Dr. Bouasy, Dr. Viengxay and Dr. Odai Strengthening SME system for Lao PDR National Malaria Programme (2016-2020) By Dr. Bouasy, Dr. Viengxay and Dr. Odai CMPE, Lao PDR With support from Dr. Seshu Babu, WHO, Lao PDR

Outline of Presentation NSP Goals, Objectives, Roadmap and Timelines Provinces selected for Surveillance Planning Exercise Review of current SME system: SWOT Analysis, Strengthening of relevant SME areas Plan to strengthen the existing system for malaria elimination PCD & ACD proposed in Lao PDR and Data flow Responsibilities for recording and transmission Case investigation for elimination, Classification and Types of Foci Assessment of human resources needs Revised essential job descriptions for surveillance workers Proposed Indicators Electronic (IT) based data management Field monitoring and Supportive Supervision, Improving the organization of supervision Communication of results, Evaluation of SME System performance Reporting National Independent Malaria Elimination Monitoring Committee Updating legislation Involvement of private sector

NSP Goals Phase 1 (2016-2020): The overall goal of the phase 1 of NSPMCE is to flatten the malaria epidemic and reduce the impact of multi-drug resistance in the southern part and move progressively towards malaria elimination in the northern and central part of the country while aligning with the GMS regional elimination efforts. Phase 2 (2021-2025): The phase 2 goal of the NSPMCE is to eliminate Plasmodium falciparum malaria in the entire country along with the entire GMS region and to eliminate all species of malaria in the northern/central provinces. Phase 3 (2026-2030): The phase 3 goal of the NSPMCE is to eliminate all forms of malaria by 2030 in the entire country.

NSP Objectives Phase 1 Phase 2 Phase 3 Sub-objectives 1. Reduce the incidence of Plasmodium falciparum to less than 5 per 1,000 in the southern Laos by 2020 2. Interrupt the transmission of Plasmodium falciparum in the northern and central Laos by 2018. 3. Reduce the incidence of indigenous cases of Plasmodium vivax to <1 per 1,000 in the northern and central Laos by 2020. 4. Prevent reintroduction of malaria transmission in areas where it has been interrupted. 1. Interrupt the transmission of Plasmodium falciparum in the entire country by 2025. 2. Interrupt the transmission of Plasmodium vivax in the northern and central Laos by 2025. 3. Prevent reintroduction of malaria transmission in areas where it has been interrupted. 1. Interrupt the transmission of all forms of malaria in the entire country by 2030. 2. Prevent reintroduction of malaria transmission in areas where it has been interrupted. 3. Apply for certification of malaria free status by 2030. Sub-objectives Establish a fully functional elimination phase surveillance system in the northern and central Laos and strengthened surveillance in southern Laos by 2017. Optimize the functionality of national malaria control, containment and elimination efforts by strengthening program management. Maximize access to and utilization of effective vector control and personal protection measures. Improve access to and early utilization of diagnosis and appropriate treatment for malaria at public health facilities as well as at community level and in the private sector. Progressively roll-out malaria elimination in selected provinces.

Roadmap to malaria elimination in Laos Sub-objectives Establish a fully functional elimination phase surveillance system in the northern and central Laos and strengthened surveillance in southern Laos by 2017. Optimize the functionality of national malaria control, containment and elimination efforts by strengthening program management. Maximize access to and utilization of effective vector control and personal protection measures. Improve access to and early utilization of diagnosis and appropriate treatment for malaria at public health facilities as well as at community level and in the private sector. Progressively roll-out malaria elimination in selected provinces.

PROPOSED TIMELINES FOR MALARIA ELIMINATION IN LAO PDR (2016-2030) 2018: Elimination of Pf in all northern/central provinces except Phongsaly and reduction of API to <10/1,000 in the southern provinces 2020: Elimination of Pf in all northern/central provinces and reduction of API to <5/1,000 in the southern provinces 2025: Elimination of Pf from entire country including southern provinces and elimination of Pv in northern/central provinces 2030: Elimination of Pv from the entire country 2017 2020 2025 2030

PROVINCES SELECTED FOR SURVEILLANCE EXERCISE CHINA VIETNAM MYANMAR THAILAND Towards elimination by 2020 VIETNAM THAILAND Towards pre-elimination by 2020 CAMBODIA

Review of current SME system: SWOT Analysis Strengths Strategic reforms in the health sector including HMIS using the DHIS2 platform Strong policy commitments to data use for decision making Good progress in Government efforts towards attaining MDG targets Clear and robust second Health Strategic Plan with an M&E component Increasing support for SME from major funding agencies Highly experienced and committed Epidemiology unit within CMPE Evolving structure in accordance with function and strategy at CMPE Increased capacity for M&E within CMPE and implementing partners Weaknesses Shortage of qualified human resources for SME at all levels Lack of clear strategies for working effectively with the private sector on malaria reporting Lack of data on individual malaria patients Lack of computers at health facilities Lack of reliable estimates of mobile and migrant populations Inadequate malaria surveillance and information systems that fail to capture data from outside the public health sector Lack of confidence to take actions at local level Opportunities Strong government support to CMPE Government's commitment to Public Administration Reform in order to ensure sustainability of staff motivation and performance Increasing participation of other line ministries and NGO partners in surveillance and M&E activities GF Grants that focus on M&E Plans and PFs More partners interested in collaborating on SME Increasing decentralisation and deconcentration Threats Low motivation of health staff (incl. for SME) Conflicting priorities particularly at provincial level with neglect of SME Difficulties in harmonising SME strategies with other partners Erratic supply of electricity making it difficult to use computers, etc. Potential reduced funding from GF for HR may affect SME /Epidem. focal persons

Strengthening of relevant SME areas The aim of the national malaria program during 2016-20 phase will be to stop the malaria epidemic in the 6 southern provinces and move progressively towards malaria elimination in the northern provinces by scaling up surveillance. Once transmission in the south is brought under control the southern provinces will follow the north in moving into pre-elimination. Hence one major set of activities during 2016-20 will be the design and implementation of a surveillance and M&E system that will be able to rapidly detect, investigate and respond first to outbreaks in 6 provinces in the south and individual instances of local transmission in the north. Necessary domestic and external financial resources will be mobilised for achieving this aim keeping financial sustainability in mind.

Plan to strengthen the existing system for malaria elimination CMPE will work with WHO and other partners in the country to develop / update relevant guidelines including SOPs for Passive Case Detection, Active Case Detection, Foci identification and investigation and response, QA Diagnosis, Data management and reporting, Supervision, etc. Some of these areas of work are described in the following slides.

PCD & ACD proposed in Lao PDR Definition: Detection of malaria cases among patients who on their own initiative visit a health post/facility for treatment, usually for febrile disease. The detection by health staff of malaria infections at community and household level in high risk population groups. Active case detection can be conducted as fever screening followed by parasitological examination of all febrile patients or as parasitological examination of the target population without prior fever screening. Purpose: The purpose is to enable measurement of incidence of malaria and define its person, place and time distribution in order to ensure more effective control. “You cannot control what you cannot measure”. It should be ensured that the collection of information is done in a timely, accurate and complete manner at every level in the system. ACD fills the gaps in the information from PCD with the purpose of ensuring that reservoirs of parasites are detected and treated early to interrupt transmission. The focus is on high-risk population groups.

Essential data elements to be collected for each case PCD ACD Date No. of patient Patient’s name, Age Sex and Pregnant Occupation Address (place of residence)(suggested: this province, another province and foreigner) History of travel Whether referred from another place Patient type (e.g. resident, migrant, etc.) Probable malaria (based on symptoms) Type of blood test() Result of blood test (Negative, Parasite Species) Treatment given ( ACT and other drugs) Referral to hospital Death from malaria. History of travel (esp. in the last 2 weeks to forest) Patient type (e.g. resident, migrant, etc) Symptoms and date of onset Temperature (if measured) RDT blood test ? G6PD RDT If slide/filter paper blot also collected Result of blood test ( Negative, Parasite Species) Treatment with ACT

Data Flow(PCD) Ministry of Health PR/DCDC CMPE 850 Health Centers   PR/DCDC 5 central Hospitals (Setthathiath, Mahosoth Military Hospital Police Hospital Friendship Hospital) CMPE 18 Provincial Hospitals / Military Hospital/Police Hospital 18 PAMS 148 District Hospitals (monthly by 143 DHs in malaria areas ) 143 District Anti Malaria Nuclei (DAMNs) Private Companies 850 Health Centers PPM Network (total 347) 2000 Villages in malaria areas (Zone 2 & 3)

Data Flow(ACD) Ministry of Health PR/DCDC CMPE 850 Health Centers   PR/DCDC CMPE 18 PAMS 143 District Anti Malaria Nuclei (DAMNs) 850 Health Centers High risk area/population group surveyed

Responsibilities for recording and transmission(PCD) Data flow Responsible for recording Responsible for transmission Responsible for decision making Village VHV/VMW HC staff (collect during monthly meetings) Health center Chief (# of RDTs/ACTs for replenishment) Health center Chief/Nurse Chief of HC HC Chief (planning services), Chief of DAM (supplies, response to outbreaks) District Antimalaria Nucleus Epidemiologist of DAMS Chief of DAM (supplies, response to outbreaks, HR deployment, etc.) Hospital (district/province) Laboratory technician Chief of PAM (supplies, response to outbreaks, HR deployment, etc.) Provincial Antimalaria Station Epidemiologist of PAMS

Responsibilities for recording and transmission(ACD) Data flow Responsible for recording Responsible for transmission Responsible for decision making Health center HC team with VHVs (if available) in high risk area Chief of HC HC Chief (planning additional services), Chief of DAM (supplies, response to outbreaks) District Antimalaria Nucleus Epidemiologist of DAMS Chief of DAM (supplies, response to outbreaks, HR deployment, etc.) Hospital (district/province) Laboratory technician Chief of PAM (supplies, response to outbreaks, HR deployment, etc.) Provincial Antimalaria Station Epidemiologist of PAMS

Recording of data on blood examination PCD: Type of test: Microscopy or RDT or PCR Result of blood examination: Negative or Parasite species (Pf, Pv and Mixed) ACD: Type of test: RDT and Microscopy or PCR RDT: Negative or Parasite species (Pf, Pv and Mixed)- For positive cases, DOT with antimalarials. Microscopy/PCR: Negative or Parasite species (Pf, Pv and Mixed). For positive cases, the HC staff will have to return to administer full course of antimalarial treatment

Use of data in the control phase PCD: At the same level to identify disease trends and plan effective control and prevention interventions. At the higher level to manage logistics for routine services and also potential outbreaks and institute prevention and control measures. ACD: At the same level to identify population groups at special risk and provide effective control and prevention interventions to these groups in order to reduce transmission. At the higher level to plan and implement additional investigation, control and prevention measures to limit the spread of the disease .

Case investigation for elimination phase in the north What is it? Every case in a low incidence area is reported and investigated immediately (and also included in the weekly/monthly reporting system). Cases are graphed daily or weekly to identify trends that require attention and are mapped by village to identify clusters of cases. The purpose of case investigation: The purpose is to identify the persons with malaria, the extent of malaria around the case (who else is affected) and probable sources of infection (local or imported from another province/country). To identify and institute measures to interrupt further transmission.

Case Investigation form and details The form: see word file Who will fill in the form: Malaria health staff (either from health center or district level) and in future surveillance teams at district level. What is the timeline for completion : Within a week of case being reported from a previously low incidence area it will be investigated How will it be transmitted: Immediately after investigation, the information will be conveyed to the next higher level by telephone and physically submitted within 48 hours. Who will check it: Malaria staff at the next higher level

Classification and use of Data Who will classify the case: Same level based on clear criteria and information collected through the investigation. Who will use the data for what: At the same level to classify case, identify potential focus and institute immediate response measures. At the higher level to plan more detailed investigations if necessary, confirm classification of the cases and institute necessary response measures.

Use of different laboratory methods in the elimination provinces Level RDT Microscopy Village √ Health center √ (if microscope and microscopist available) District Province Microscopy We will refine SOPs after returning to Laos Slides will be collected from the field and examined at the nearest laboratory. Upon microscopy confirmation, the appropriate treatment by DOT will be provided to those found to be positive. Negative RDT results will be double-checked by microscopy on a sample basis Discrepancies will be handled by reference to clearly developed SOPs and institution of quality assurance measures

Types of Foci

Assessment of human resources needs Levels Positions required Positions in place Gaps to be filled Total gap for Lao PDR Provincial level: Coordinator of PAM Epidemiologist Lab technician IT Entomologist logistic 1 3 2 District level: Malaria management Lab Technician Logistics Manager To be estimated separately for elimination and control areas after further analysis at CMPE. Health center level: Monitoring Officer Village level: VHV/VHW

- Yes, for e.g. Coordinator PAM, IT, Logistics, etc Need for new people: - Yes, for e.g. Coordinator PAM, IT, Logistics, etc Challenges to recruit these positions: Government policies and procedures Limited availability of skilled HR at provincial and district level Competition from private sector and NGOs for skilled HR How to recruit: Approach concerned authorities within Government to allow MOH for special recruitment for Saravane province Undertake temporary recruitment of contract staff with donor support- clear handover arrangements to GOV staff to be written in to the MOU with donor.

How will training and supervision be done Training needs analysis will be undertaken Curricular committee to be set up Curricular committee to design/redesign training curricula, training plans and training materials Training of trainers will be undertaken for CMPE and provincial trainers with WHO and other partner support Training courses and on the job training will be conducted in a cascade manner [ including at community level} Supervision guidelines and checklists will be updated by CMPE staff with provincial representatives and implementing partners Supervision guidelines and checklists will be included into the ongoing training courses Quarterly Supervision plans will be developed at all levels and implemented. Supervision visit reports will be followed up to track changes in programme implementation and correlated with other data at monthly and quarterly review meetings.

Need for HR once elimination has been achieved Many of the staff will be needed when the province enters into elimination phase since surveillance will need to be further strengthened at that stage. A fresh HR needs analysis will be undertaken at that stage and staff redeployed or assigned revised tasks as per requirement. Once elimination is achieved, malaria specific staff will be redeployed for other vector borne and parasitic disease control and also to prevent re-introduction.

Revised essential job descriptions for surveillance workers Detailed TORs will be developed for Surveillance Staff at different levels incorporating the following key tasks. Verification, quality review and compilation of data collected through passive case detection from public health facilities, PPM outlets and communities Organising and implementing Active Case Detection in high risk areas (hotspots) and population groups (hot pops) Monitoring of ecological and social determinants incl MMPs and development projects Organising Rapid response during outbreaks and following ACD Case and foci investigations in elimination areas Coordinating with other malaria staff in use of data for decision making Report and provide feedback at all levels

Proposed Indicators in Selected Province in Malaria Elimination Phase Name of selected Province: HUAPHAN PROVINCE Total population: 35872 Population at Risk of Malaria: 35872 Annual Parasite Incidence (2014): 0.02 # Selected Indicator name Definition (numerator/denominator) 2014 data Remarks 1. ABER N= total test done during the year( RDT+Micro+Both) D= Total Pop ( at risk) of the province (mid-year estimate) 0.13 Will decline over time in elimination areas 2. % expected monthly reports received from health facilities and laboratories N= Total # of expected monthly reports received from health facilities and laboratories D= Total # of health facilities and Laboratories 96.3% Emphasis will be on receipt of timely and complete reports

Proposed Indicators in Selected Province in Malaria Elimination Phase (contd.) # Selected Indicator name Definition (numerator/ denominator) 2014 data Remarks 3. % of confirmed cases fully investigated N= Total # of fully investigated confirmed cases D= Total # of confirmed cases 0% To be monitored only in the elimination provinces. Full investigation includes case investigation form, focus investigation form and active case detection. 4. % of foci fully investigated and registered (on register, with maps of each focus) N= Total # of foci fully investigated and registered D= Total # of foci identified and reported Full investigation of a focus includes focus investigation form, entomological investigation form and active case detection.

Electronic (IT) based data management Upgrade Malaria Information System The MOH is introducing a national health information system (DHIS2) This will have a module for malaria data In the meantime CMPE will recruit a short-term technical advisor to upgrade the current MIS taking into account the revisions to the M&E plan and to develop an integrated database covering all aspects of the national malaria control/elimination effort, both technical (e.g. drug resistance, bednets, entomology and insecticide resistance etc.) and administrative (e.g. HR [including volunteers], PSM, infrastructure etc.). Mapping will be incorporated to allow detailed spatial analysis of all relevant aspects of the program and to thereby improve targeting. The system will be designed to produce a quarterly bulletin that summarizes the epidemiological situation and highlights important trends. Data collection forms will be simplified and data collection, analysis and interpretation will be strengthened and supported through on-the-job training and supportive supervision. The program will ensure adequate supply of reporting forms (or access to computers/printers/copiers for printing).

Electronic (IT) based data management (contd.) Introduce 'mHealth' for surveillance. mHealth will be rolled-out to enable real time reporting by health staff and volunteers. Staff and volunteers will be provided with smart phones as required. This will be integrated into the mHealth initiative for supply chain management. Elimination specific data entry formats will be introduced in areas targeted for elimination. Data collection will be expanded to include results of case investigations, DOT and weekly follow-up to ensure clinical cure. (collection, analysis, validation, use, feedback at all levels)

Field monitoring and Supportive Supervision Strengthen routine supervision and programmatic M&E Conduct routine programmatic monitoring and supportive supervision at all levels. Detailed SOPs, updated checklists and discussion topics will be provided to supervisors to ensure that all activities are thoroughly assessed at every level. Emphasis will be placed on problem solving. Mechanisms will be developed to ensure that feedback is provided to supervisees at all levels and to ensure that follow-up occurs, and continues to occur until issues are resolved.

Improving the organization of supervisory visits Intervention: Malaria diagnosis by microscopy. Problems How to manage (solutions) Diagnosis Improve skills in identifying species Slide preparation Train in correct slide preparation including cleaning of slide before preparation and preservation. Poor staining Coach on following proper staining procedures Poor maintenance of microscopes Demonstrate how to clean and maintain microscope before and after.

Outline of an improved organization of supervisory visits for the intervention considered Where What and who to supervise Supervisory methods When: Frequency Who will conduct sup. visits Other interventions that could be supervised at the same time Community Not applicable Health center with microscopy Microscopy service of HC lab technician On the job supervision by hospital lab technician Once per month District hospital lab technician Check stock of slide, reagents, RDT and ACT. District level Microscopy service of district lab technician Province hospital lab technician Provincial level Microscopy service of province lab technician On the job supervision by central lab technician Once in three months CMPE lab technician Central Level Internal QA of microscopy External QA Once in two years WHO hired expert National slide bank

Communication of results Outcome 1: Enlist support of provincial governor for launching LLIN mass distribution campaigns Message Audience Media Timing Resources LLINs if used regularly and correctly can bring down malaria significantly in our province. Provincial governor PowerPoint presentation to the Governor with charts showing malaria declines in provinces with good LLIN coverage One-to-one meeting arranged at least 2 months prior to campaign launch date Money- not required HR- need ministry senior officials to support and attend the meeting

Communication of results (contd.) Outcome 2: Enlist support of director of province health department to improve quality of malaria microscopy Message Audience Media Timing Resources Malaria microscopy is the gold standard for malaria diagnosis for malaria elimination and this is currently poor in province X Health department of province X Supervision report and slide cross check result for province X Debriefing at the end of supervision visit Participation of province health director, chief of provincial malaria station and microscopists.

Evaluation of SME System performance Baseline SME System assessment has been commissioned by ERAR and carried out by MC in collaboration with DCDC and CMPE. The baseline assessment findings will be disseminated in a workshop in early Nov 2015 and an action plan to address weaknesses will be finalized. This action plan will be nested within the National M&E Plan for 2016-20 to be finalized by Dec. 2015. Mid-term SME System assessment will be incorporated into the National Malaria Programme Review to be carried out in 2017. An end of term SME System assessment will be incorporated into the National Malaria Programme Review to be carried out in 2020.

Reporting Type of Reports Contents of reports Recipients/audience Comments Immediate Malaria cases and deaths Malaria commodities Case and focus investigations Surveillance and response staff Logistics staff Real-time reporting will be introduced in a phased manner in order to provide prompt response. Monthly Summary of case and focus investigations Programme, surveillance and response staff Standardised reports will be generated and disseminated both upwards and downwards in the system.

Reporting (contd.) Type of Reports Contents of reports Recipients/audience Comments Semi-annual Performance against selected key indicators Overall performance, challenges and plans for following periods. Ministry of Health Donors Implementers Semi-annual malaria bulletins and standardised reports will be generated and disseminated both upwards and downwards in the system in addition to being submitted to donors (for e.g. GF, ADB) and MOH. Annual As above Ad-hoc/ special For e.g. outbreak reports, focus response reports, special reports to Government, UN agencies, etc. Ministry of Health and stakeholders making special requests Reports will be prepared and submitted as required from time to time.

Establish a National Independent Malaria Elimination Monitoring Committee An external Quality Assurance Committee will be constituted comprising of the following members and tasked with providing external quality assurance for implementation of the NSP. National level epidemiologists Former malaria programme managers Retired WHO experts Others nominated by government and development partners

Updating legislation, as part of enabling environment CMPE will advocate and coordinate efforts for enacting and updating facilitative legislations: Mandatory notification initially in elimination provinces and later extended to entire country ; Compulsory parasite based diagnosis; Private sector participation; Appropriate treatment and follow up of confirmed cases; Access to quality anti malarial medicines(ban on monotherapy and counterfeit/substandard antimalarials)

Involvement of private sector Expansion and improvement of the existing PPM initiative. The network of licensed private sector providers will be expanded to cover all six southern provinces. Abetter enforcement by FDD on the accreditation scheme (used for continuing issuance of licenses) under the GPP (good pharmaceutical practice). SOPs for PPM have already been designed, but need to be revised and implemented better. PPM facilities will be provided with free RDTs and ACTs and in return will have to ensure all suspected cases are confirmed, notified, investigated and appropriately managed and provide reports on cases diagnosed and treated to the malaria programme. Training and support for referrals will be prioritised. Engagement of the corporate sector The program will engage the corporate sector and encourage corporate support/sponsorship for malaria control/elimination efforts (including World Malaria Day activities).

Khop jai lai lai! Thank you very much!