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

2. 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

3. NSP Goals
Phase 1 ( ):
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 ( ):
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 ( ):
The phase 3 goal of the NSPMCE is to eliminate all forms of malaria by 2030 in the entire country.

4. 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.

5. 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.

6. 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

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

12. 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

13. Strengthening of relevant SME areas
The aim of the national malaria program during 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 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.

14. 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.

15. 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.

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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 .

23. 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.

24. 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

25. 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.

26. 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

27. Types of Foci

28. 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

29. - 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.

30. 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.

31. 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.

32. 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

33. 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

34. 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.

35. 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).

36. 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)

37. 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.

38. 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.

39. 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

40. 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

41. 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.

42. 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 to be finalized by Dec
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.

43. 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.

44. 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.

45. 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

46. 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)

47. 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).

48. Khop jai lai lai! Thank you very much!