Plan to strengthen the existing SME system for

malaria elimination in Mon State

Myanmar

Background

• Aimed to achieve elimination of malaria by the year 2030. • The goals and targets -- in line with WHO Global Technical Strategy (GTS) for

Malaria and Strategy for Elimination of malaria in GMS. • Among GMS countries, Myanmar still has high malaria incidence and malaria

deaths although it has achieved marked reduction in its burden during recent decade (2005-2014).

• Most of the areas will be in the “Transmission reduction phase” from 2016 to 2020 aiming universal access to prevention (vector control), quality diagnosis and treatment to bring down the incidence below 1 case per 1000 people at risk per year.

• At the same time, some areas are going to be prioritized to start subnational elimination. For those areas, activities of “Pre-Elimination Phase” will be expected to be carried out.

This scenarios made National Malaria Programme to consider “Phased Programme of Malaria Elimination”.

The high burden areas such as Rakine State, Sagaing Region, KachinState, Ayeyawaddy Region, Southern Shan State and Chin are to be in “Transmission Reduction Phase”.

The rest will be in “Pre-elimination Phase”.

The areas of Myanmar- Thailand border where Artemisinin resistant is confirmed should be prioritized for the starting of implementation.

Strength & weakness of programStrength Weakness

• Political commitment- 9th East Asia Summit in Napyi taw, President of Myanmar commit to implement Malaria Elimination in Myanmar.

• Deputy Minister, representatives from KNU & NLD party, other sectors, INGO attended the malaria conference in US and all agree to become “Malaria free Myanmar”

• Malaria burden was drastically declined in Myanmar with the support of the GF, 3MDG.

• WHO support technical role to NMCP• Many implementing partners• Development partners prioritize the Myanmar

as high burden disease and support more funding

• High malaria burden in hard to reach and border area, some pocket areas.

• Multi drug resistant Pf problem• Core intervention malaria surveillance need to

be improved in Myanmar.• Human resources (as whole country) is limited

in NMCP and need to improve technical and managerial capacity.

• Telecommunication system is still poor in Myanmar for IT Data Based System.

• More collaboration and monthly data sharing from implementing partners is still needed.

• Difficult to implement in Non-state Actors area.• Private sector involvement is passive and

needs more engaging and actively participation

• Reporting centers – from volunteers and BHS• Gap in supervision of sub-centers and volunteers• Logistic management information system- still need to

be strengthened• Data reporting as a whole country is incomplete due to

transportation but still timeliness is to be speed up but not properly monitored &recorded.

• Data utilization at township level – still weak

1. General Review on Current SME System

2014 2015 2016 2017 2018 2019 2020

Mon Villages1195 1195 1195 1195 1195 1195 1195

Population (,000) 2050 2070 2091 2112 2133 2155 2176

3 priorities for period 2015-20 PAR (,000) 1263 1276 1289 1302 1315 1328 13411. Preparation period 2016 including verification of data

reported API (local)/1000 PAR 1.50 1.5 1 1 0.9 0.9 0.9

#local cases reported 1889 1914 1289 1302 1183 1195 1207

2. Reorientation in 2016 % of cases reported 95% 97% 98% 100% 100% 100% 100%

# surveillance staff (Gov) 37 37 37 50 50 50 50

3. Strengthening surveillance system

#surveillance staff (Volunteers) 1125 1125 1125 1200 1200 1200 1200

and HR Phase (Con/Elim/Prev) C C C C E E

• As an example, Myanmar select Mon State for Elimination plan. Mon State is bordering with Thailand, and proved Artemisinin resistant area. Current situation in Mon State is “Transmission reduction phase” and move into pre-elimination phase on 2020 and plan to achieve elimination in Mon State by the year 2025.

Legend

0.5

IOM

UNICEF

WC

PSI

MAM

ARC

MMA

CPI0 0.1 0.2 0.3 0.40.05

Decimal Degrees

Number of positive cases & Implementing Partners (INGOs) distribution in Mon State

Development of Planning • Development of Planning for malaria elimination should be country led, in line with GMS

malaria control strategy & WHO guideline. • For development of planning, Working group committee will be formed and committee should

include following:-• Deputy Director General(Disease Control), Department of Public Health• Representative from Department of Medical Care• Representative from Department of Health Professional Resource Development and

Management• Representative from Department of Medical Research• Representative from Department of Medical Services, Ministry of Defense • Director (Disease Control), Department of Public Health• National Malaria Control Programme Manager, Department of Public Health• Representatives from WHO• Training attendees (from Myanmar), Malaria Elimination for the GMS training course, Chiang

Mai, Thailand• Regional Officer (Malaria)/Team leader, VBDC• Other VBDC staffs as necessary

2. Development of the Guideline & SOPs for PCD, ACD, Foci, identification and investigation and response, QA Diagnosis, Data management and reporting, Supervision

Guidelines to be developed- Guideline on Elimination of Malaria in Myanmar (in English & Burmese)

which include all concept and practical aspects of the activities to be done in the country for transmission reduction phase, and elimination

- SOPs under this – PCD, ACD, PCD, ACD, Foci, identification and investigation and response, QA Diagnosis, Data management and reporting, Supervision

- Each SOP – consist of Definition, who has to do, what to do, how to do, when to do & where to do

Existing Guidelines Guideline on Prevention and Control of Malaria among Migrant populations (English & Burmese) – to be revised inline with Elimination.National Treatment Guideline on Malaria diagnosis and Treatment (English) – recently developedGuidelines for Quality Assurance and Quality Control of Malaria Microscopy in Myanmar (English) – to be revised inline with Elimination

3. Essential Job Descriptions for Surveillance Workers

• Job Descriptions for each staff (Both VBDC & BHS) are already existed

• Job Descriptions for Field Coordinators (MO) and Data Assistants recruited by WHO (Country Office) are already existed

• Those include roles and responsibilities of each staff (both Govt; & WHO) for Data collection, compilation, verification, reporting, analysis, dissemination of routine Data reporting system

• For the new elimination activities, JDs to be review and revised and to be clearly instructed

4. Human resources Planning

Township

RO & TL (Med. Dr.)

MA/MI MS/PS Ento staff AE, EA, IC

Lab Tech Grade 1

# of VMWs

Total confirmed malaria cases (2014)

Average Cases/ month

State VBDC 2 3 5 3 2 204 17Bilin 3 102 24 2Chaungzon 4 45 130 11Kyaikmaraw 3 102 34 3Kyaikto 1 3 92 288 24Mawlamyine 1 42 22 2Mudon 1 4 78 259 22Paung 3 67 144 12Thanbyuzayat 1 3 76 247 21Thaton 1 5 128 145 12Ye 3 95 392 33Total 37 827 1889

Existing Human Resources & Malaria Positive Case load , Township wise, Mon State

Activity Agent Existing situation Plan Time-line

By whom

Survei-llance activity (case finding & Treat-ment

PCD agent MW, VMW

Total MW&VMW (existing surveillance agent for PCD posts) -1183,Total villages – 1214

Each and every village should have PCD posts either by MW or VMW. Additional 31 posts will be filled up by newly recruited VMWs. New PCD posts in high transmission areas also considered.In non-receptive villages with high vulnerability, PCD posts will be created to detect & T internally imported cases.

2017 State PH Director, RO

Hospi-tal staffs

All CSM cases will be tested by RDT or microscopy.

Assigned 1-2 staffs to test CSM cases

2016 Med. Superintendent, TMO,SMO

ACD agentMS/PS

Each and every township has MS/PS. Altogether 37 MS/PS are there in 10 townships

ACD might be done to fill up the gaps of PCD in hard-to-reach, high malaria risk areas, and migrant population.

Activity Agent Existing situation & Plan Timeline By whom

Case investiga-tion, foci identifica-tion, inves- tigation & response

MA, MI, HA,Entom-ology staffs

Total positives in 10 townships were 1889 and total 72 staffs (7 MA/MI &65 HA) sanctions are there. There might be some vacancies are there. With full strength, average # of cases investigated per agent per month is about 3. (Township wise requirement will be considered). Entomology staffs, Positive case concerned MW or VMW are also members of investigation team.

All vacancies would be filled up before training/orientation on elimination.

2016-2017 State PH Director, DD Malaria, RO

RO/ Team leader VBDC

Review and verification of case/foci investigation and response activity would be done by RO/TL (VBDC) for approval.

Training on Malaria elimination including all other staffs. (Task oriented)

2016 VBDC + WHO + Trainees (GMS elimination)

Activity Existing situation Plan Time-line

By whom

Strength- ening man power in Central level and Mon State

Need strengthening man power. (M&E Officer, Data assistant, Data management, Technical Assistant, etc.)

Approval/agreement from MOH DOPH on strengthening man power.Review of tasks and additional HR requirement.Exploring possible donors for manpower expansion (like ADB, CHAI)Recruitment of additional staffsTraining of new additional staffs

2016-2017

DG, PM-NMCP

Retaining staffs With the approval of MOH Policy development (To retain the staff within the project area townships)

2016n on wards

DG, PM-NMCP

No electronic (IT) based data management system (DMS).

Creation of new post and recruitment of staff who has experience on electronic based DMSTraining of data assistant on IT based DMS (for data entry)

2016 DG, PM - NMCP

Activity Existing situation Plan Time-line

By whom

Technical Assistant Planning

Routine Technical assistant is being given by WHO. During Transmission reduction phase of elimination, technical assistant on Development of Planning on Malaria Elimination and Communication specialist are required

- To be hired each Technical Assistant for:

- (1) Development of Planning on Malaria Elimination.

- (2) Costing on Planning on Malaria Elimination.

- (3) communication specialist

2 016 Q1 & Q2

WHO, NMCP

5. Identify and prioritize relevant indicators include SME indicators in the overall malaria indicator framework

• Transmission Reduction Phase• Confirmed malaria cases (/1000 population) - (number and rate

per month & per year, disaggregated data) – trend, location of ongoing transmission, progress

• In-patient malaria cases & deaths (/1000 population at risk)- impact of program on severe diseases and deaths.

• Malaria test positive rate (/1000 pop.) – trend, identify intense malaria area

• % of cases disaggregated by species• ABER • Completeness of Health facility reporting

• Elimination Phase• Tx reduction indicators + the following • % of positive patients contact with the health system within 48 hours

from first symptom (fever)• % of positive test result notified to NMCP (township or State/Region,

cc to NMCP)• % of confirmed cases fully investigated• No. of foci by classification• % of foci fully investigated• % of foci (active, potential) taking response (within/after 7 days after

foci investigation)

6. Electronic (IT) based data management• The data base will serve as National repository of following information.

Township level also has the following registers & records. Field level also keeps records.

• National malaria case register (single database of all individual case information) for detail analysis and synthesis of epidemiological information , trend

• Malaria patient register –all malaria patient records including copies of public/private health facility/hospital records, case investigation records

• Laboratory register• Entomological monitoring /vector control records• Foci investigation, classification, response register and records (to be Prepare 2016

Q3)•Monitoring, monthly analysis , continuous evaluation of national surveillance network for weak point and corrective action

• - When – starting from 2016-2017, and onwards• By whom – M&E Officer, Data management person, Township PH Officer

7. Field monitoring and supervisionTo which Level By which level &

by whom?What to monitor? How frequent When to

start?Field level Township level, HA,

MA/MIPatient register, Patient record –completeness, quality of data, correctness, timeliness

Quarterly and ad hoc.Priority should be given to weak volunteer, not reporting for 2 consecutive months.

2016

Health Facility level TPHO, THO, THA Above + case investigation records, Foci records

Quarterly 2017

Township level State RO, Team leader, (VBDC), MA, THA

Patient register, case & foci classification records & register – data discrepancies, data validation, completeness, timeliness- Some validation by

phone immediately

Quarterly in early part and later monthly

On-site supervision immediately if necessary

2017 onwards

7. Field monitoring and supervisionTo which Level By which level &

by whom?What to monitor? How frequent When to

start?State level Central VBDC, PM,

M&E Officer, Patient register, Patient record, Patient register, case & foci classification records & register – data discrepancies, data validation, completeness, timeliness of reporting- Some validation by

phone immediately –completeness, quality of data, correctness, timeliness of reporting

Quarterly and Elimination phase -monthly

2017-18

Central level Independent task force on Malaria Elimination

Every 2 months

8. Evaluation of SME System performance

Following 2 indicators are prioritized for transmission reduction phase. • Annual Blood Examination Rate This indicator reflect the extent of diagnostic of testing in the population and aids in interpretation of other surveillance indicators. In Mon State, ABER (2014) was 2.15 per 1000 population and in future it will be calculated based on per 1000 population at risk.• Completeness of Health facility reporting In Mon State, total reporting units is 1215 which include PCD agents (Midwife, Volunteers, and hospitals). Up to now NMCP not monitoring on % of completeness of Health facility reporting. During past 5 year data, number of people tested were about 40 thousands in every year. Estimated reporting status was about 95% completeness because of good communication/transportation system. Starting from 2016, this indicator will be collected not only from PCD agents but also from Private hospitals and GPs. At present time, data from private sectors are not included.

During elimination phase, above 2 indicators will be continue to use and in addition to that the following SME System performance indicators will be used .• % of confirmed cases fully investigated• No. of foci by classification• % of foci fully investigated• % of foci (active, potential) taking response (within/after 7 days after

foci investigation)• % of positive patients contact with the health system within 48 hours

from first symptom (fever)• % of positive test result notified to NMCP (township or State/Region,

cc to NMCP)

9. Reporting

• There are three main types of data flow (immediate, monthly and annually), and three points to which data are reported (Township, State/Region and National Malaria Programme).

• During transmission reduction phase hospitals, surveillance agent and laboratories, they send the reports to higher level by report monthly related to case finding and management. Report includes patient’s name, age, sex, address, type of population (migrant, resident), test results, species. Annual compilation data on above information will be send at the end of the year. Epidemic report must be reported immediately by phone, followed by paper report.

• During elimination phase, hospitals, surveillance agent and laboratories, should notify the confirmed malaria cases by phone, e.mail, fax immediately followed by paper record as a document. All detail information as in transmission reduction phase must be included. Report should be sent to township, State/Region and National level.

• Once initial notification is received, Township Health Assistant, together with VBDC staff go there and conduct case investigation, foci identification and investigation. It should be done within 3 days from notifying the confirmed positive case. These results should be sent to State/Regional VBDC and copy to Central VBDC. State/Regional VBDC review all the investigation forms and approve it to take the response.

• If new cases come out during investigation and response, these positive cases are entered into data based. All investigations should follows SOPs strictly.

• If a case is obviously imported case and occurred in non-receptive area, in setting where imported cases are quite common, it may be sometimes acceptable to relax the above rules on immediate reporting. But this fact should be included in SOP need to follow strictly.

• Monthly – All health facilities (both public and private sector), case finding by ACD should be reported monthly to higher level. Updated focus numbers and classification should also be included.

10. Establishment of National Independent Malaria Elimination Monitoring Committee

• This committee would be formed in 2017.• This committee should include Epidemiologist, Entomologist (not in-

service), Technical Officer from WHO, representative from NGO with sound malaria knowledge on elimination, persons working in other public health fields, representative from Epidemiology Unit (Department Of Public Health) and University of Public Health (UOPH), Physician (Professor and Head, Medical college).

• The main purpose of this committee is regular monitoring on performance and achievements, give guidance and suggestion on technical ground to DOPH, NMCP and if necessary to MOH.

• Committee should monitor the progress, achievement every 2 months.

• During monitoring, committee should review all documents on case based registers & case/foci investigation records/register, original copy of patients’ record, monitor on quality aspects of data, assessment on SME System performance indicators.

• It must be conducted all levels and field assessment (field visits) must also be included.

• First summary findings on salient points will be given feedback to MOH, DOPH, NMCP and Mon State Public Health Department within 3 days after M&E visit and detail final report should be given within one month.

• SOP should be developed on assessment on SME System performance by independent group. (2016 Q4)

11. Updating legislation, as part of enabling environmentItems Purpose What should be done? By

Whom?Starting Time line

Mandatory notification

For case/foci investigation and appropriate response depending on type of foci.

-Permission from MOH/ DOPH -Put up to Health Sector Coordinating Committee for approval-Circulation on mandatory notification

DOPH, NMCP

2017

2017

2018

HR policy To strengthen and retain the human resources for malaria elimination .

- Inform to MOH- Put up to Executive

Committee of DOPH

NMCP, DOPH

2017 Q4

Private sector participation

For the completeness of the data for investigation and response- Following NTG by private sector

- Discuss with Myanmar Medical council

- Department of Medical Care

NMCP, DOPH

2016

12.Improve Private SectorItems Purpose To whom By whom When

Advocacy meeting

- Develop case based register at the hospitals (private/public)- To keep confirmed

malaria patients’ charts systematically.

- Notification of all confirmed cases for investigation and response.

- To follow the NTG according to species (including PQ) and provide DOT

Professor & Head, Physician, Medical superintended of Private Hospitals, Physicians, Pediatricians,

DOMCNMCPMyanmar Medical Council

After approval of mandatory notification of confirmed malaria cases (2018)

THANK YOU