1. Plan to strengthen the existing SME system for malaria elimination in Mon State Myanmar

2. 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.

4. 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.

5. Strength & weakness of program StrengthWeakness Political commitment- 9 th 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

6. 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

7. 2014201520162017201820192020 MonVillages 1195 Population (,000)2050207020912112213321552176 3 priorities for period 2015-20PAR (,000)1263127612891302131513281341 1. Preparation period 2016 including verification of data reported API (local)/1000 PAR1.501.5110.9 #local cases reported1889191412891302118311951207 2. Reorientation in 2016% of cases reported95%97%98%100% # surveillance staff (Gov)37 50 3. Strengthening surveillance system #surveillance staff (Volunteers)1125 1200 and HRPhase (Con/Elim/Prev)CCCCEE

8. 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.

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

10. 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

11. 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

12. 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 developed Guidelines for Quality Assurance and Quality Control of Malaria Microscopy in Myanmar (English) – to be revised inline with Elimination

13. 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

14. 4. Human resources Planning

15. Township RO & TL (Med. Dr.) MA/MIMS/PS Ento staff AE, EA, IC Lab Tech Grade 1 # of VMWs Total confirmed malaria cases (2014) Average Cases/ month State VBDC 23532 204 17 Bilin 3 102242 Chaungzon 4 4513011 Kyaikmaraw 3 102343 Kyaikto 13 9228824 Mawlamyine 1 42222 Mudon 14 7825922 Paung 3 6714412 Thanbyuzayat 13 7624721 Thaton 15 12814512 Ye 3 9539233 Total 37 827 1889 Existing Human Resources & Malaria Positive Case load, Township wise, Mon State

16. ActivityAgentExisting situationPlanTime- 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. 2017State PH Director, RO Hospi- tal staffs All CSM cases will be tested by RDT or microscopy. Assigned 1-2 staffs to test CSM cases 2016Med. Superinten dent, TMO,SMO ACD agent MS/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.

17. ActivityAgentExisting situation &PlanTimelineBy 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/orienta tion on elimination. 2016-2017State 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) 2016VBDC + WHO + Trainees (GMS eliminati on)

18. ActivityExisting situationPlanTime- 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 staffs Training of new additional staffs 2016- 2017 DG, PM- NMCP Retaining staffsWith 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 DMS Training of data assistant on IT based DMS (for data entry) 2016DG, PM - NMCP

19. ActivityExisting situationPlanTime- 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

20. 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

21. 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)

22. 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

23. 7. Field monitoring and supervision To which LevelBy which level & by whom? What to monitor?How frequentWhen to start? Field levelTownship level, HA, MA/MI Patient 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 levelTPHO, THO, THAAbove + case investigation records, Foci records Quarterly2017 Township levelState 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

24. 7. Field monitoring and supervision To which LevelBy which level & by whom? What to monitor?How frequentWhen to start? State levelCentral 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 levelIndependent task force on Malaria Elimination Every 2 months

25. 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.

26. 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)

27. 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.

28. 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.

29. 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.

30. 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.

31. 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)

32. 11. Updating legislation, as part of enabling environment ItemsPurposeWhat 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 2018 HR policyTo 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

33. 12.Improve Private Sector ItemsPurposeTo whomBy whomWhen 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, DOMC NMCP Myanmar Medical Council After approval of mandatory notification of confirmed malaria cases (2018)

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