malaria elimination concepts, strategic direction

Mkude.S (MD); NMCP/MoHSW

Malaria Elimination Concepts, Strategic direction (2008-

2010), Steps, Activities, Requirements

Feedback on New Global “Malaria elimination” Initiative to NMCP

12th November 2007Morogoro


Contents of Presentation• Introduction• The concept: towards malaria elimination• Strategic direction (2008-2010)• Steps & activities (Global level)• “Resource moderators”• Requirements for initiation of the processSub regional responsibility Countries initiation processWHO country office responsibilities & support to

be given


Introduction


The Anatomy of Global Malaria initiative

WHO DG

WHO RBM

Partners

(Resource contributors)

WHO GMP

Technical Board

Regional WHO

WHO/AFRO

Country WHO Offices

HWG

(Resource Moderators)

HWG Nairobi Meeting 22nd-23rd October 2007

GMP Nairobi Meeting

24th- 26th October 2007

Nairobi 2 in 1 Meeting


Introduction (1)• There is a Global movement which has created

new “Malaria Elimination” initiative• The initiative is going to be in full scale within 6

months • It advocate rapid scaling of intervention to achieve

RBM targets of universal coverage of 80% by 2010 (Intensive 36 months)

• What is immediately required by donors community is to know the individual country needs (Needs Assessment)

• Thereafter a business plan before February 2008• The country Needs Assessment (NA) & Business

Plan (BP) must be in line with (our) MMTSP


Introduction 2

• The RBM Harmonization Working Group (HWG) will fill the gap of required resources

• WHO will be the focal partner at country level• There was a 2 in 1 meeting (WHO GMP & RBM

HWG) in Nairobi to initiate the process of country NA & BP

• The meeting was attended by NMCP’s PMs and their WHO Malaria NPO from selected 15 African

countries Representation from all WHO regional offices world wide WHO HQ RBM HWG members


Introduction 3

• There was a request from participating countries for an official communication to Government Ministries of Health.

• In principal we are “nominated” but we have to fulfil the requirements:Initiate prescribed process in a tight

framework of timelinesCentre to all is the re-orientation of Country

Malaria STP


The concept: towards malaria elimination


The aims of the “new initiative” global fight against malaria

1. reduce the burden of malaria in endemic areas (rapid scaling up to 80% by 2010)

2. reduce the geographical extent of endemic areas (rapid scaling up to 80% by 2010)

3. Support elimination where feasible


From malaria control to elimination


II Attack 4 years

III Consolidation3 years IV Maintenance

The Origin of the idea: Traditionally 4 phases in malaria eradication

WHO certification

annual reporting to WHO

3 years free of local transmission

I Preparatory 1 year Intense malaria

end of population-based

interventions

information collected, plan developed, systems ready, trained staff and

resources in place


Eligibility to “Malaria Elimination”

• Cut of point of slide positivity rate <5% in fever cases as a criterion for initiation of elimination process

• The minimum area is a district of about 100,000 population


Definitions

Malaria control: reducing disease burden to a level where it is no longer a public health problem

Malaria Elimination: interruption of local mosquito-borne malaria transmission in a defined geographical area. Means zero incidence of locally contracted cases , imported cases will continue to occur. Continued intervention measures are required

Eradication: permanent reduction to zero of the worldwide incidence of infection caused by a specific agent – i.e. Extermination of the infectious agent


Malaria elimination: a WHO Field Manual

Target audience: endemic country governments, programme managers, staff from partner agencies

Purpose: provide the overall picture, point to more detailed information

Current format: 96 pages total


GMP malaria elimination field manual

Clarity on malaria elimination concepts (for moderate-to-high transmission countries that consider moving towards elimination)

Clarity on WHO policies, procedures and reporting requirements (for countries that are near malaria elimination or have recently achieved it)


Strategic direction (2008-2010)



1. Develop scientific consensus on control strategy and business plan

2. Intensified implementation of national malaria programmes

3. Effective advocacy / resource mobilization


Recommended (proven intervention) Malaria control package (1)

• Diagnosis-based treatmentDiagnostic useTreatment use

• Prevention (LLITN + IRS)Transmission control with ITNsTransmission control with IRS

• Monitoring and evaluation Performance monitoring and impact evaluation

• Insurance (protect effectiveness of current tools)• Operational research


Malaria control package(2)

• "Documentable" effective case management systems

National – District – Health facility, Community, Private Sector

• Prevention LLITN for community prevention, 80% coverage of

total population at risk IRS for community prevention as a supplement to

LLITN, for epidemic preparedness, etc.


2. Intensified implementation

• Effective treatment and prevention coverage increased to 80% in 54 countries

• Elimination / certification in 25 countries• More gradual scale up in 28 countries


Intensified implementation• 57 Programmes*: support led by WHO

– Endemic (10 in Africa; 22 in other regions)– elimination / certification: 25

• 22 Programmes* in Africa: support coordinated by RBM harmonization working group (which includes WHO)

• 28 Programmes*: scaling up gradually, supported by WHO & other interested partners

• Coordination with International Health Partnership on health systems strengthening (Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal, Zambia)

* Proposed


Proposed countries• Group A: Scaling up Malaria control to 80% (2008-2010)

– Africa: Angola, Benin, Burundi, Burkina Faso, Cameroon, CAR, Chad, Congo, DRC, Equatorial Guinea, Eritrea, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Sao Tome & Principe Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Uganda, Zambia, Zimbabwe

– Latin America: Brazil, Colombia, Guatemala, Honduras, Nicaragua, Peru, Venezuela

– Asia & Middle East: Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, Laos, Myanmar, Papua New Guinea, Philippines, Thailand, Solomon Islands, Vanuatu, Vietnam, Yemen

• Group B: Pre-elimination to elimination phase (2008-2010)– Algeria, Argentina, Azerbaijan, DPRK, El Salvador, Georgia, Iran, Iraq,

Krygsztan, Malaysia, Mexico, Paraguay, Tajikistan, Turkey, Turkmenistan, Russia, Sri Lanka, Saudi Arabia, Swaziland

• Group C: Certified Malaria Free (2008-2010)– Mauritius, Morocco, Oman, Armenia, Syria,

• Group D: Gradual scale-up in remaining 28 countries


3. Resource mobilization• Ensure investments and resource flows

– More resources and effective, innovative implementation of investments: GF

– More investments: PMI, WB, UNITAID, new bilaterals, new international NGOs

– Increasing National investments• Resources mobilization – USD 6 billion (2008 -2010)

– National programmes & commodities – 85 %– TA and Operational research – 15 %

• Advocacy– In-country efforts– Individual (Ray Chambers) and institutional (WHO, WB, PMI, UNICEF,

etc.) initiatives– UN Special envoy– Media campaigns (in-country and international)


Phase 1(Strategic Direction): 6 months (Sep 07 – Feb 08)

• Development of the plan• Consensus building • Endorsement and launch of the plan


Steps & Activities(Global level)


Global Key activities in Phase 1(strategic direction-Plans on proven interventions):

6 months (Sep 07 – Feb 08)• Gates Malaria Forum- Seattle, 16-18 October

– Presentation of strategic direction by DG– Endorsement of strategy by key stakeholders (Tanzania attended

with 4 other African countries)• Operational plans

– Workshop to develop country plans - WHO supported national programmes, Nairobi, Kenya- October 22-26, 2007 (Tanzania attended)

– Workshop to develop country plans: (?? deadline for in country process end of January 2008) – facilitated by RBM harmonization working group

• Launch of the Business plan - High level forum, February 2008.– Endorsement of plan by Heads of State (US, UK, Canada, etc);

endemic countries; and H8 group (WHO, World Bank, UNICEF, Gates Foundation, GFATM, GAVI, UNITAID, and UNFPA)

– Launch of Intensified implementation towards a “malaria free world”


Global Key activities in Phase 2: (strategic direction-Intensified implementation)

12 months (Mar 08 – Feb 09)• Intensified implementation

– Roll-out of WHO's new case management cum disease surveillance strategy

– Substantial strengthening of national malaria programme management (structure, logistics, etc)

– Roll-out of WHO new country monitoring and evaluation system– Roll-out of WHO new ITN and IRS strategy

• Establish commodity needs forecasting system (ACT & LLIN)– Negotiations with manufacturers– Establish ACT raw material buffer stock system– Expansion of LLIN production capacity

• Documentation and Report Card1. WHO Global Malaria Report (World Malaria Day in 2008)2. Monthly information system (tracking commodity & progress) 3. Biannual performance report on GMP website4. Analysis: impact, cost-effectiveness, success stories


Global Key activities in Phase 2: (strategic direction-Advocacy)

12 months (Mar 08 – Feb 09)

• Media Awareness campaign with regular events • Clearer policy/position on other

interventions/tools (IPTp, IPTi, IVM, vaccine, etc)

• Global consensus on priority research agenda• Consensus-based new estimates of Global

Malaria Burden• Development of Plan Mar 2009 – Dec 2010• Development of Plan for a "Malaria Free World"

2010 - 2015


“Resource Harmonization”


RBM Harmonization Working Group (HWG)

• Major financial and implementation support partners

• Constituency Membership is decided by RBM Board

• Membership includes: WHO (AFRO and HQ), UNICEF, World Bank, Global Fund, MACEPA, Bill and Melinda Gates Foundation, Malaria No More, UN Foundation, Johns Hopkins VOICES Project, Millennium Project, UNF, PSI

• All RBM sub-regional networks and RBM Working Group Chairs


Scaling-up for impact:

• The Board has endorsed a new rallying cry at the core of Roll Back Malaria:

• “Scale Up”– Existing full package of proven interventions

• Nation-wide to high coverage– Rapidly

• “For Impact” – Track action and document changes in coverage and

benefits in human and economic terms– Moving from high coverage towards elimination as

a public health problem and eventually eradication


RBM Harmonization Working Group (HWG)

1. Coordinate a process to support the development of and adherence to the “3-ones” concept at country level

2. Assist countries to identify support needs for scaling-up through comprehensive gap analyses and needs assessment

3. Track and Facilitate resource flows from partners to countries

4. Harmonize partner efforts to fill country-identified gaps5. Facilitate the development of a “rapid-response”

mechanism to support countries to overcome implementation bottlenecks (reactively and proactively)

6. Secure additional resources from the Global Fund, PMI, World Bank and others in support of country scale-up


But, 1st……Needs Assessments

• Support >30 national programs to develop malaria needs assessments and business plans over the next 4-6 months that will result in achievement of 2010 RBM Goals (>80% coverage)

• Plans will result in an improved understanding of country support needs (financial and technical/implementation support) and the resources and strategies required to fill them.

• Present plans to a series of high-level donor meetings, as well as to individual partners, for immediate support


Process for Needs Assessments

• Develop common template for needs assessment and plan

• Countries lead needs assessment and business plan development

• Each country will be paired with one lead partner and additional supporting partners

• Each country will be offered consultant support to assist in writing/documentation of assessment and plan

• RBM will aggregate assessments and plans, and assist in the development of regional/cross-border investments/actions


SudanSudan

MaliMali

ChadChad

NigerNiger

Congo, DRCCongo, DRC

AngolaAngola

EthiopiaEthiopiaNigeriaNigeria

NamibiaNamibia

TanzaniaTanzania

MauritaniaMauritania

ZambiaZambia

KenyaKenya

BotswanaBotswana

GuineaGuinea

MozambiqueMozambique

MadagascarMadagascar

CongoCongo

ZimbabweZimbabwe

Ghana

UgandaUganda

Cote d'Ivoire

SenegalSenegal

Burkina Faso

Benin

Eritrea

MalawiMalawi

LiberiaLiberia

TogoSierra LeoneSierra Leone

BurundiBurundi

RwandaRwanda

DjiboutiDjibouti

SwazilandSwaziland

The GambiaThe Gambia

Cameroun

Eq Guinea

Gabon

Central African Rep

South AfricaLesotho

Somolia

Comprehensive Needs Assessments

August-December

Not targeted

October-February

January - March

Timeframe


Process for Needs Assessments & Business plan

Needs Assessments:• Workshop (Nairobi), October 22nd -23rd , 2007 with initial 15

countries to be hosted by WHO • Template to be developed by MACEPA and revised by wider

partnership• Consultants will be contracted to carry out the data collection

and actual writing/filling-in of the template to ensure consistency

Business Plans:• Template to be developed by MACEPA • Process for country level development to be managed by RBM

HWG Task Force members with in-country presence, namely WHO, UNICEF, MACEPA, US PMI, and the World Bank, under the auspices of the RBM sub-regional networks.


Requirements(Sub regional & Countries)


Requirement (1): Sub regional


1st Nairobi workshop, October 22, 2007 with initial 15 countries

• Adaptation of proposed initiation process to individual countries – Identification of key milestones in country – (Selection and) timing of consultants– Discussion on mechanism of in-country

initiation of the processes (Need Assessment) (workshops/retreats)

– Financial requirements


Sub region requirements

• HWG develop a template for business plan by end November

• 2nd workshop for countries on business plan template (early February 2008?).

• translation of needs assessment to business plan through in-country planning

• Finalization (March)


Sub region to facilitate

• Global level synthesis (March)• High level donor/partner consultation

(march) to mobilize necessary resources to meet identified needs:– financial– technical– implementation support


INITIATION FOR RAPID SCALING OF MALARIA

INTERVENTIONS IN TANZANIAStepping in “Malaria Elimination”

Initiative


Contents

• Where are we in line with what is required?

• Key milestones (events) in the initiation process

• Resources to support Focal Partner (WHO Country Office)

• Some future implementation issues to be considered


Where are we in line with what is required?

Requirement 1: In each individual country Malaria Medium Term Strategic Plan (MMTSP) will be the reference document to the “Malaria

Elimination” initiative• The current 2002-2007 Malaria MTSP is in its last

days. • In the development process of the new MMTSP

(2008-12) we are aware that: The context of malaria prevention and control has changed and a much more aggressive approach is needed



• At present the consensus on the framework of our new MMTSP (2008-2012) has been much influenced by GFR7 application, it is a right direction: Concept partNeeds assessment/Gap analysisOperational plan/Business plan (1 year roll out

plan? Fixed .e.g. 3 yrs plan? .e.t.c.)



• In the meantime available needs assessment/Gap Analysis (NA/GA) have been calculated through different recent requested proposal (GF R7, IRS Master Plan, ITN “Sacchs”) based on the new strategies identified in the draft of 2008-12 MMTSP

• Through different above proposals we have in place the patchy frame works for MMTSP Needs Assessment/Gap Analysis which will contribute to our MTSP Operational/business plan

• The MMTSP (2008-2012) draft still needs developed/adoptation NA/GA from different recent proposal to contribute to operational/business plan (a resource moderation component of MMTSP)


Where are we in line with what is required?• Mid of November 2008 there is an already planned

NMCP workshop to finalize the draft of the MMTSP/dissemination

• In principle, we have to review our Goals, Objectives & Targets in the concept part in the new MMTSP to address the high universal coverage (80% or above) concept to every intervention (SUFI).

• The timing for the country initiation process of new “Malaria Elimination” with regard to MMTSP is perfect

• Finalization of our MMTSP in November 2008 is now a must! It will in time(!) merge issues from the new Malaria Elimination initiative required to be reflected in MMTSP



Requirement 2: In each individual country WHO country office is

proposed to be focal partner among country partners

• In Tanzania is a known fact among Development Partners Group in SWAP: WHO is the lead partners for health


Requirement 3: Initiation & process for Needs Assessment

– Identification of preparatory ground key milestones (Events) for Needs Assessment

– Selection/confirmation of local/ international consultant

– Implementation framework for Needs Assessment

– Financial requirements


Identification of preparatory ground key milestones (Events) for Needs Assessment

Activity Timelines Budget

Review and finalization Mid Term Strategic Plan 2008-2012

2nd week of November 2007

Funds available

Dissemination of MTSP to stakeholders/partners/Regional & Districts representative

3rd-4th week of November 2007

$ 50,000

Orientation of MTSP with submitted GMP/HWG business plan frame work to 21 RHMTs and 130 CHMTs

May 2008 $ 200,000


Implementation Framework for Needs Assessments

(Selection of consultants for Needs Assessment)

Activity Timelines Budget

International consultant

1st week of December 2007

WHO/RBM

Local consultant

1st week of December 2007

NMCP/MoH


Activity Timelines Budget Timing of consultants•International consultant

2nd- 4th week January 2008

(WHO/RBM to cost for international consultant)

Local consultant 2nd- 4th week January 2008

$ 9,000

Arrival of international consultant

6th Jan 2008

Consultants meet with NMCP/Desk Review/Field visit

7th-13th January 2008

Field visit of task force and consultants

8th – 13th January 2008

$25,000

Implementation Framework for Needs Assessments


Implementation framework for Needs Assessments Activity Timelines Budget Summarizing field and desk review

13th – 14th January 2008

Retreat 14-19th week January 2008

$ 10,000

Prepare final draft NA 20th-21st January 2008

Feedback of the 1st draft to NMCP and incorporation of comments

22nd-23rd January 2008 $ 3,000

Partners dissemination and incorporation of any comments etc

24th January 2008 $ 20,000

Consultants leave 26th January 2008


Resources to support WHO country office

1) to support country initiation process, needs assessment & Business plan

2) To support scaling up of interventions


RESOURCES FOR NEEDS ASSESMENT FOR WHO - estimates

Milestone1: • Consensus building and briefing on rapid scaling-up at country level

(Government and partners) and support available from HWG• Mobilise partners to contribute to process at country level (HWG to

debrief partner HQ)Resource requirements $ 5 000 Nov (WHO costs) for 8 countries

(Approximate :: $625 available for Tanzania in November)

Milestone 2:Secretariat /Task Force for coordination until Business Plan completed

(country specific depending on country co-ordination mechanism) 6 months

Task force to –pre-review tool

Resource requirement: $5 000 (WHO costs) for 8 countries(Approximate :: $625 available for Tanzania for 6 months)


RESOURCES FOR NEEDS ASSESMENT FOR WHO - estimates

Milestone 3: Comprehensive needs assessment Methodology – desk review + data collection & analysis / 4 * stakeholder meetings (includes districts / regional / provincial meetings) / field visits / Interviews / retreat Logistics - $30 000 – $50 000 TA costs - $20 000 (exclusive of 25,000 allocated for NMCP Field visit of task force and consultants)

Milestone 4: Dissemination meetingTA costs - $10 000(exclusive of 25,000 allocated for NMCP Partners dissemination and incorporation of any comments etc)

)


RESOURCES FOR SUPPORT TO SCALE-UP FOR WHO - estimates

2008 2009 2010

HR (for 8 ESMC)See detail next slide

$760 000 – $7,990,000

$760 000 – $7,990,000

$760 000 – $7,990,000

Office Operating costs (includes training and travel, transport, stationery etc)

$ 300 000 $200 000 $200 000

TA $200 000 $200 000 $200 000

M&E $500 000 $400 000 $500 000

Advocacy $100 000 $100 000 $100 000


WHO country office /NMCP strengthening issues(thru WHO funding channel)

• Technical assistance Human Resource: i. Mainland: M&E, logistician, Program

assistant, IPO (partnership), NPO (existing), 8 zonal officers, 1 NPO (lab).

ii. Zanzibar: - IPO+ NPO, 2 Program assistantNeeded approx $1 300 000 annually

Communication (fast internet services) Short course training on Program

management (managerial skills) to Program officers;


Some future implementation issues to be considered

(Raised by NMCP Program Manager during feed back)


Some implementation considerations (1)

• Service areas on Technical Strategies no big deal• Diagnosis-based treatment

Diagnostic useTreatment use

• Prevention (LLITN + IRS)Transmission control with ITNsTransmission control with IRS

• Monitoring and evaluation Performance monitoring and impact evaluation

• Insurance (protect effectiveness of current tools)Efficacy testing

• Operational research



But probably revisit our capacities on:• Program management (Organization,

administration, financial management & reporting)

• District (Region?) & community involvement (review service delivery arrangement at district level towards the community ie Community Malaria intervention package)

• Partnership engagement (including summarization of various partner contribution, both financial &human resources as well as reporting needs



• Given the expected very rapid scale up of activities, resource available & recommended Malaria control package .

i. Coordination (inside NMCP)?a. Critical analysis of strength & weaknesses of NMCP for

the expected activities ii. Revisit Home Malaria Management (HMM) approach?a. Prepare community ant malaria based package(RDTs,

peripheral rectal artesunate, paracetamol, case reporting data)

b. Should we explore further the issue of (C/VHW) with other programs (Structural/functions/coverage) and have at least 2 C/V-HWs per village as 1° implementers of HMM (Approx 20,000 C/V-HWs country wide)



iii. Coordination (outside NMCP)?a. Should we explore further the potential roles of

“Regional Malaria Focal Person” (RMIFP)? Train them with CMIFP like package?

b. Should we find the way to facilitate the RMIFP to easily access the districts? (4-wheel car?, fuel?)

c. NGOs network to facilitate CHMTs (CMIFP) coordination of C/V-HWs ? Through peripheral HFs? etc etc


Rapid scaling up to 80%! 2008-10! Within 36 months!What are the implications?

I hope we are clear on the burden of activities!

Thank you for listening

malaria elimination concepts, strategic direction

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