Surveillance, Monitoring & Evaluation (SME) System Assessment in the GMS Findings & Recommendations Surveillance, Monitoring & Evaluation (SME) System Assessment in the GMS Findings & Recommendations Bayo S. Fatunmbi Monitoring & Evaluation, ERAR-GMS

ERAR–GMS M&E activity (Workplan, 2014) Principle: – Evidence based system strengthening Key objectives: – To give an overview of the different aspects of surveillance systems in the six different countries, – To highlight gaps and examples of good practice, and chart key indicators and system characteristics. – To guide future efforts to strengthen malaria surveillance across the GMS.

Methodology: Rapid ‘desktop’ analysis in selected countries (May 2014) – review of available policies, plans and other documentation Detailed review of the malaria SM&E status of the different malaria control programmes was conducted between October 2014 and February – Key Informants Interviews (using modified M&E assessment tool) and – Observation (direct and indirect) during field visits to different administrative levels of the surveillance systems Data analysis and validation Reporting: – A detailed and fully referenced report is available for each individual country in addition to a regional summary.

Thematic areas Malaria context Organizational structure and human resources Stratification and targeting Passive case detection and reporting Reporting, data management including analysis Case Notification, case and focus investigation Response mechanisms Cross border activities and coordination Operational research Others

Malaria surveillance guidance documentation and indicators in the GMS, 2014 VietnamMyanmarThailandLao PDRCambodiaChina Available documentation Surveillance plan/strategy Elimination plan/strategy National Strategic Plan Malaria Monitoring and evaluation plan Malaria surveillance SOPs Well-defined indicators Indicators Access to early diagnosis Prompt and effective treatment LLIN and IRS coverage Stratification status of admin areas Elimination status Knowledge and behaviour change Malaria mortality Annual Parasite Index Surveillance and epidemic response Drug availability Private sector Some countries have surveillance and response tools, some do not have. Majority of the available documents are outdated. Existing malaria indicator framework is weak in terms of malaria elimination. need updating to reflect the mood of the day – accelerating towards malaria elimination. Indicator standardization and harmonization across the region is required urgently.

Organisational structure of malaria surveillance – System is weak IndicatorVietnamMyanmarThailandLao PDRCambodiaChina Malaria Surveillance within the wider health system Vertical MIS in place Essential malaria data from MIS linked/integrated to HMIS Community-based malaria report system In place Harmonised within country Fully linked within MIS Organisational structure for surveillance: Clearly documented Roles and responsibilities clearly defined Annual updated register or database of health facilities/reporting units clearly exists A complete register/database of village volunteers and mobile volunteers for health facility/district exists Identified focal SM&E person at NMCP Sufficient SM&E capacity and staff time at NMCP Training and Supervision SM&E training plan in place Frequency of training availableevery 2 yearsnot regular every 2 yearsannually Major constraints reported Lack of sufficient training Lack of proper staffing Lack of sufficient supervision Training materials available For community-based personnel For data management, analysis, interpretation For case investigation, ACD, outbreak response Coordination mechanisms Mechanism for collaboration on policies and strategies for malaria control between NMCP and relevant government sector Mechanism for collaboration on policies and strategies targeting vulnerable populations between NMCP and different health programmes Mechanism to review SM&E data, coordinating external technical support

Malaria stratification and PAR targeting IndicatorVietnamMyanmarThailandLao PDRCambodiaChina Formal stratification exists Updated in previous five years Incorporates malaria case data Village level stratification Specific SOPs for stratification Stratification used to estimate PAR n/a As at time of assessment, no published evidence of current efforts to target and strengthen malaria surveillance in specific high-risk groups was available. However, several innovative partners’ efforts across the sub-region were reported during Yangon, Hanoi and Phuket MMP meetings. There is a need to carry out a more extensive survey of stakeholders and partners to systematically document relevant approaches to learn from best practice in the region. All six countries have a formal system for malaria stratification in place, but there is considerable variability in the methods and data used. Incidence-based stratifications incorporate a variety of thresholds to define individual strata in different countries. There is a need for standardising classification schemes across the region.

Passive case detection components within NMCPs (1): Health Facility based VietnamMyanmarThailandLaosCambodiaChina Public health facilities Policy for always testing before treatment Occasions when treatment may happen without test * Separate system for HIS/other nationally collected data * Residence (village level) captured Case classification: local/imported captured Written SOPs for data collection available Monthly case reporting aggregated Electronic aggregation Fully electronic reporting system Village disaggregated data available at national level Adequate systems in place to check completeness of health facility data partialn/a Adequate systems in place to check completeness of health facility data partialn/a Training Training includes data entry * * Training includes data manipulation (indicator calc) * ** Training includes data management * *

Passive case detection components within NMCPs (2): Community based VietnamMyanmarThailandLaosCambodiaChina Community based systemsVHVs in some remote areas VHVsVHV, VMWsVMW and VHVVMWNONE Standardised case management guidelines available n/a Do testing n/a Do treatment n/a System for recording malaria test and diagnosis n/a Data combined with public health facility data *n/a Case classification: local/imported captured n/a Written SOPs for data collection available n/a Indicator: which units did not report *n/a Standardised arrangements for dealing with late reports *n/a Initial training for community workers n/a How regular is training for community workers **annual2 yearsn/a Incentive structure in place some areas only n/a VHV monthly salary/incentive n/a Approximate/example salary amount40 USDn/a20USD12 USD10 USDn/a Transport subsidies n/a Targeting of VHV systemstratificationstrata 1+RAIA1-A2 areasstrata 2-3distance from health facility, enlarged spleen rate and distance to forest n/a VHV coverage review policy n/a

Confirmatory diagnosis of malaria as a surveillance tool: quality assurance processes in the GMS Indicator VNMMThaiLao PDRCambodiaChina Microscopy Microscopist paid specifically to prepare/read slides Routine testing of microscopists – reference slides/slide bank Is there a refresher training for microscopists that do not pass routine testing? Is there a system of accreditation of microscopists (WHO ECA accreditation)? Is a sample of slides routinely submitted for cross- checking in a reference? RDT Is there a system for training and re-training of health workers in use of RDTs? All malaria endemic countries in the GMS have adopted the policy of confirmatory diagnosis of suspected malaria in the national and regional malaria strategies. However, the quality assurance system remains a suspect in many countries. QA diagnosis resources within and outside the sub-region should be optimized

Key indicators of malaria surveillance in the private sector Indicator VNMMThaiLao PDRCambodiaChina Microscopy Microscopist paid specifically to prepare/read slides Routine testing of microscopists – reference slides/slide bank Is there a referesher training for microscopists that do not pass routine testing? Is there a system of accreditation of microscopists (WHO ECA accreditation)? Is a sample of slides routinely submitted for cross- checking in a reference? RDT Is there a system for training and re-training of health workers in use of RDTs? In all countries it is currently legal for some or all entities in the private sector to diagnose and treat malaria. Registration of private facilities varies between the countries. The private sector is extensively used in most countries especially by migrant populations. Efforts to capture private sector data should be intensified. Data entry forms should incorporate private data. Supportive supervision and regulatory measures institutionalised by authorities at all levels

Key indicators of management and analysis of malaria data IndicatorVietnamMyanmarThailandLao PDRCambodiaChina Use of database for reporting Case-based data entered into electronic system Data entered into electronic system at low levels (below province) Electronic system covers whole country Routinely integrates data from community n/a Routinely integrates data from private sector Routinely integrates data from other (military, worksites etc.) SOP for data quality exists Mechanism to monitor timeliness of reporting Mechanism to monitor completeness and mistakes Mechanism for addressing missing data Designated staff for monitoring data quality Adequate IT infrastructure at national level Adequate IT infrastructure at lower levels Use of SMS/internet/ for reporting Adequate backup systems Focal points for data analysis exist at different levels Automated analysis used Analysis at peripheral level Analysis at province/district levels Analysis at national level Geographic information systems used Formal feedback system in place * Specific training on data management and analysis Situation varies in countries. Poor performance on some indicators cuts majority of GMS countries e.g. formal feedback mechanism, backup systems, analysis and use of data for action at lower levels, IT infrastructures. Policy intervention may be needed in some countries to strengthen data management, especially on information sharing for cross border and regional level actions

Case notification, case and focus investigation IndicatorVietnamMMThailandLao PDRCambodiaChina Case notification Malaria a notifiable disease Case-base reporting implemented If yes, is it nationwideRAI areas First level of notificationtownship Timeline for notification/reportingwithin 2 weeks daily Non-public sector sources included Case investigation Standard system in place Recording of number of cases investigated in place Standardised malaria case investigation form Locations mapped as part of investigation Ecological/entomological data routinely collected? Roles and responsibilities defined Training materials, SOPs in place Supervision systems in place Incentive mechanisms in place System of incentives differ. How to sustain incentives for active case detection? Experience across countries will be useful

Response mechanisms (1) IndicatorVietnamMyanmarThailandLao PDRCambodiaChina Formalised system to connect surveillance system outputs to responses System functional n/a n/a Outbreak detection, investigation and control Outbreak detection included in NSP ** Outbreak detection system in place Outbreak detection/guidance in place Does a national outbreak plan exist Is outbreak plan adequately resourced n/a * Software/electronic system for detecting outbreak at national level (xl) Outbreak detection system effectively implemented Roles and responsibilities for outbreak detection and response documented? * Roles and responsibilities for outbreak detection and response clear and implemented? * Outbreak investigation SOPs in place for those (formally or informally) implementing * Outbreaks consistently identified and investigated Plans for development of improved tools and systems Emergency stockpiles of insecticides and antimalarials Emergency funding in place * Emergency funding sufficiently flexible n/a

Response mechanisms (2) Indicator VietnamMyanmarThailandLao PDRCambodiaChina Other responses ACD response ACD during/following outbreak investigations n/a n/a ACD is a routine response n/a ACD methodology is standardised n/a n/a Vector control as a response n/a n/a Vector control response is routine and defined IRS response ** IRS is a routine response *n/a* LLIN distribution as a response *n/a* n/a LLIN is a routine response *n/a* Clear and standardised response deployment system/thresholds in place for ACD n/a Clear and standardised response deployment system/thresholds in place for vector control n/a Lack of staff to respond to available data raised as an issue Tracking of migrants raised as issue Reactive case detection (RCD) RCD used in country Formalised system for RCD exists n/a RCD only in context of outbreak control n/a RCD used in foci investigations (active/inactive) n/a * Other case detection Any further case detection activities outside outbreak control/response Border screening RAI areas n/a Mass blood surveys limited areas RAI areasn/a Mobile malaria clinics

Operational research structures and priorities IndicatorVietnamMyanmarThailandLaosCambodiaChina Operational research OR coordination mechanism in place n/a OR priorities focusing on vulnerable populations Evidence that OR outputs feed into control/elimination strategies n/a n/a Current operational research priorities Improved diagnostic techniques for surveillance G6PD tests and rollout of Primaquine (PQ) Drug discovery Approaches for elimination, alert, response, modelling, etc. Molecular surveillance for drug resistance MMPs and border areas Vector control (outdoor transmission) New mHealth evaluations

Recommendations (Regional level) 1.Develop adequate and up-to-date guidelines and policy documentation at country and regional level 2.Improve case-based automated data management 3.Strengthening linkages with the private sector 4.Harmonize elimination and resistance SM&E indicators 5.Strengthen SME capacity at all levels of NMCP 6.Avoid multiple reporting systems and transition to case-based reporting and investigation systems only where viable

Perspective Diverse and rapidly changing surveillance situation in GMS countries: – many documents, strategies and plans are actively under development, with countries at different stages of positioning themselves for elimination This assessment should be regarded as a working document, a ‘baseline’ or starting point, from which countries can be best assisted to transition their surveillance from malaria control into an elimination setting.

Way forward Publication – WHO Technical Report (Approved IPPF by WPRO) – Peer review papers (during dissemination in Nov 2015) Dissemination meeting planned for 13 November 2015 Update vital national malaria tools – NSPs, M&E Plans, Regional SME Framework, SOPs, etc. – Resource mobilization for SME system strengthening Support countries to implement recommendations and assess performance in system strengthening

Acknowledgement National Malaria Programs in the Greater Mekong Sub-region (including collaborating sectors and programs) – Kingdom of Cambodia – People’s Republic of China – Lao People’s Democratic Republic – Republic of the Union of Myanmar – Kingdom of Thailand, and – Socialist Republic of Vietnam Malaria Consortium (WHO technical partner): conceptualization, field work, data management, reporting Development Partners: – Financial support from Bill & Melinda Gates Foundation (BMGF) and Australia Department of Foreign Affairs & Trade (DFAT) Other technical partners at regional and country level Expert reviewers – internal and external to WHO for WHO colleagues (at all levels for technical inputs)