED MALARIA CASES IN THE E8 Datasource: World Malaria Report, ; E8 Scorecard, 2017 MILLIONS Angola Mozambique Zambia Zimbabwe ELIMINATION 8 STRATEGY: Acceleration Plan

12 2 BACKGROUND E8 MALARIA TRENDS DECLINE Rapid expansion of prevention and treatment programmes, complementing national investments Additional technical support available to countries through funding mechanism Additional visibility and capacity of malaria programmes, which enabled significant improvements in coverage PLATEAU Reorientation to elimination Introduction of enhanced and diagnosis policies Challenges in health systems capacity, including and diagnosis Drought RESURGENCE Poor vector control coverage Weaknesses in and epidemic preparedness and response Potential changes in vector profile and insecticide resistance Increased vulnerability due to connected cross-border zones 10

13 : Decline in the frontline four The enabling factors were threefold: firstly, a marked increase in funding, particularly through the Global Fund to Fight AIDS, TB and Malaria (Global Fund). Secondly, WHO guidance and assistance from the RBM Partnership to End Malaria (RBM) encouraged scale-up of indoor residual spraying (IRS) and use of new insecticides, long lasting insecticidal nets (LLINs) usage and deployment of more effective combination therapies. Thirdly, the introduction of rapid diagnostic test (RDT) kits during this period improved malaria testing coverage and allowed for more prompt point of care diagnosis. Between 2007 and 2012, there was a sustained downward trend in malaria cases in the frontline four countries from a combined total of 201,672 cases in 2007 to 10,943 in During the same period, the four second line countries saw a decline from 14,284,426 cases in 2007 to 11,208,247 in : Plateau After a period of impressive declines in malaria transmission, the frontline four began to pursue malaria elimination while the second line countries, with higher disease burden in combination with larger populations and territories, continued to scale up their control programmes, focusing primarily on their high burden districts in the north. The transition from control to elimination among the frontline four meant focusing on improving diagnosis and enhancing to provide data on where and when malaria cases were occurring. This reorientation was challenging in the frontline countries due to health system constraints and the presence of malaria sinks, areas that continue to receive infections from connected malaria ecologies both within and across borders : Resurgence Since 2015, the E8 region saw several outbreaks, with a resurgence of malaria cases and marked increase in malaria related morbidity across frontline and second line countries. While testing rates dramatically improved with the introduction of RDTs, case-based systems, and community health workers (CHWs) to enhance the diagnosis efforts, persistent malaria outbreaks led to a rapid increase in malaria. Preliminary quantitative and qualitative reviews identified the drivers of the recent malaria outbreaks as: poor access to (and coverage of) malaria testing and treatment in some areas of the region due to limited resources and operational barriers such as distance and availability of supplies for testing and treatment; poor IRS coverage and quality due to delays in procurement of IRS commodities and supervision of spray operators; malaria importation due to population mobility and migration of individuals from higher to lower transmission areas, both within and across country borders; insufficient epidemic detection and rapid response systems, which undermined the ability to detect and respond to outbreaks promptly; limited entomological, translating to a poor understanding of vector species abundance and distribution as well as the prevalence and distribution of insecticide resistance; climate change resulting in warmer temperatures (3 C to 5 C above the climatological average) and significantly higher rainfall (ranging 100 mm and 250 mm, above the climatological average) in some areas of the E8, particularly during the 2016/2017 season 1. In response to the resurgence of malaria across the region, the E8 Chair commissioned an effort to halt the upward trend, led by member states and supported by a wide range of malaria experts. The E8 approach to eliminating malaria in the current context along with key challenges are presented in the next section: Achieving Elimination: A Framework for Malaria Elimination in the E8. FIGURE 6. RESURGENCE OF MALARIA CASES SINCE 2012 IN FRONTLINE E8 COUNTRIES Botswana South Africa Eswatini Namibia 1 The E8 member states have noted, however, that with good control measures, the effect of rainfall should be minimal. 2 World Malaria Report, ; E8 Scorecard, 2017 ELIMINATION 8 STRATEGY: Acceleration Plan

14 A FRAMEWORK FOR ACCELERATING MALARIA ELIMINATION IN THE E8 Malaria elimination in the E8 region requires the timeous delivery of the appropriate intervention packages. Whereas national control programmes require large scale coverage of basic interventions given the homogenous nature of transmission, elimination initiatives require specialised approaches, to address more heterogeneous transmission. As frontline and second line countries transition to elimination mode, it is important to reflect on programmatic challenges and changes required to meet the countries respective malaria elimination targets and goals. Improving systems across the E8 will also enable countries to better focus scarce resources to target sources of malaria transmission nationally and regionally. A framework, modelled on the WHO Global Technical Strategy for Malaria ( ), facilitated the review of the E8 Approach to malaria elimination and identification of gaps and challenges that target zones across one or more E8 countries. The framework consists of three pillars and one underlying supporting element. 12

15 THIS SECTION IDENTIFIES THE E8 APPROACH UNDER EACH PILLAR TOWARDS MALARIA ELIMINATION IN THE CURRENT CONTEXT AND SUMMARISES THE GAPS AND CHALLENGES IDENTIFIED WITHIN EACH PILLAR. FIGURE 7. ACCELERATION PLAN FRAMEWORK TO ACHIEVE E8 MALARIA ELIMINATION Elimination 8 Strategy: Acceleration Plan Pillar 1 Review and refine integrated vector management strategy Pillar 2 Integrated patient and parasite management; ensuring universal prompt access to accurate diagnosis and effective treatment Pillar 3 Enhance and epidemic preparedness and response Supporting element: Programme management and health systems PILLAR 1 Comprehensive and effective coverage of vector control strategies to ensure integrated vector management PILLAR 2 Integrated patient and parasite management to ensure prompt universal access to accurate diagnostic testing and effective treatment PILLAR 3 Enhanced to ensure availability of real time data for foci investigation and clearance of endemic malaria including epidemic preparedness and response SUPPORTING ELEMENT Robust health systems and programme management are critical to providing an enabling environment for optimal delivery under each pillar PG 14 PG 16 PG 18 PG 20 ELIMINATION 8 STRATEGY: Acceleration Plan

16 3 A FRAMEWORK FOR ACCELERATING MALARIA ELIMINATION IN THE E8 PILLAR 1 INTEGRATED VECTOR MANAGEMENT Routine entomological within the region, especially along the epidemic prone border areas, is critical to fully understand the vector bionomics, including their resistance to different classes of insecticides. In Namibia, studies to determine the underlying epidemiology of malaria have found that areas where there is decreased vector control coverage have an increase in local transmission due to imported parasites leading to onward local transmission 1. These findings point towards the need for improved vector control coverage in specific high risk areas defined by distance from the borders, human movement, localised environmental factors and past or current malaria cases, as well as developing specific strategies to reduce importation of malaria. Countries such as Mauritius and Sri Lanka eliminated malaria by maintaining vector control and entomological monitoring as core components of their elimination strategy 2. However, high coverage alone will not sustain impact; vector control needs to be targeted based on robust entomological and malaria epidemiology. To implement high quality entomological, countries need access to entomologists who can provide technical support and work to develop communitylevel entomological monitoring systems. This entomological data can then be used to tailor vector control interventions for different epidemiological and geographic areas and high-risk populations (e.g. LLINs for migrant or displaced populations or larval source management in areas with mainly outdoor biters). TABLE 1. INTEGRATED VECTOR MANAGEMENT CHALLENGES EXAMPLES CHALLENGES Limited workforce for vector campaigns The inadequate ratio of supervisors to spray operators (1:3) 3 Lack of adequate technical capacity and skilled labour for entomology in E8 countries No routine entomological in some countries (e.g. Eswatini, Botswana, Namibia) 3 Inadequate support for sub-national training Trainings in vector control conducted in less days than approved by national level vector control experts due to lack of funds 3 Lack of entomological data available to support informed evidence-based vector control strategies Inconsistent entomological across E8 countries 4 Limited support at the community level for larval source management Gaps in larval source management at the community level 3 Limited resources for vector based intervention elimination strategies (including LLINs and qualified sprayers) Gaps in vector based intervention coverage 3,4 CHALLENGE CATEGORY Malaria workforce resources Malaria workforce training Malaria workforce support Entomology data Entomology technical support Entomology resources 1 Nghipumbwa MH, Ade S, Kizito W, Takarinda KC, Uusiku P, Mumbegegwi DR. (2018). Moving towards malaria elimination: trends and attributes of cases in Kavango region, Namibia, Public Health Action. 8(Suppl 1):S18-S23 2 Smith Gueye, C., Newby, G., Gosling, R., Whittaker, M., Chandramohan, D., Slutsker, L., & Tanner, M. (2016). Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis. Malaria Journal, 15(1). doi: / s z 14

17 CURRENT CHALLENGES: WHY THIS IS IMPORTANT: To achieve malaria elimination, transmission must be tackled in whatever form it takes. Malaria vector is needed to determine whether outbreaks of malaria are due to operational factors, such as low coverage or quality spraying, or due to technical issues, including insecticide resistance or outdoor biting. Routine entomological is critical to understanding transmission patterns and the application of appropriate vector control interventions. Across the E8 region, the lack of comprehensive and up-to-date entomological data is impeding the ability to understand the extent to which changing vector species abundance and behaviours are contributing to the recent malaria outbreaks. There are no standardised E8 regional routine systems to determine the species present, their seasonal patterns, spatial distribution and their preferred breeding sites. More importantly, in some E8 countries the vector resistance to the current insecticide used for vector control especially IRS is extremely poorly resourced, monitored, and documented. A summary of the challenges identified is presented in Table 1 below, with supporting evidence. Stockouts of vector control commodities during outbreaks Poor transportation logistics Low rate of foci investigation Misaligned regional campaigns for vector control Inconsistent/ unmeasured quality of vector control intervention across the E8 No commodities in various E8 countries, resulting in a gap in coverage 5 Delays in campaigns due to travel and operational issues in some E8 countries Regional and national laboratories inadequately equipped for entomological investigations 3 No regional strategic operating plans for entomological / inconsistent entomologic across E8 countries to enable a coordinated regional approach 5 Countries lacking functional insectaries with susceptible colonies for conducting cone bioassays 3,5 Commodity insecurity Commodity systems Entomology resources Entomology technical support Entomology technical support 3 E8 Vector Control and Entomology Assessment, E8 Vector Control TWG Meeting Report, E8 Strategy Mid-Term Review, 2017 ELIMINATION 8 STRATEGY: Acceleration Plan

18 3 A FRAMEWORK FOR ACCELERATING MALARIA ELIMINATION IN THE E8 PILLAR 2 UNIVERSAL INTEGRATED PATIENT AND PARASITE MANAGEMENT Malaria elimination can only be achieved and sustained if high coverage of timely and quality malaria diagnosis, treatment, and reporting takes place consistently. One of the most effective interventions to address challenges of access to testing and treatment is the provision of malaria health services at the community level. Harnessing the potential of communities to provide these services will be key to the success of malaria elimination in the region. In Zambia s Southern Province, the roll-out of CHWs to test and treat the disease saw a decrease in deaths from 32 to 1 (97%) over a three-year period 1. The identification of foci through the CHW network in Southern Province also enabled a more optimal use of resources. In the eastern part of Zambia, data show that approximately 56% of malaria infections were detected through home visits by CHWs 2. In addition to universal early access to testing and treatment, monitoring of drug resistance is important to support malaria elimination. During 2017, there have been isolated reports from across the African continent of confirmed artemisinin resistance in patients infected in Equatorial Guinea, Uganda, Liberia and Angola 3. A recent study in Angola, however, found the therapeutic efficacy of artemether/lumefantrine (for treating uncomplicated malaria) to be above 96%. All treatment failures carried mutations associated with lumefantrine tolerance 4. Areas of low and very low intensity malaria transmission, such as the E8 frontline countries, are ecosystems at high risk of developing antimalarial drug resistance due to reduced parasite diversity, low natural human immunity to malaria, and high drug pressure on the parasites. TABLE 2. PATIENT AND PARASITE MANAGEMENT CHALLANGES CHALLENGES Lack of capacity for standardised proficiency testing in diagnostic methods High malaria case fatality rates Limited access to testing and treatment particularly in vulnerable populations Antimalarial drug resistance EXAMPLES Inadequate diagnostic testing for malaria in sub-saharan Africa to support disease management, prevention programmes and need 5 Frontline states exceed WHO recommended 0.5% malaria case fatality rates 6 Effective coverage for malaria case management ranges from 30% to 72% in the region 7 No recent therapeutic efficacy studies from any E8 frontline countries 8 CHALLENGE CATEGORY Malaria workforce training Access to testing and treatment Access to testing and treatment Surveillance data 1 Hamainza, B. (2017) Transitioning Southern and Western Zambia to pre-elimination lessons from Zambia s community active. Presentation by MOH, NMEP, Zambia. 2 Lu, F., Culleton, R., Zhang, M., Ramaprasad, A., von Seidlein, L., & Zhou, H. et al. (2017). Emergence of Indigenous Artemisinin-Resistant Plasmodium falciparum in Africa. New England Journal Of Medicine, 376(10), Lynch, C., Pearce, R., Pota, H., Egwang, C., Egwang, T., & Bhasin, A. et al. (2017). Travel and the emergence of high-level drug resistance in Plasmodium falciparum in southwest Uganda: results from a populationbased study. Malaria Journal, 16(1). Sutherland, C., Lansdell, P., Sanders, M., Muwanguzi, J., van Schalkwyk, D., & Kaur, H. et al. (2017). pfk13 -Independent Treatment Failure in Four Imported Cases of Plasmodium falciparum Malaria Treated with Artemether-Lumefantrine in the United Kingdom. Antimicrobial Agents And Chemotherapy, 61(3), e Davlantes, E., Dimbu, P., Ferreira, C., Florinda Joao, M., Pode, D., & Félix, J. et al. (2018). Efficacy and safety of artemether lumefantrine, artesunate amodiaquine, and dihydroartemisinin piperaquine for the treatment of uncomplicated Plasmodium falciparum malaria in three provinces in Angola, Malaria Journal, 17(1). 5 Aidoo, Michael. Factoring Quality Laboratory Diagnosis into the Malaria Control Agenda for Sub-Saharan Africa. The American Journal of Tropical Medicine and Hygiene 89.3 (2013): PMC. Web. 8 June Esu, Ekpereonne et al. Artemether for Severe Malaria. The Cochrane Database of Systematic Reviews 9 (2014): PMC. Web. 8 June Galactionova K, Tediosi F, de Savigny D, Smith T, Tanner M (2015) Effective Coverage and Systems Effectiveness for Malaria Case Management in Sub-Saharan African Countries. PLoS ONE 10(5): e

19 WHY THIS IS IMPORTANT: Universal early access to accurate testing and effective treatment is integral to case management and essential for malaria control and elimination. E8 countries need to facilitate the achievement of universal health coverage by ensuring prompt access to accurate diagnosis and effective treatment by bringing testing and treatment closer to individuals at risk, optimising supply chain management and promptly detecting and managing antimalarial drug resistance, if it arises. CURRENT CHALLENGES: Stock out of malaria tests and treatment Preliminary quantitative and qualitative data from reviews conducted by the Clinton Health Access Initiative (CHAI), identified that poor access to malaria testing and treatment was a challenge in certain areas of the E8 countries. Major barriers identified include distance to healthcare, availability of supplies for testing and treating, and poor treatment-seeking behaviours of E8 mobile and migrant populations (MMPs). Underserved areas and populations within and across countries are thought to be reservoirs of infection, and act as drivers of residual malaria transmission in those areas attempting to eliminate malaria. A summary of the challenges identified is presented in Table 2, with supporting evidence. Reported stock out of supplies during 2017 E8 Situation Room calls 9 Commodity insecurity Underserved areas of regional concern: Limited resources for malaria programmes force national programmes to prioritise areas based on local case burden and transmission risk. This results in areas being underserved with the required supplies of malaria prevention, testing, and treatment for effective coverage to achieve malaria elimination. Underserved areas of regional concern are those that are strategically important to a regional elimination approach, where addressing and supporting improved coverage within this area will have far-reaching impact, not just for the country in which the intervention is taking place but for other sinks in the region which are absorbing the ongoing transmission. Underserved populations of regional concern: In some well served areas, certain populations often migrant labourers are omitted by national health systems. Tackling malaria in these high risk groups will require use of travel histories and other data to inform better targeting and regional prioritisation. 8 Ménard, D. et al. A Worldwide Map of Plasmodium Falciparum K13-Propeller Polymorphisms. The New England journal of medicine (2016): PMC. Web. 8 June E8 Situation Room minutes, ELIMINATION 8 STRATEGY: Acceleration Plan

20 3 A FRAMEWORK FOR ACCELERATING MALARIA ELIMINATION IN THE E8 PILLAR 3 ENHANCED CASE-BASED SURVEILLANCE AND EPIDEMIC PREPAREDNESS AND RESPONSE High quality and response systems are the cornerstones for malaria elimination. Case-based is essential for identifying groups and areas at risk of malaria, ensuring accurate case classification and evidence-based targeting sources of transmission. It is critical that the E8 countries have a strong monitoring and system in place to also detect when successful endemic malaria elimination is achieved. Recent analysis of malaria cases classified as imported from health facilities demonstrated the value of improved and monitoring systems. By identifying the source of imported malaria cases in Mpumalanga and KwaZulu-Natal Provinces (South Africa) and Eswatini, 39% of imported malaria cases could be mapped to a district in Mozambique, shown in Figure 8. Of these imported cases linked to districts in Mozambique, it was found that 94% of imported cases came from only 26 districts 1, suggesting that targeting these sources would have an impact on both eliminating countries. An analysis from the Trans-Kunene Malaria Initiative (TKMI) shown in Figure 9, found that most of the malaria transmission in many areas along the northern border of Namibia originates from sources in southern Angola 2. An analysis of transmission risk conducted in southern Angola, using predicted risk (based on MIS prevalence), found that population density and accessibility (interconnectedness) were drivers of the connected malaria ecologies. Underserved sub-populations within well-served populations also contribute significantly to malaria transmission. Migrant agricultural workers appear to be particularly well represented as populations that are at high risk of carrying malaria parasites from high-malaria endemic areas to low-transmission areas where they temporarily reside for work, for example migrant Mozambican sugar cane workers in Eswatini, cow herders in Zambia, and informal agricultural labourers in Namibia. Although significant gains in systems have been noted across the E8 countries, additional support is needed to achieve the reporting coverage required for malaria elimination. Emergency preparedness and response (EPR) teams at the sub-national, national and regional levels can prevent further outbreaks and address their root causes if the outbreak is identified early. The processes and health systems involved in declaring outbreaks and responding in time are cumbersome. E8 countries need flexible mechanisms for national and regional responses, as well as more sensitive tools for malaria outbreak forecasting, early detection of increased risk of outbreaks and rapid deployment of mitigative interventions. TABLE 3. SURVEILLANCE AND EPR CHALLENGES CHALLENGES Limited human resources for timeous data analysis Routine entomological reporting at a deficit at all levels by all E8 countries Undetermined areas of connected ecologies Changes in climate not being incorporated in planning and forecasting models Limited real-time data to support resource allocation No independent expert task team to inform or review programme progress towards malaria elimination EXAMPLES Weekly data not reviewed by country situation rooms 3 There is inconsistence in reporting and management of routine entomological in the region 4 Evidence of MMPs in border health posts travelling to frontline countries, from second line countries 5 Malaria early warning systems not established in the region Country databases not linked to the regional database 6 Mock Country Elimination Certification CHALLENGE CATEGORY Malaria workforce resources Entomology data Surveillance data analysis Surveillance systems Surveillance data Surveillance monitoring 1 South Africa Malaria Information System; Eswatini Malaria Surveilance Database System 2 Government of Namibia HMIS; Republic of Angola HMIS 3 E8 Situation Room Call Minutes, E8 Vector Control and Entomology Assessment, MOSASWA report on sources of importation in Eswatini and South Africa, E8 Regional Surveillance Database 7 E8 TWG Report September Ministers of Health Extraordinary meeting report of March

21 FIGURE 8. MOZAMBIQUE SOURCE OF IMPORTED CASES IDENTIFIED IN SOUTH AFRICA AND ESWATINI FIGURE 9. PROPORTION OF IMPORTED CASES REPORTED IN HEALTH FACILITIES IN NAMIBIA AND TARGETED AREAS FOR IRS 2 (JANUARY MAY 2017) WHY THIS IS IMPORTANT: Late identification and response to EPR plans and thresholds are out of date and not effectively implemented Resource challenges limit capacity for prompt investigation and response at a large scale Rapid case investigation and improved data use to target rapid response efforts will support clearance of active malaria foci and significantly reduce importation and onward transmission. Effective early epidemic responses will prevent small source outbreaks from developing into widespread epidemics that take several years to contain. Eliminating malaria in any one country will continue to be an elusive goal without sufficient attention to areas with highly connected malaria ecologies. Poor use of mobile health platforms to immediately share information on outbreak districts EPR timeliness EPR resources March 2017 Ministers Extraordinary meeting on EPR, resulting in resource mobilisation for outbreak response. Seven countries request support for EPR in the 2017/18 malaria season. 7,8 Commodity resources CURRENT CHALLENGES: Rapid case-based systems in the E8 are still in their infancy, resulting in sub-optimal data quality and limited ability to analyse connected ecologies. The capacity for those systems to detect and rapidly respond to epidemics is not well established, with government bureaucracy undermining the speed of the response. Improved reporting coverage, particularly at the community level, is required to facilitate more robust analysis to inform implementation and course correction interventions. A summary of the challenges identified is presented in Table 3, with supporting evidence. ELIMINATION 8 STRATEGY: Acceleration Plan

22 3 A FRAMEWORK FOR ACCELERATING MALARIA ELIMINATION IN THE E8 SUPPORTING ELEMENT: PROGRAMME MANAGEMENT AND HEALTH SYSTEMS Specialised skills are needed at the regional, national, and subnational level including entomology, data analysis, management, and community engagement to effectively combat malaria. While the E8 region has continued to receive a strong political commitment for malaria elimination since the E8 was first established, domestic and external funding for most E8 countries has deteriorated. Sixty-one eliminating countries experienced a resurgence after resource constraints weakened their malaria control efforts 1. The E8 region must avoid following this path. Experience gained from the polio eradication campaign shows that elimination requires a substantial workforce of foot soldiers for the delivery, supervision, and sub-national programme coordination. The introduction of skilled CHWs in the E8 region will expand access to diagnosis and treatment and reduce the burden of health facility workers. Health systems also need to be in place to procure and monitor supplies and activities for malaria elimination. Traditional procurement systems are based on standard quantification methods, which in turn are based on previous consumption, with marginal buffers for outbreaks. Given harmonisation of case management commodities, a regional stock of commodities can reduce the risk of overstocking in one country and smooth out the spikes in demand for outbreak stocks. TABLE 4. PROGRAMME MANAGEMENT AND HEALTH SYSTEM STRENGTHENING CHALLENGES CHALLENGES Countries have identified gaps in the workforce Interruption in critical areas of elimination service delivery Tendering procedures take a long time, which contributes to delays in epidemic response and vector control Need for increased regional support to national technical leadership for malaria elimination EXAMPLES All E8 countries report gaps in technical capacity for elimination activities, particularly at sub-national level (Surveillance, Vector Control, Environment, Entomology) 2 All E8 countries receiving Global Fund support have critical technical staff dependent on grant renewal Second line countries with operational plans for districts selected for elimination (Mozambique, Zambia, and Zimbabwe) are not adequately staffed with personnel to implement elimination activities E8 countries report limited budgets and capacity to implement communitylevel LSM 2 Countries report that although outbreaks in recent seasons were detected early, response and containment was delayed due to bureaucracies in national procurement processes 2 E8 countries report a need for increased attention at ministerial level, and domestic funding to identified workforce gaps 4 CHALLENGE CATEGORY Malaria workforce resources Malaria workforce policy Commodity systems Malaria workforce support 1 Cohen, J., Smith, D., Cotter, C., Ward, A., Yamey, G., Sabot, O., & Moonen, B. (2012). Malaria resurgence: a systematic review and assessment of its causes. Malaria Journal, 11(1), Emergency Ministerial Meeting to address outbreaks 3 Emergency ministerial meeting joint action plan 4 E8 Strategy Mid-Term Review,

23 WHY THIS IS IMPORTANT: The continued investment in the malaria workforce and the development of systems that meet and respond to each country s procurement and emergency response needs is critical to malaria elimination. Maintaining high level political commitment for elimination is critical for the E8 region; it will ensure that elimination is achieved and sustained in the frontline countries and that the transition to elimination in the second line countries is completed. CURRENT CHALLENGES: Restrictions in national budget allocations for full-time and seasonal healthcare workers for vector control at national and subnational levels E8 countries report limited budgets to hire adequate spray operators and supervisors to maintain a WHOrecommended ratio 2,3 Inability for governments to match co-financing agreements with the GF National budget cycles do not align with seasonality of malaria operations 2,3 Malaria workforce resources Need for improved regional coordination and harmonisation of indicators and quality of interventions All E8 countries identified gaps in quality of IRS, and a need for regional accountability for quality vector control across borders Malaria workforce training The lack of progress and performance in sub-national and national malaria elimination across the E8 can be attributed to several factors including the inability to sustain coverage to malaria interventions and develop and maintain a real time malaria and response system. The health systems upon which elimination is based are inadequate in quality as well as programme management at all levels (regional, national, district, and community), an issue that has not historically been a focus of ministries or donors. The lack of attention to the core business of managing a programme has translated to an overall loss of direction and a decline in skills, morale and motivation of health workers. The scale of and distribution of malaria transmission is complex and multi-factorial, creating challenges for commodity forecasting and procurement. National pharmaceutical and diagnostics supply chain management systems across the region use the previous year s consumption data for procurement and distribution and do not have the agility to respond to unexpected changes in malaria cases which are likely in elimination settings. At the same time, complex and rigid bureaucratic processes for procurement have resulted in major disruptions in the availability of insecticides, delaying and impeding IRS campaigns. Procurement delays of insecticide and other essential commodities have become a time-consuming issue for many malaria programmes in the region. The recent outbreaks across the region were exacerbated by stock-outs of RDTs, artemether/lumefantrine (for treating uncomplicated malaria) and intravenous artesunate (for treating severe malaria). Improved procurement and supply chain management is essential to achieve universal access to malaria case management and on-time quality prevention interventions. A summary of the challenges identified is presented in Table 4, with supporting evidence. ELIMINATION 8 STRATEGY: Acceleration Plan

24 GETTING TO ZERO Arranging the challenges according to thematic areas, seven cross-cutting accelerators were developed to help mobilise support and resources toward malaria elimination in the E8. 22

25 ELIMINATION 8 STRATEGY ACCELERATION PLAN An enhanced implementation plan to compliment existing national and regional strategic plans PILLAR 1 Integrated vector management PILLAR 2 Universal integrated patient and parasite management PILLAR 3 Enhanced and EPR SUPPORTING ELEMENT Programme management and health systems Resources Training Support CHALLENGES Entomology data Surveillance systems Access to testing and treatment Surveillance data Commodity system Data analysis Entomology technical support EPR timeliness Commodity insecurity SOLUTIONS Enhanced malaria workforce Ensure adequately skilled staffing for technical and programmatic coordination, supervision, and implementation Commodity security and supply Achieve universal coverage by ensuring quality-assured prevention and treatment commodities are available Regional strategic priority areas Mobilise resources and enhance evidence-based delivery of malaria prevention and treatment in underserved areas of regional relevance Regional Improve regional data and information sharing to inform national decisionmaking and resource allocation Entomological Robust monitoring of abundance, distribution, and behaviour of vector species and insecticide resistance Epidemic preparedness and response Provide incidence management support for rapid response at the regional, national, and sub-national levels Advocacy Reinvigorate and maintain commitment for malaria elimination from national government and partners THE INITIATIVES OF THE ACCELERATION PLAN ARE LED AND IMPLEMENTED BY E8 MEMBER STATES SUPPORTED BY PARTNERS. ELIMINATION 8 STRATEGY: Acceleration Plan

26 4 GETTING TO ZERO 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy ENHANCED MALARIA WORKFORCE: ENSURE ADEQUATELY SKILLED STAFFING FOR TECHNICAL AND PROGRAMMATIC COORDINATION, SUPERVISION AND IMPLEMENTATION AIM: An efficient, effective, and adequate malaria workforce to optimise the returns from investments in delivery and analytical functions To enhance and improve the efficiency of the malaria workforce the E8 will implement the following activities: Activities, outputs, and implementation targets REGIONAL NATIONAL Activity Coordinate regional proficiency testing and accreditation to build capacity in various diagnostic methods Review workforce models and structures of different E8 transmission scenarios; identify efficiencies (i.e. integration), including careful review of the CHW model Output Four countries with WHO ECAMM certified microscopists Comprehensive workforce models and skills gap analysis across E8 transmission scenarios Routine National Plan Outcomes Malaria test positivity Increased proportion of suspected malaria cases who received a parasitological test Regional Objective Review different models of district malaria elimination programme structure, capacity, and systems model supported by regional and national level Recruit additional staff to country programmes in line with identified capacity gaps Service delivery models in place in all eight countries No gaps in selected workforce model across E8 countries Reduction of cross-border malaria transmission Develop staffing continuity of service policies and documents (succession plans) Develop job descriptions and training programmes for district malaria teams (static and mobile) Identify appropriate number and profile of human resources for service delivery, across different transmission scenarios (to prevent overloading) All E8 countries have adequate continuity service policies in place All E8 countries have job descriptions and training programmes in place for district malaria teams Workforce numbers mapped to workforce models to identify skills gaps Strengthened national capacity to eliminate malaria BUDGET USD 1,394,027 Percentage of Acceleration Plan budget 0.7% Primary cost drivers PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT Recruitment of additional staff required for malaria elimination USD 741,637 Coordinate regional proficiency testing and accreditation to build capacity in various diagnostic methods USD 604,825 Review workforce models and structures of different E8 transmission scenarios USD 41,748 IMPACT: A dedicated workforce to allow countries and the region to realise full returns on all malaria investments. 24

27 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy COMMODITY SECURITY AND SUPPLY: ACHIEVE UNIVERSAL COVERAGE BY ENSURING QUALITY ASSURED PREVENTION AND TREATMENT COMMODITIES ARE AVAILABLE AIM: Sufficient and high quality stock of all malaria commodities and supplies, on time and on demand, at every point of service To address the challenges to commodity security and supplies the E8 will implement the following activities by 2020: Activities, outputs, and implementation targets Activity Output REGIONAL Routine National Plan Outcomes Regional Objective Root cause analysis to identify bottlenecks (management, capacity, etc) in the procurement and supply management process Support establishment of the country and regional stockpiles to prevent stockouts Report with recommendations on the status of procurement and supply management processes in the region Protocol in place to prevent stockouts including the quantification of essential commodities and IRS Provide technical support to governments and funders to improve routine procurement mechanisms and timelines including pooled procurement and early warning systems Support coordination in regional, national, and sub-national forecasting including mobilising resources in advance to ensure on time access to insecticide for IRS activities Provide a fund guarantee to allow a regionally appointed procurement agent to procure insecticides without waiting for funding to be released by government treasuries Generate and disseminate market intelligence information Share procurement best practices and market insights for members facing procurement challenges Technical support provided as required All countries have evidence-based forecasts for malaria commodities and IRS Funding available to support procurement of malaria commodities and IRS Dissemination of market intelligence information to all eight countries Dissemination of best practices and market insights to all eight countries No stockouts of key commodities for diagnostic testing and first-line treatment Promotion of knowledge management, quality control, and policy harmonisation to accelerate progress towards elimination NATIONAL Strengthen tracking of stock and set up an early warning system for stockouts Early warning systems in place and active in all eight countries BUDGET USD 2,600,378 Percentage of Acceleration Plan budget 1.2% Primary cost drivers PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT Support establishment of country and regional stock piles to prevent stockouts USD 2,556,673 Share procurement best practices and market insights for members facing procurement challenges USD 37,986 Provide technical support to governments and funders to improve routine procurement mechanisms and timelines including pooled procurement and early warning systems USD 5,715 IMPACT: No stock out of malaria commodities and supplies in any of the E8 countries. ELIMINATION 8 STRATEGY: Acceleration Plan

28 4 GETTING TO ZERO 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy REGIONAL STRATEGIC PRIORITY AREAS: MOBILISE RESOURCES AND ENHANCE EVIDENCE-BASED DELIVERY OF MALARIA PREVENTION AND TREATMENT IN UNDERSERVED AREAS OF REGIONAL RELEVANCE AIM: Eliminate malaria in E8 frontline countries by 2020 The identification of the strategic geographic priority areas serves as a guide on prioritisation of districts for support and complementary investment towards key IRS, LLIN, diagnosis, treatment, and packages. Activities in the identified districts may include: Activities, outputs, and implementation targets REGIONAL Activity Support analysis of data including pathways of migration and parasite movement Bi-annual analysis of under-resourced areas for deployment of interventions Monitor drug efficacy data at a regional level to identify key trends and develop strategies for replacement drugs, as required Assessment of access to early diagnosis and treatment and identification of key gaps in the region Scale up community case management in priority areas with limited access to testing and treatment (CHW, mobile teams, health facility outreach) Health Posts Profile regional landscape of Plasmodium species using existing country parasite data Output Surveillance data mapped to identify areas for all eight countries of targeted regional interventions Bi-annual map to inform intervention deployment sent to eight countries Annual regional consolidated drug efficacy report released Gap analysis completed on access to early diagnosis and treatment across all eight countries Testing and treatment centres increased in priority areas identified to meet access gaps in all eight countries Annual regional profile of Plasmodium species released Routine National Plan Outcomes Decrease in malaria case incidence Decreased malaria mortality rate Decreased prevalence of malaria parasite Regional Objective Strengthen regional coordination to achieve elimination in each of the E8 member countries NATIONAL Implement protocols for innovative approaches in targeting hard-to-reach populations in underserved areas Roll out protocols to guide targeting of asymptomatic individuals (detect and eliminate asymptomatic infection) Integrate entomological data into routine electronic systems Country malaria programme plans include an approach to target hard-to-reach populations in underserved areas Country malaria programme plans include an approach to target asymptomatic individuals Entomological data integrated into electronic systems Increased proportion of suspected malaria cases who received a parasitological test All foci investigated classified 26

29 Angola Zambia FIGURE 10. E8 PRIORITY DISTRICTS Zimbabwe Mozambique Namibia Botswana Eswatini South Africa Activity Output Routine National Plan Outcomes Regional Objective DISTRICT Establish a community-level programme (building on CHW and mobile agents) including the identification of at risk and vulnerable priority populations Support entomological activities in underresourced priority areas Community-level programmes in place in districts identified for elimination No stock outs of commodities and supplies for entomology in resource priority areas All foci investigated classified Establish community-level programmes to support larval source management Provide additional annual training, sub-national meeting support and quality control to improve spray coverage beyond 85% Implement IRS and Integrated Vector Management (IVM) in under-resourced priority areas Larval source management community programme established in districts where feasible 85% spray coverage achieved IRS implemented with WHO appropriate ratio of supervisors to sprayers in place Increase in proportion of malaria cases detected reported in systems Increase in proportion of the population at risk protected by IRS during previous 12 months Strengthen regional coordination to achieve elimination in each of the E8 member countries Provide LLINs in under-resourced priority areas Distribution of LLINs in districts identified to have gaps in vector control coverage Increased proportion of the population at risk sleeping under an LLIN or living in a house sprayed by IRS in the previous 12 months PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT BUDGET USD 165,414,115 Percentage of Acceleration Plan budget 77.6% Primary cost drivers Implement IRS in under resourced priority areas USD 104,229,778 Provide LLINs in under resourced priority areas USD 22,180,446 Scale up community case management in priority areas with limited access to testing and treatment Health Posts USD 10,339,484 Establish community level programmes to support larval source management USD 9,685,951 Provide additional annual training, sub-national meeting support, and quality control to improve spray coverage beyond 85% USD 8,225,535 IMPACT: Coverage of prevention and universal access to testing and treatment in all underserved areas with regional impact. ELIMINATION 8 STRATEGY: Acceleration Plan

30 4 GETTING TO ZERO 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy REGIONAL SURVEILLANCE: IMPROVE REGIONAL DATA SHARING AND INFORMATION TO INFORM DECISION MAKING AND RESOURCE ALLOCATION AIM: Real time monitoring of malaria data across the E8 region To ensure timely and accurate data sharing across the E8 countries, this initiative will implement the following activities: Activities, outputs, and implementation targets Activity Output REGIONAL Routine National Plan Outcomes Regional Objective Establish and maintain a network of country situation rooms, linked to the regional situation room Strengthen regional climate-based early warning systems Support data and information management and robust analysis to inform decision making and resource allocation Support the coordination of national independent expert task teams to review and inform national programme progress National situation room established and linked to the regional situation room Regional climate-based early warning system in place Technical support provided as required Independent expert task team in place as part of the regional situation room Decrease in malaria case incidence Strengthen regional coordination achieve elimination in each of the E8 member countries Enhanced risk profiling, stratification, and receptivity measurement Strengthen programme reporting by supporting case-based electronic reporting and mobile technology Annual risk profiles developed Case-based electronic reporting in districts identified for elimination Increase in proportion of case reports received less than 24 hours after detection Facilitate the reduction of cross-border malaria transmission PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT BUDGET USD 22,153,772 Percentage of Acceleration Plan budget 10.4% Primary cost drivers Strengthen programme reporting by supporting case-based electronic reporting and mobile technology USD 20,942,376 Establish and maintain network of country situation rooms, linked to the regional situation room USD 777,935 Enhanced risk profiling, stratification, and receptivity measurement USD 398,060 Strengthen regional climate-based early warning systems USD 26,263 Support data and information management and robust analysis to inform decision making and resource allocation USD 9,137 IMPACT: Real-time data to inform decision making and effective resource allocation across the E8 countries. 28

31 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy ENTOMOLOGICAL SURVEILLANCE: ROBUST MONITORING OF ABUNDANCE, DISTRIBUTION, AND BEHAVIOUR OF VECTOR SPECIES AND INSECTICIDE RESISTANCE AIM: Effective vector control implementation driven by evidence This initiative seeks to address entomological challenges through the following activities: Activities, outputs, and implementation targets Activity Output REGIONAL Routine National Plan Outcomes Regional Objective Regional competence and accreditation of vector control scheme for the quality application of intervention Vector control scheme accredited according to WHO guidance Establish a regional network of entomologists Train and enhance skills of regional entomologists The inclusion of entomology data to determine country risk profiling, stratification, and risk activity management Develop and support laboratory and insectary infrastructure for countries A network of entomologists established Three entomologist trained (per country) Risk profiling and stratification of entomology data to manage risk Adequate laboratory and insectary infrastructure in place for malaria elimination activities Increased proportion of the population at risk sleeping under an LLIN or living in a house sprayed by IRS in the previous 12 months Promote knowledge management, quality control, and policy harmonisation to accelerate progress towards elimination PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT BUDGET USD 502,160 Percentage of Acceleration Plan budget 0.2% Primary cost drivers Train regional entomologists USD 398,420 Develop and support laboratory and insectary infrastructure for countries USD 103,177 Establish a regional network of entomologists USD 563 IMPACT: Enhanced entomological intellegence for improved vector management in the E8. ELIMINATION 8 STRATEGY: Acceleration Plan

32 4 GETTING TO ZERO 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy EPIDEMIC PREPAREDNESS AND RESPONSE: PROVIDE INCIDENCE MANAGEMENT SUPPORT FOR RAPID RESPONSE AT THE REGIONAL, NATIONAL, AND SUB-NATIONAL LEVELS AIM: Strong epidemic preparedness and response systems to contain all outbreaks in the E8 region This initiative focuses on implementing the following activities to support EPR across the E8 region by: Activities, outputs, and implementation targets Activity Output REGIONAL Routine National Plan Outcomes Regional Objective Establish a mechanism to support timely response to EPR requests Assessment of the national status of EPR and overarching response Mechanism in place to support EPR requests EPR assessment conducted and report released NATIONAL Support countries to establish emergency protocol thresholds for incidence management and collaboration with national disaster management Enhance epidemic operational centres (EOC) diligence, quality assurance (QA), and accountability in the implementation of EPR plans Emergency protocols for incidence management in place EOCs linked to national malaria programme EPR Decrease in malaria case incidence Strengthen regional coordination to achieve elimination in each of the E8 member countries DISTRICT Support an integrated approach to epidemic response Integrated outbreak team members identified for rapid response PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT BUDGET USD 11,928,117 Percentage of Acceleration Plan budget 5.6% Primary cost drivers Support an integrated approach to epidemic response USD 11,736,216 Assessment of national status of EPR and overarching response USD 148,472 Support countries to establish emergency protocol thresholds for incidence management and collaboration with national disaster management USD 71,390 Establish a mechanism to support timely response to EPR request USD 221 IMPACT: Rapid and integrated responses to malaria outbreaks in the E8 region. 30

33 1 Enhanced malaria workforce 2 Commodity security and supply 3 Regional strategic priority areas 4 Regional 5 Entomological 6 Epidemic preparedness and response 7 Advocacy ADVOCACY: REINVIGORATE AND MAINTAIN COMMITMENT TO MALARIA ELIMINATION FROM NATIONAL GOVERNMENTS AND PARTNERS AIM: High level financial and political commitment for malaria elimination To further reinforce the malaria elimination agenda and mobilise resources, the E8 will support the following advocacy activities: Activities, outputs, and implementation targets Activity Output REGIONAL Routine National Plan Outcomes Regional Objective Harmonise regional policy and indicators Establish a guiding coalition of malaria champions at the regional and national level Engage with key stakeholders to ensure and improve political buy-in and accountability E8 Annual Scorecard A coalition of malaria champions established at regional and national level Engagement with key stakeholders Decrease in malaria case incidence Strengthen regional coordination to achieve elimination in each of the E8 member countries Elevate and maintain the regional elimination agenda at the highest political levels within the E8 countries NATIONAL Advocate for streamlining vector control commodities as emergency procurement to lessen challenges Advocacy and support for the expansion of (temporary) national malaria workforce structures and provision of dedicated personnel at the national and sub-national level Meeting with government procurement official on vector control commodity streamlining Meeting of National Malaria Control Programme (NMCP) with high ranking government officials on malaria workforce needs and gaps Increased proportion of the population at risk sleeping under an LLIN or living in a house sprayed by IRS in the previous 12 months Strengthened national capacity to eliminate malaria Secure resources to support the regional elimination plan, and to ensure long-term sustainable financing for the region s elimination ambitions BUDGET USD 9,155,841 Percentage of Acceleration Plan budget 4.3% Primary cost drivers PILLAR 1 PILLAR 2 PILLAR 3 SUPPORTING ELEMENT Regional collaboration, accountability, and programme performance for malaria elimination in the E8 USD 8,586,563 Harmonise regional policy and indicators USD 569,278 IMPACT: Secured resources to support the regional malaria elimination strategy in Southern Africa. ELIMINATION 8 STRATEGY: Acceleration Plan

34 RESOURCE MOBILISATION Within the E8 region, there exists a tension between the need to allocate finite resources for high burden areas while maintaining support for national and regional elimination goals. FIGURE 11. PROPORTION OF DOMESTIC FINANCING FOR MALARIA PROGRAMME (2015 VS 2016) 100 Percentage of Domestic Financing Botswana Eswatini Mozambique Namibia South Africa Zambia Zimbabwe SADC Malaria Report PMI Malaria Operational Plans: Mozambique, Zambia, and Zimbabwe, FY 2016 Revised Funding Table WHO World Malaria Report 2017 The E8 platform will continue to link technical needs identified by NMCPs and communicating them to ministers and heads of government who have the power to mobilise domestic funds. This will be particularly critical as countries transition from donor support which could result in defunding of core programmatic strategies and reversal of collective gains to date. ACCELERATION PLAN TOTAL BUDGET USD 213,148,407 Budget by pillar Pillar 1: Integrate vector management USD 143,667, % Pillar 2: Universal integrated patient and parasite management USD 20,895, % Pillar 3: Enhance and EPR USD 36,040, % Supporting Element: Programme management and health systems USD 12,545, % 32

35 ELIMINATION 8 STRATEGY: Acceleration Plan

36 MONITORING AND EVALUATION National level outcome and impact indicators will be monitored through the E8 national malaria strategic plans and the E8 Regional Strategic Plan. The outcome and impact indicators that will be reported by the national programmes to evaluate the overall outcome and impact of the Acceleration Plan initiatives are presented in Table 5 below. Indicators will be reported from E8 countries on a bi-annual basis for review. TABLE 5. NATIONAL MALARIA OUTCOME AND IMPACT INDICATORS National Malaria Programmes Indicator Acceleration Initiative OUTCOME INDICATORS Increase in proportion of case reports received <24 hours after detection Increase in proportion of case reports received <24 hours after detection Increase in proportion of population at risk protected by IRS during previous 12 months Increased proportion of population at risk sleeping under an LLIN or living in a house that received IRS in the previous 12 months Increased proportion of suspected malaria cases who received a parasitological test No stock outs of key commodities for diagnostic testing and first-line treatment Strengthened national capacity to eliminate malaria IMPACT INDICATORS Percentage of case reports received <24 hours after detection Percentage of case reports received <24 hours after detection Proportion of population at risk protected by IRS during previous 12 months Proportion of population at risk sleeping under an LLIN or living in a house that received IRS in the previous 12 months Proportion of patients with suspected malaria who received a parasitological test Proportion of health facility months with no stock outs of key commodities for diagnostic testing Proportion of health facility months without stock outs of first-line treatment Strengthen national capacity to eliminate malaria Situation room: regional and national Situation room: regional and national Regional priority areas Advocacy Building regional capacity for entomology Regional priority areas Malaria workforce Regional priority areas Commodity security and supply Commodity security and supply Advocacy Malaria workforce All foci investigated classified Decrease in malaria case incidence Decreased malaria mortality rate Number of foci by classification (active, residual, cleared and pseudo) Malaria case incidence: number and rate per people per year Malaria mortality: number and rate per people per year Regional priority areas Advocacy Regional EPR Situation room: regional and national Regional priority areas Regional priority areas Decreased prevalence of malaria parasite Parasite prevalence Regional priority areas Malaria test positivity Malaria test positivity rate Malaria workforce 34

37 QUALITY ASSURANCE AND ACCOUNTABILITY Ongoing quality improvement and assurance programmes are critical components to ensure successful malaria elimination. QA is a systematic framework in which iterative cycles of measurement, observation, and data-driven team-based tests of change are applied to the improvement of processes to ensure high quality implementation of activities. QA will use real time performance measurement data collected as part of enhanced data collection systems and tools under the acceleration initiatives to track indicators derived from the respective national guidelines and evidence-based practice. Through routine analyses of these data, site level teams of malaria workers will be engaged to design, implement, and evaluate interventions using methods such as Plan-Do-Study-Act (PDSA) cycles, root causes analysis, process mapping, and data-driven team-based problem solving. The impact of tested interventions on system level performance is assessed on a continuous basis using principles of statistical process control, leading to the adoption, and routinisation of efficacious, contextually tailored interventions. ELIMINATION 8 STRATEGY: Acceleration Plan

38 APPENDICES COMPREHENSIVE MONITORING AND EVALUATION PLAN Enhanced malaria workforce Activity Coordinate regional proficiency testing and accreditation to build capacity in various diagnostic methods Review workforce models and structures of different E8 transmission scenarios; identify efficiencies (i.e. integration), including careful review of the CHW model Review different models of district malaria elimination programme structure, capacity and systems model, supported by regional and national level Recruit additional staff to country programmes in line with identified capacity gaps Develop staffing continuity of service policies and documents (succession plans) Develop job descriptions and training programmes for district malaria teams (static and mobile) Identify appropriate number and profile of human resources for service delivery, across different transmission scenarios (to prevent overloading) OUTPUT Four countries with WHO ECAMM certified microscopists Comprehensive workforce models and skills gap analysis across E8 transmission scenarios Service delivery models in place in all eight countries No gaps in selected workforce model across E8 countries All E8 countries have adequate continuity service policies in place All E8 countries have job descriptions and training programmes in place for district malaria teams Workforce numbers mapped to workforce models to identify skills gaps National Outcomes Malaria test positivity Increased proportion of suspected malaria cases who received a parasitological test Strengthened national capacity to eliminate malaria Regional Objective Reduction of cross-border malaria transmission Activity OUTPUT National Outcomes Regional Objective Commodity security and supply Root cause analysis to identify bottlenecks (management, capacity etc) in the procurement and supply management process Support establishment of the country and regional stockpiles to prevent stockouts Report with recommendations on the status of procurement and supply management processes in the region Protocol in place to prevent stock-outs including the quantification of essential commodities and IRS Provide technical support to governments and funders to improve routine procurement mechanisms and timelines including pooled procurement and early warning systems Support coordination in regional, national and sub-national forecasting including mobilising resources to procure a year ahead to ensure on-time access to insecticide for IRS activities Provide a fund guarantee to allow a regionally appointed procurement agent to procure insecticides without waiting for funding to be released by government treasuries Technical support provided as required All countries have evidence-based forecasts for malaria commodities and IRS Funding available to support procurement of malaria commodities and IRS No stockouts of key commodities for diagnostic testing and first-line treatment Promotion of knowledge management, quality control, and policy harmonisation to accelerate progress towards elimination Generate and disseminate market intelligence information Dissemination of market intelligence information to all eight countries Share procurement best practices and market insights for members facing procurement challenges Dissemination of best practices and market insights to all eight countries Strengthen tracking of stock and set up an early warning system for stock outs Early warning systems in place and active in all eight countries 36

39 Regional strategic priority areas Activity Support analysis of data including pathways of migration and parasite movement Bi-annual analysis of under-resourced areas for deployment of interventions Monitor drug efficacy data at a regional level to identify key trends and develop strategies for replacement drugs, as required Assessment of access to early diagnosis and treatment and identification of key gaps in the region Scale up community case management in priority areas with limited access to testing and treatment (CHW, mobile teams, Health facility outreach) Health Posts Profile regional landscape of Plasmodium species using existing country parasite data Implement protocols for innovative approaches in targeting hard-to-reach populations in underserved areas Roll out protocols to guide targeting of asymptomatic individuals (detect and eliminate asymptomatic infection) Integrate entomological data into routine electronic systems Establish community-level programmes to support larval source management Support entomological activities in under-resourced priority areas Establish a community-level programme (building on CHW and mobile agents) including the identification of at risk and vulnerable priority populations Provide additional annual training, sub-national meeting support and quality control to improve spray coverage beyond 85% Implement IRS and Integrated Vector Management (IVM) in under-resourced priority areas Provide LLINs in under-resourced priority areas OUTPUT Surveillance data mapped to identify areas for all eight countries of targeted regional interventions Bi-annual map to inform intervention deployment sent to eight countries Annual regional consolidated drug efficacy report released Gap analysis completed on access to early diagnosis and treatment across all eight countries Testing and treatment centres increased in priority areas identified to meet access gaps in all eight countries Annual regional profile of Plasmodium species released Country malaria programmes plans include an approach to target hard-to-reach populations in underserved areas Country malaria programmes plans include an approach to target asymptomatic individuals Entomological data integrated into electronic systems Larval source management community programme established in districts where feasible No stockouts of commodities and supplies for entomology in resource priority areas Community-level programme in place in districts identified for elimination 85% spray coverage achieved IRS implemented with the WHO ratio of supervisors to sprayers in place Distribution of LLINs in districts identified to have gaps in vector control coverage National Outcomes Decrease in malaria case incidence Decreased malaria mortality rate Decreased prevalence of malaria parasite Increased proportion of suspected malaria cases who received a parasitological test All foci investigated classified Increase in proportion of malaria cases detected reported in systems Increase in proportion of the population at risk protected by IRS during previous 12 months Increased proportion of the population at risk sleeping under an LLIN or living in a house sprayed by IRS in the previous 12 months Regional Objective Strengthen regional coordination to achieve elimination in each of the E8 member countries Regional Activity Establish and maintain a network of country situation rooms, linked to the regional situation room Strengthen regional climate-based early warning systems Support data and information management and robust analysis to inform decision making and resource allocation Support the coordination of national independent expert task teams to review and inform national programme progress (eliminating and pre-eliminating countries) OUTPUT National situation room established and linked to the regional situation room Regional climate-based early warning system in place Technical support provided as required Independent expert task team in place as part of the regional situation room Enhanced risk profiling, stratification and Annual risk profiles developed receptivity measurement Strengthen programme reporting Case-based electronic reporting in by supporting case-based electronic districts identified for elimination reporting and mobile technology National Outcomes Decrease in malaria case incidence Increase in proportion of case reports received less than 24 hours after detection Regional Objective Strengthen regional coordination achieve elimination in each of the E8 member countries ELIMINATION 8 STRATEGY: Acceleration Plan

40 7 APPENDICES COMPREHENSIVE MONITORING AND EVALUATION PLAN CONTINUED Entomological Activity Regional competence and accreditation of vector control scheme for the quality application of intervention Establish entomology network Train and enhance skills of regional entomologists The inclusion of entomology data to determine country risk profiling, stratification and risk activity management Develop and support laboratory and insectary infrastructure for countries OUTPUT Vector control scheme accredited according to WHO guidance A network of entomologists established Three entomologists trained (per country) Risk profiling and stratification of entomology data to manage risk Adequate laboratory and insectary infrastructure in place for malaria elimination activities National Outcomes Increased proportion of the population at risk sleeping under an LLIN or living in a house sprayed by IRS in the previous 12 months Regional Objective Promote knowledge management, quality control, and policy harmonisation to accelerate progress towards elimination Epidemic preparedness and response Activity Establish a system and line up partners and resources to support EPR requests Assessment of the national status of EPR and overarching response Support countries to establish emergency protocol thresholds for incidence management and collaboration with national disaster management Enhance EOCs for diligence, QA, and accountability in the implementation of EPR plans Support an integrated approach to epidemic response OUTPUT Mechanism in place to support EPR requests EPR assessment conducted and report released Emergency protocols for incidence management in place EOCs linked to national malaria programme EPR Integrated outbreak team members identified for rapid response National Outcomes Decrease in malaria case incidence Regional Objective Strengthen regional coordination to achieve elimination in each of the E8 member countries Advocacy Activity Harmonise regional policy and indicators Establish a guiding coalition of malaria champions at the regional and national level Engage with key stakeholders to ensure and improve political buy-in and accountability Advocate for streamlining vector control commodities as emergency procurement to lessen challenges Advocacy and support for the expansion of (temporary) national malaria workforce structures and provision of dedicated personnel at the national and subnational level OUTPUT E8 Annual Scorecard A coalition of malaria champions established at regional and national level Engagement with key stakeholders Meeting with government procurement official on vector control commodity streamlining Meeting of NMCP with highranking government officials on malaria workforce needs and gaps National Outcomes Decrease in malaria case incidence Increased proportion of the population at risk sleeping under an LLIN or living in a house sprayed by IRS in the previous 12 months Strengthened national capacity to eliminate malaria Regional Objective Strengthen regional coordination to achieve elimination in each of the E8 member countries Elevate and maintain the regional elimination agenda at the highest political levels within the E8 countries Secure resources to support the regional elimination plan, and to ensure long-term sustainable financing for the region s elimination ambitions 38

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