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PAKISTAN MALARIA

PROGRAMME REVIEW

(MPR)

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Contents

Executive summary ......................................................................................................................... 4

1. Introduction ............................................................................................................................... 17

1.1 Background ...................................................................................................................... 17

1.2 Objectives of the MPR ........................................................................................................ 17

1.3 Methodology of the MPR ................................................................................................... 18

1.4 Outline of the document...................................................... Error! Bookmark not defined.

2. Context of malaria control ........................................................................................................ 20

2.1 Historical milestones in malaria control .............................. Error! Bookmark not defined.

2.2 Malaria control within the national development agenda .... Error! Bookmark not defined.

2.3 National health policy .......................................................... Error! Bookmark not defined.

2.4 National health sector strategic plan .................................... Error! Bookmark not defined.

2.5National development plan ................................................... Error! Bookmark not defined.

2.6 Organizational structure for malaria control ....................................................................... 25

2.7 Key strategies for malaria control ....................................................................................... 26

2.8 Key players in malaria control ............................................................................................ 27

2.9 Linkages and coordination .................................................................................................. 28

2.10 Conclusions and Recommendations ................................................................................. 28

3. Epidemiology of malaria ........................................................................................................... 28

3.1 Geographical distribution of malaria ................................... Error! Bookmark not defined.

3.2 Population at risk ................................................................. Error! Bookmark not defined.

3.3 Stratification and risk map ................................................... Error! Bookmark not defined.

3.4 Malaria parasites .................................................................. Error! Bookmark not defined.

3.5 Malaria vectors..................................................................... Error! Bookmark not defined.

3.6 Disease trends ...................................................................... Error! Bookmark not defined.

3.7 Conclusions and recommendations. .................................... Error! Bookmark not defined.

4. Programme performance by thematic areas ............................... Error! Bookmark not defined.

4.1 Programme management ..................................................... Error! Bookmark not defined.

4.2 Procurement and supply chain management ....................................................................... 91

4.3 Malaria vector control .......................................................... Error! Bookmark not defined.

4.4 Malaria diagnosis and case management .......................................................................... 213

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4. 5 Advocacy, BCC, IEC and social mobilization.................... Error! Bookmark not defined.

Error! Bookmark not defined.

4.7 Surveillance, Monitoring and Evaluation ......................................................................... 168

Conclusions .................................................................................... Error! Bookmark not defined.

Key recommendations ................................................................... Error! Bookmark not defined.

Annexes.......................................................................................... Error! Bookmark not defined.

Annex 1: Agenda for all the phases of the MPR ....................... Error! Bookmark not defined.

Annex 2: People involved in MPR ............................................ Error! Bookmark not defined.

References ...................................................................................... Error! Bookmark not defined.

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Executive summary

The specific objectives of the MPR were:

To review the epidemiological outlook of malaria disease in each province of Pakistan with particular reference to disease trends, Slide positivity rate, Species wise distribution, Blood exam rate BER,

Severe Malaria and Outcome of the managed cases at health facility with particular reference on

disease specific mortality.

To review the Malaria program structure, capacity and management in each province and at national level (DOMC), in view of its new roles after devolution and identify issues and challenges arising

post devolution.

To assess the current programme performance by intervention thematic areas and review progress, challenges and towards achievement of targets in each province and progress towards achieving

national and regional goals.

To identify way forward, priority needs and gaps for improving programme performance and coordination at provincial and federal level.

To define steps to improve programme performance and redefine the strategic direction and focus, including revision of policies and strategic plans at provincial levels which can help tapping the

available funds from various sources including the public sector and donors e.g. Global Fund from

R10 malaria grant phase II and from the new funding model.

To assess the effectiveness of Global Fund grants supported projects in highly endemic regions of the country and to suggest ways and means for quality assured interventions following the principals of

transparency, accountability and value for money.

To develop the post MDG strategic plan at provincial and national level for Pakistan for 2015-2020, based on the results of PRM, which will help mobilize resources based on new funding model.

Key Findings

Pakistan was one of the high endemic countries who launched Malaria eradication program in the 1960s,

with the support of WHO, UNICEF and USAID. As a result of this campaign there was marked reduction

in malaria cases from a reported 7 million cases in 1961 to 9,500 cases in 1967 with associated slide

positivity rate reduction from 15% to less than 0.01%. However there was a major resurgence and

epidemics in early 1970s even in urban areas such as Karachi with reported malaria cases rising to 10

million in 1974. Some of the reasons for the resurgence were the onset of vector resistance to

Organochlorines (DDT & Dieldrin/BHC), under estimation of A. stephensi in maintenance of urban

malaria, inadequate planning for malaria control within irrigation and water development projects

together with financial and administrative constraints, inadequate administration of programs, inadequate

research, training, and supplies of chemicals and drugs, inadequate health services infrastructure with

premature withdrawal of donor support. The Malaria Program switched from Eradication to Control

Program during 1975-1985 and implementation handed over to provincial government and district health

offices and malaria control program was integrated with general health services in 1985.

In 2003 as part of the global Roll Back Malaria Movement, Pakistan launched its Roll Back Malaria

program with support of government planning commission Roll Back Malaria plan 2008/2009-2012/2013

with support of GF Round 7 and Round 10 malaria grant. This started accelerated malaria control

activities in 38 priority high malaria transmission districts out of the 136 districts in the country.

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Today Pakistan has an estimated population of 173.5 million people, out of which, according to the 2012

national malaria disease surveillance annual report, 9% are living in high transmission districts (34) with

an annual parasitic index (API) ranging from 5 to 28, 20% are living in moderately endemic districts (41

districts) with API ranging from 1 to 5, and 71% living in low endemic districts with an API below

1/1000 population. The national API for the entire country is averaging 1.69, which classifies Pakistan as

a moderate malaria endemic country. Malaria mappings show clearly that the highly endemic districts are

located mainly in the provinces of Baluchistan, FATA, Sindh, and KPK. The lowest malaria incidence

was reported in two provinces Punjab and AJK with combined population of more than 56% of total

population of the country.

The primary malaria vectors are A.culicifacies and A.stephensi. A number of secondary vectors have

been reported and their contribution to malaria transmission is being investigated. The last nationwide

vector surveillance was in 2009 and a new one has been completed in 2013 and data is being analysed and

report under preparation

The primary malaria parasite is P. Vivax with P. falciparum being the secondary parasite. In 2012,

Annual Blood Examination Rate (ABER) varied between 1.78% in Punjab to 7.09% in Baluchistan. Out

of the 289,759 malaria cases confirmed positive in 2012, 249,504 were identified by microscopy (86.1

%), while 40,255(13.89%) by rapid diagnostic test. Majority of cases were considered as P.vivax (74.39

%) and 23.95 % as P.falciparum and 1.65 % as mixed infections. Highest P.falciparum malaria

proportion is reported in Baluchistan (44%) followed by Sindh (27%).

Malaria indicator survey of 2009 showed malaria prevalence rates in Baluchistan 6.2% (Pf 2.4% Pv 3.8%

), FATA 13.9% (Pf 0.6%:Pv13.3%),Khyber Pakhtunkhwa 3.8% (Pf0.9%:Pv2.9%) and Sind 0.7% (Pf

0.7%: Pv0.4%).

The provincial prevalence is consistent with the reported incidence from the malaria surveillance system.

The 2013 prevalence survey is being analysed and report should be available in early 2014.

The historical malaria trends in Pakistan from the malaria surveillance system between 1973 and 2012

shows clearly: 1)That the Annual parasitic index dropped drastically from 1973 ( API 13.18) to below

1/1000 in 1977 ( API 0.93) with a sharp decline in the slide positivity rate from 14% to 0.62% with

malaria eradication campaigns in less than 5 years; 2)A tremendous increase of positive cases was

observed between the years 2005-2009 with around 130.000 cases /year (malaria strategic plan) to almost

300.000 positive cases in 2012 ( National malaria disease surveillance report 2012)., The annual parasitic

incidence went up from 0.74 in 2009 to 1.46 in 2010 and 1.88 in 2011. Similar trends were observed in

low transmission areas of Punjab province which also suffered from the floods, the malaria cases went up

from 3,432 cases in 2009 to around 30,000 cases in 2010; 3) It is important to note during this long period

,that the blood examination rate ( indicator for malaria surveillance ) dropped from 9.36 in 1973 to 5.46 in

1980 and remains quasi stable around 2-3 / 1000 inhabitants between 1983 and 2013 , indicating a poor

case detection during almost 30 years.;4)Given the variety of ecotypes in the country (valleys with rivers

at various altitudes, agriculture-related malaria, peri-urban type, migrant malaria,) the epidemiology of

malaria varies considerably between provinces / districts and union councils. More detailed spatial

analysis with micro-stratification by districts is critical for malaria control/elimination monitoring.

Transmission of malaria in most parts of the country is highly seasonal and unstable with peaks of

transmission in the summer (June-Sept) for P.vivax and late-summer and winter months (August-

November) for falciparum malaria. Because P.vivax relapses, there is a peak of relapse episodes seen in

the early summer (April-June) resulting from transmission in the previous year.

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Malaria epidemics frequently occur in Pakistan which has a history of unstable transmission. Between

2010 and 2013, Disease Early Warning System (DEWS) reported maximum number of malaria alerts and

outbreaks from Baluchistan followed by Sindh, These alerts and outbreaks peaked in 2011 and 2012

which might be explained by the fact that during those years, both provinces had major emergency due to

floods and secondly during the same period almost every district had a DEWS surveillance officer in the

provinces thus detecting alerts and outbreaks was quite efficient. Predictably, 7 out of 15 districts

reporting the highest number of alerts and outbreaks during 2010-13 belonged to Baluchistan province

with highest numbers reported from Jaffarabad with 44 alerts and 32 outbreaks.

The new malaria information system launched in 2009 in 19 priority districts managed by the DOMC

shows an increase of API from 7.13 in 2009 to 10.13 in 2012 associated with increased malaria risk with

major flood emergency and increased access to RDT and Microscopy, followed by a decrease to 7.82 in

2012 following the control measures especially with increased access to Primaquine and ACT. It is noted

that in 2010, out of 122,350 positive slides, 20,051 were taken in IDP camps. Age distribution of cases

indicates the confinement of malaria to the age group above 15 years with only 17.82% of confirmed

cases among children below 5 years.

The District Health Information System (DHIS) data from primary/clinic-health centre health care

facilities suggests that proportion of suspected/clinical malaria cases presenting to OPD is highest in

Baluchistan with 8.9% and 8.6% of total OPD consultations followed by Sindh with 8.50% and 7.36%,

KPK with 3.7% and 2.3% and Punjab with 1.5% and 1.5% for 2011 and 2012 respectively.

Similar proportions can also observed in DHIS secondary/ hospital health care facilities data with 2.6%

and 5.54% malaria OPD consultations for Baluchistan followed by Sindh with 7.8 % and 5%, KPK with

3.1 % and 2.3% and Punjab 0.6% and 0.6% respectively in 2011 and 2012.

Punjab tested the highest proportion of suspected Malaria cases with 83% and 86% of total suspected malaria

cases followed by low testing rates In KPK with 28.4% and 36.3%, and Baluchistan with 19% and 23% and very

low testing rate in Sind with 18% and 18% respectively in 2011 and 2012.

In 2011 and 2012, Baluchistan had the highest proportion of malaria cases admitted in the primary health

care facilities where as in the secondary health care facilities, Sindh province had the highest proportion

of malaria admission during the same time period. Taking admissions as proxy indicator for severe

malaria, proportion of inpatient admissions in secondary hospitals was highest in Sind with 6% and 8%

followed by Baluchistan with 1.8 and 2.7%, KPK 2% and 2.2 % and Punjab with 0.2 and 0.3%

respectively in 2011 and 2012. The hospital fatality rate among the severe malaria cases was highest in

Punjab 2% with 67 deaths in 2011 and in 2012 Sindh had a case fatality rate of 1.73% with 155 deaths.

However inpatient admission from primary health care facilities was highest in Baluchistan with 52% in

2011 and 43% in 2012.indicating the continued challenges of PF transmission and different level of

access to primary and secondary facilities in Baluchistan and Sind.

The nationwide epidemiological data shows clearly that Pakistan is a low to moderate endemic country

with an important diversity within and between the provinces and districts. The mapping of Malaria

situation (2012 data) shows clearly that the highly endemic districts are located gradually in Baluchistan

(API 7.68), FATA (6.83), Sindh (2.92), and KPK (2.76), Punjab (0.19) and AJK (0.10).

The MPR showed the existence of a fragmented malaria and health information system, with very limited

capacities of analysis. The geographical information system necessary for the strategic orientation of

malaria control interventions is absent at all levels. There is a need to understand much better the

epidemiology of malaria in all provinces.

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Key best practices, success stories and facilitating factors

Access and coverage to malaria control interventions

Malaria control program and all malaria partners supporting delivery of malaria control services have not

adequately focused on the needs and demands of the malaria risk populations and have not tracked trends

in universal access and coverage to malaria control services.

An estimated 20 % of the population have access to public health facilities, from which the number of

reported cases by per year is approximately 300,000 resulting in the total number of malaria cases to be

an estimated 1.5 million per year.

The demographic health survey conducted in 2012-13, with a representative sample of 12,943

households, recorded 38% of children under age 5 had fever symptoms in the 2 weeks preceding the

survey. Children under 5 who sought treatment from health facilities/providers was estimated to be 58.2%

in Sindh, 50.1 % in Punjab and 39.1% in Baluchistan. A higher percentage of children under the age of

fiver were detected with fever (38%) than diagnosed as confirmed malaria (20%) highlighting the need

for further investigation on the origin of fever cases and more efforts needed to confirm all suspected/

clinical malaria cases in Pakistan.

Similarly data collected from DEWS on suspected malaria indicates many fever cases of fever are

diagnosed as malaria cases, for example in Jamal Kot ( Okara district, Punjab) BHU and rural

dispensary,717 suspected malaria cases were reported in 2013 ( up to October 2013), 99 slides taken and

0 malaria cases confirmed. Lack of diagnostic facilities in BHUs and non-availability of trained staff

weakens the coverage and access to malaria control activities.

To date, the programme has distributed 2.4 million LLINs since 2009, initially targeting pregnant women

and children under the age of five in high risk areas. The current National Malaria Strategy targets 85%

(6.9 million) of the 8 million populations living in high risk areas with Long Lasting Insecticidal Nets

(LLINs) and the remaining 15% (1.2 million) of the population living in epidemic prone areas are

targeted with Indoor Residual Spraying (IRS). The overall LLIN operational coverage in targeted districts

(38) is 41%, ranging from 25% to 65% at district level. The overall IRS operational coverage at union

council level in the 38 districts targeted by Global Fund is 99%, ranging from 25% to over 100% in

targeted union councils. The programme has based their estimations for IRS on the census data taken

from 2010 which consequently has resulted in districts over achieving their original targets. Furthermore,

given that only targeted union councils are subjected to both interventions undermines the whole concept

of universal coverage as denoted by WHO guidelines, especially in the case of IRS where the total

population at risk, the distribution of malaria cases in all union councils and geographical reconnaissance

have been overlooked.

There are 24 reported anopheline species in Pakistan. The predominant vectors vary according to

ecological niches in the Country: An. culcifacies (sibling species A and B), An.stephensi (urban and

mysorensis). Insecticide resistance has been reported in Pakistan since 1980s to organochlorine and

organophosphate used in past Indoor Residual Spraying (IRS) campaigns. To date, the programme has

distributed 2.4 million LLINs since 2009, initially targeting pregnant women and children under the age

of five in high risk areas. The current National Malaria Strategy targets 85% (6.9 million) of the 8 million

populations living in high risk areas with Long Lasting Insecticidal Nets (LLINs) and the remaining 15%

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(1.2 million) of the population living in epidemic prone areas are targeted with Indoor Residual Spraying

(IRS). The National LLIN operational coverage is approximately 39% and for IRS it is 15%.

There is a LLIN distribution strategy with an accountable voucher system (among Global Fund (GF)

supported districts), which utilizes a continuous distribution channel i.e. routine immunization campaigns

for registration and collection from Basic Health Units. A basic monitoring system exists for IRS and

larviciding in selective provinces

Disease early warning system (DEWS) supported by WHO includes malaria outbreak detection and alert

and rapid response.

Coverage of health facilities with microscopy and RDTs, particularly in 38 target districts supported by

GFATM, has expanded. Malaria diagnostic centers are available in district hospitals, Rural Health

Centers (RHC) and District Health Offices (DHO). Diagnostic support is provided by CDC labs in DHOs

to all Basic Health Units (BHUs), though there is a significant delay in providing feedback to health

facilities in the periphery. Malaria treatment in the public sector is being provided free of charge. A

registration system for medicines exist, procurement of anti-malarial drugs (with unknown quality) from

local market is common at the district level. Monitoring of drug efficacy of first line drugs is conducted

regularly and so far is efficacious.

Key malaria indicators mostly available at central, provincial and district levels are the API, SPR, BER

and Parasites species proportion. Multiple malaria information systems are in place such as the old

malaria surveillance system, new malaria information system (MIS), DHIS and DEWS generating

different malaria indicators. New malaria information system (MIS) s being rolled out to cover 38 targets

districts and plans in place to roll out in non GF supported districts. Malaria indicator surveys conducted

in 2009 and in 2013. The results of MIS 2013 are being analysed and report under preparation. Excellent

federal annual malaria surveillance reports and malaria reports prepared as part of Ministry of Health year

book. In some provinces such as Punjab active case detection and case investigation surveys are

conducted by CDC officers. M&E capacity is being developed with M&E officers in districts and

provinces.

Malaria provincial and federal financing was started under Roll Back Malaria initiative though the

provincial and federal planning system till 2012/2013 and new cycles are being initiated as integrated

vector disease control management. Plans are underway to increase health and malaria financing in 2013

in all provinces. The Federal Malaria strategic framework 2011-2015 has been developed to support the

transition of provincial and federal PC1 2013-2018 plans. Malaria control activities are being successfully

piloted in some union councils with, supply of commodities, capacity building and M&E in 38 high

malaria burden districts supported by Global Fund and contracting malaria partners.

There is a PSM plan to support the procurement in Global Fund supported 38 districts. There are

estimates prepared for malaria commodities as part of the PC-I by the FMCP and PMCP. WHO

specifications are being used for procurement of LLIN, IRS insecticides, RDT and ACT. There is a

standardized procedure for procurement -Public Procurement Regulatory Authority-PEPRA. There is a

good malaria storage system in provinces with partners such as Merlin and SCF. ACT and RDT stock

control and reporting system is part of new MIS. There are drug quality control laboratories at federal

and provincial level with drug regulatory officers at district level. There are insecticide quality control

centers in Kharachi and Faisalabad

Main problems and challenges

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Advocacy for prioritizing malaria control with high level policy makers and political leaders needs to be

strengthened to ensure adequate funding for BCC activities. A Malaria BCC strategy has been developed

at the Federal level but needs to be approved and made available to the provinces and districts. There is

limited capacity and insufficient staff in advocacy, information, education, communication at the

provincial level. Complex socio-cultural settings exist in different provinces and districts, further

highlighted by the low literacy rate in provinces such as Baluchistan and FATA and limited access to

households, specifically women and children has resulted in the lack of broad based community

involvement. Hence the need to develop community based malaria control, design context specific IEC

messages and ensure the judicious use of communication channels (mass media, interpersonal and

printed materials). The capacity of lady health workers has been overlooked as a potential for expanding

and strengthening community based malaria control interventions.

No systematic approach towards LLIN replacement has been initiated. Universal coverage for IRS and

LLINs is not being met in all the targeted districts and union councils and universal equity for LLINs is

not being met within all targeted households. There has been observed instances of wear and tear of

recently distributed LLINs. The timing of IRS campaigns does not always coincide prior to the rainy

season and peak transmission period (on religious grounds) in all the targeted union councils/localities.

Some provincial programmes conduct larviciding which is not done consistently throughout the

transmission season and dosages and quantities may not be applied appropriately according to the type of

breeding sites.

There is a functioning vector control program in some provinces and districts with few trained and

experienced staff; this includes an entomologist and insect collector. Vector control strategies (malaria,

dengue, LLIN distribution), guidelines (IRS, community mobilisation for LLINs, Crimean Congo

Haemorrhagic Fever) , training manuals (IRS, LLINs) have been developed by the federal programme but

with restricted circulation to the provincial programmes, while vector control guidelines (2007) are

utilised in some provincial programmes but this needs updating. Furthermore, IRS guidelines are not

widely available at provincial and district level nor in local languages making it difficult for field use. The

Federal programme has established a basic IRS and LLIN database yet lacks tracking of operational

coverage of interventions by province and district. Evidence-based need assessment and M&E tools

developed at the federal level have yet to be disseminated to provincial programmes.

At the provincial level, there is a lack of adequate equipment, supplies, inappropriate use, maintenance

and storage of available ones. The provincial programmes are at times incapacitated by poor logistical

support which impacts on the quality of service delivery.

Despite Pakistans long history of malaria operational research, which documents the change in vector

composition in different ecological surroundings, vector sampling surveys, entomology and susceptibility

surveys. There are no updated vector maps with information on vector species, distribution, breeding

sites, resting and biting habits and insecticide susceptibility. This is partly attributed to a lack of adequate

resources (entomology lab and insectaries) and skills (by newly recruited and existing staff) to conduct

routine monitoring on key entomological indicators at established sentinel sites. The programme has yet

to develop an integrated vector management strategy, which addresses the increasing demands of dengue

and irrational use of public health pesticides. There is no collaboration with provincial universities for

vector surveillance and research.

Malaria transmission is unstable with high risk of epidemics but there are no maps of districts with high

epidemic potential and those with reported malaria outbreaks over the last 5 or more years. Malaria

emergency risk is high due to political and security challenges in some districts and provinces and past

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risk of floods and earthquakes. There are no malaria epidemic-emergency focal points in the federal and

provincial malaria programs supported by a technical working group. Malaria epidemic threshold for

detection of malaria outbreaks being used by the DEWS system but no thresholds are in use in by the

malaria information (MIS) system and the DHIS system.

There is a lack of trained malaria program teams on malaria epidemic-emergency preparedness and

response at all level. There are numerous partners such as WHO- provincial sub-offices and emergency

programs such as OCHA, UNHCR, UNICEF working in health emergency but inadequate partnership by

malaria program to address universal access and coverage of malaria control interventions in emergency

affected districts and provinces.

Parasitologicaly confirmed cases count for around 20% of all reported cases over the last few years. A

systematic approach for quality control/assurance for lab services is missing. There are no reference labs

at the provincial and federal levels. There is limited number of trained and qualified microscopists and on

average one third of their positions remain vacant. Shortage of trained staff, supplies, refresher training

and poor practice is more evident in districts outside GFATM support. The treatment chart based on

national treatment guideline is present in some of the health facilities, yet the adherence to guidelines is

poor. The guideline was not distributed widely and the health staffs are in need of refresher trainings on

malaria case management. Second line ACT, and in some health facilities SP, is used for the treatment of

PV and suspected cases. The radical treatment by Primaquine for P. vivax is still not available in all health

facilities. There is no designated focal person for case management in provincial and federal levels.

Regular supportive supervision for case management activities and standard supervisory checklist are

lacking. Treatment of malaria during pregnancy is part of national treatment guidelines, though adherence

to it is poor. The reporting of inpatient and severe malaria cases and deaths from health facilities appears

incomplete and not accessed consistently by the malaria program. There is inadequate focus on severe

malaria case management in the program and in general are not managed in secondary district hospitals

but referred for ICU care at tertiary hospitals. Measures to control and assure the quality of anti-malaria

drugs needs to be further strengthened. The supply management system is weak, improper estimation and

distribution of anti-malarial drugs leading to stock outs in health facilities. The estimated utilization of

public health facilities remains low (20 - 30% in different districts), private sector plays a key role in

malaria case management. However, a systematic approach for involving private sector in malaria case

management is missing.

Different malaria case definitions used by DEWES and DHIS, new and old malaria surveillance and

information systems. Lack off comprehensive compilation of access and outcome-coverage Indicators of

the program complied by, district, province and federal levels. Impact indicators such as % of malaria

admissions and deaths among hospital admissions and % of severe malaria cases are poorly collected,

with few exceptions. There is no comprehensive ONE malaria data base at district, provincial and federal

level to bring together malaria information from different sources and systems. Questions are being raised

regards the accuracy and completeness of the malaria information from public sector and it is also

estimated that 70% of malaria cases are seen in the private sector.

There is not enough mapping of malaria data due to limited malaria program GIS capacity but excellent

mapping capacity in other program such as EPI, Polio, DEWS and WHO malaria atlas that could be used.

Malaria Epidemiological orientation capacity is inadequate at all levels with many vacant provincial posts

of malaria epidemiologists.

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There are serious delays and gaps between funds allocated, released and actual expenditure. International

financing is mainly though Global Fund and the contracted local malaria partners. Despite this, malaria

control is not seen as a priority by policy makers and politicians at the district, provincial and federal

levels with more implementation efforts being placed on the millennium development goals 4 and 5 as

well as many other competing health priorities such as dengue, expanded programme for immunization,

polio, hepatitis, emergencies and health reform.

There is inadequate sharing of information and coordination and alignment between the district,

provincial and federal malaria control programs with lack of clarity with regards to their roles and

responsibilities. Inadequate partnership exists at all levels (Federal, provincial and district) of the Malaria

Control Programme as well as with other programs such as, Primary Health Care and Lady Health

worker program, District Health Information system, DEWES, etc. There is inadequate coordination and

alignment between the malaria program at federal and provincial levels and the various malaria control

partners.

Different components of malaria control policies have been integrated with the strategic and PC -1 plans

and federal guidelines although they are generally in line with WHO recommended policies. The annual

malaria operational plans are only being used in Global Fund supported districts and partially in others

and not holistically within the overall district and provincial malaria programs. Federal malaria control

guidelines and wall charts are available in certain Global Fund supported districts but appear to be

complex to use and not widely available in all provinces and district, especially in local languages.

There is inadequate partnership between malaria program with provincial and federal universities and

health institutes to support operational research and training malaria control and elimination. Malaria

control program is oriented towards neither supply based on output and neither on need nor demand based

on access, equity and coverage towards rapidly achieving and sustaining universal access and coverage.

There is a fragmented district, provincial and federal public health system which is unable to provide

adequate support to the devolution transition, emergency, health reform and is overshadowed by a

dominant private sector. The formal and informal private sector provides a large part of the fever/malaria

control services especially in urban areas and in some rural areas. Federal cross- border meetings

(Pakistan-Iran- Afghanistan) have been held with inadequate practical follow up in border districts and

provinces.

The unstable political and security situation in some districts and provinces has created challenges for

access and M&E of the malaria program but also presents opportunity for developing a malaria

emergency support. There are multiple malaria control activities being implemented at all levels of the

health system, resulting in a desynchronized malaria control program at the district, provincial and federal

level that fails to achieve systematic coverage and impact that can be sustained. Provincial malaria

managers/ coordinators are at times not senior to support district health coordinators such as EDOS/DHO.

There is a lack of functioning district malaria focal points/coordinators to be able to comprehensively

follow up implementation in all malaria thematic areas. There are lack of malaria epidemiologists,

entomologists, case management coordinators at federal and provincial levels of the program and malaria

supervisors/technicians and malaria microscopists at district and BHU levels.

Malaria PSM is a push system based on supply and not a pull system based on need and demand. There

are multiple malaria procurement and supply systems within the DOMC, PMCP, district health offices

and hospitals and the various implementing malaria partners. There is no quality assurance system in

place for RDT

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Key action points

Advocacy, Information Education Communication/ Behavior Change and Social and Community

mobilization

1. To develop a strategy for increasing malaria advocacy and prioritization for community, district, provincial and federal government action.

2. To build partnership with LHW program and PPHI for social mobilization and community based malaria control program delivery.

3. Update malaria messages to target the local situation and adopt a local strategy which identifies appropriate inter-personal channels for reaching the local communities and families

4. Harness the capacity of lady health workers for improving community BCC and scaling up malaria control activities;

5. Prioritize the use and develop tools for inter-personal malaria communication for BCC using schools, madrasas, local traditional and political leaders.

6. Introduce qualitative monitoring tools, which assess how well the elements of the COMBI strategy are being carried out.

Malaria Prevention: Entomology and Vector control

1. LLIN gap analysis towards accelerated coverage of 80% in target high transmission districts through mass campaigns supported by routine continuous distribution mechanisms (outreach,

routine, schools, community, commercial sector, social marketing) for hard to reach areas and

three yearly replacement.

2. Revise the LLIN distribution strategy to ensure there is universal equity at the household level.

3. Develop a simple stratification and mapping method using reported incidence, topography and local experts opinion to focus evidence based vector control on high transmission districts and

union councils.

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4. Reserve IRS (80%) to target high PF transmission districts to control and eliminate PF as well as to prevent epidemics and eliminate malaria foci in pre-elimination phase and prevent re-

introduction

5. LSM to be targeted to support urban malaria control & elimination and can be used in general nuisance mosquito control. LSM to be targeted to eliminate malaria foci in districts for pre-

elimination and elimination of PF and PV

6. Establish vector sentinel surveillance sites in different eco-epidemiological settings with standard guidelines by PMCP in collaboration with HSA and provincial universities and research institutes

7. Update vector distribution maps stratified at district level which reflects the seasonal distribution (vivax and falciparum) as well as vector binomics and susceptibility status of the predominant

malaria vectors.

8. Establish an integrated vector borne disease control program (Malaria, Dengue, Leishmania) with adequate focus on each disease control and elimination as appropriate.

9. Develop a integrated vector management strategy, which addresses insecticide resistance management and identifies innovative approaches for inter-sectoral collaboration

10. Entomological spot surveillance to be conducted by insect collectors and malaria supervisors supported by districts and provincial entomologists with provincial entomological reference

laboratories.

11. Conduct LLIN hole index proportion study

12. Revive the vector control technical committee with updated TOR

13. Update and simplify the national vector control guidelines and supporting training materials

Malaria Prevention: Epidemic-Emergency Preparedness and Response

1. Update risk maps and tables on malaria epidemics and emergencies

2. Provincial quarterly malaria emergency update on needs and gaps in emergency affected populations and districts for follow up with provincial health emergency cluster

3. Malaria program and DEWS, DHIS to jointly review and update malaria case definitions and malaria outbreak and emergency thresholds and guidance for malaria outbreak control

4. To develop specific malaria emergency strategies such as simple community based malaria control to access and deliver malaria control to emergency affected areas.

5. To build malaria partnership with other organizations such as OCHA, WHO, UNICEF, UNIHCR, IOM, JICA, etc to move to universal coverage with malaria interventions by MDG 2015 in

emergency affected districts

14

Parasite Control: Malaria diagnosis and treatment

1. Strengthening lab capacity: all suspected/clinical malaria cases should be tested with RDT or microscopy before anti-malaria treatment is administered. RDT to be rapidly scaled up to all

BHUs in partnership with PPHI, IMNCI and PPNCP programs in malaria high risk districts.

2. Introduction of a systematic quality assurance system: strengthen quality control by establishing provincial and district reference labs with adequate infrastructure, competent lab technicians with

support for annual cascade training and supervision, and continuous availability of consumables.

3. Training and development: after thorough need assessment at the central, provincial and district levels, a comprehensive training plan (refresher, pre-service and in-service training) for

strengthening diagnostic capacity should be developed.

4. Recruitment of new staff: deployment of lab technicians in all relevant vacant positions, particularly in malaria high risk districts is needed.

5. Competent officers should be assigned as focal points for malaria case management at federal and provincial levels.

6. Update the federal and provincial essential drug list for health facilities and follow up the de-regulation and ban on all malaria mono-therapy in public and private sector

7 Radical treatment for PV with Primaquine with DOTS for 15 days to reduce relapse and transmission, supported by regular supply of Primaquine to all health facilities in malaria high

risk districts.

8 Provision of new malaria treatment policy, guidelines and wall charts to all public and private health facilities by April 2014 supported by a ban on mono-therapy and standardized training for

all clinical staff

9 Establish community based malaria control with RDT and ACT with LHS-LHW and community based organizations.

10 Case based reporting system be established for severe malaria cases followed by supportive clinical investigation and audit.

11 Engagement and scale up public- private partnership in malaria control through professional association and sharing guidelines and wall charts and orientation sessions

12 Supervision by PPHI and DHO supported medical officer for implementation of high standard of malaria case management.

15

13 DoMC and PRs should ensure efficient drug supply management system with monthly stock situation update especially for RDTs and ACTs.

Surveillance, Monitoring and Evaluation

1. Production of monthly, quarterly and annual district, provincial and federal malaria program reports based on strategic information at district and provincial level such as outcome/impact and

mortality data

2. Update information on needs and gaps on RDT, ACT, Primaquine, LLINs and IRS to achieve universal coverage.

3. Establish one standard malaria case definition for diagnosis and treatment and , MIS, DHIS, DWES .

4. Review and update the old malaria surveillance system in place in districts targeting elimination of Malaria

5. Move to one malaria information system with data collection tool for an integrated malaria M&E system in all malaria risk districts by first quarter 2014.(Harmonize the M&E system among the

PRs and SRs)

6. Malaria program to collect data on malaria inpatients and mortality from secondary and tertiary hospital DHIS reporting.

7. To establish GIS and malaria mapping capacity within the provincial and federal malaria program using WHO country office EPI and malaria atlas programs to guide malaria epidemiological

analysis and target interventions at districts level.

8. DEWS to be sustained and transferred to the DHIS provincial and district departments to support malaria epidemics detection and response and in the future district malaria elimination.

9. MDC/PMRC/WHO/MEDVC HSA to propose an agenda for operational research to support malaria control efforts

10. Use the available GF funds to extend the M/E system to all district under malaria control strategy and adjust the M&E system for the districts targeted for elimination

Program Leadership and Management

1. Development of a new joint provincial and federal vision for malaria control and elimination in

Pakistan supported by one simple and comprehensive malaria and Integrated Vector Borne Disease

(IVBD)policy document.

2. Need to accelerate and intensify towards greater than 80% universal coverage by 2015 in Global

Fund supported districts (38) and rapidly introduce the new malaria policies and interventions in the

remaining 15 high transmission districts.

3. Establish functioning malaria and integrated Vector Borne Disease partnership mechanism between

the District Malaria Control Programme (DMCP), Provincial Malaria Control Programme (PMCP)

and Federal Malaria Control Programme (FMCP) and other programs such as, Primary HealthCare

and Lady Health worker program, District Health Information system, DEWES, MNCH etc

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4. To develop a special community based malaria and integrated Vector Borne Disease control

strategy for accessing hard to reach populations (Remote areas, emergency situations, IDPS, Nomads

) in selected districts and provinces.

5. To develop a special strategy for public-private partnership for malaria and integrated Vector

Borne Disease control with private medical care provider and also private retailers and producers of

combination drugs, Rapid Diagnostic Tests (RDT), Long lasting Insecticidal Nets (LLIN) , Indoor

Residual Spraying (IRS) and Larval Source Management (LSM) chemicals and hand compression

pumps to ensure standards of quality and local production at affordable costs in provinces which

involves a combination of information sharing ,training of health worker and information to public,

legislation, regulation and enforcement.

6. The malaria federal Inter-provincial coordinating committee (IPCC) and Technical Advisory

Committee on malaria (TACOM) and the technical various working groups be revived with updated

TOR on malaria and IVBD and be supported by provincial coordinating committees.

7. Joint annual operational /implementation malaria and IVBD planning started from 2014 at district,

provincial and federal with the active involvement and contribution of all malaria partners and

stakeholders

8. Joint monthly, quarterly and annual malaria and IVBD program performance reporting at district,

provincial and federal level based on a uniform performance framework of input, outputs, outcome

and impact towards sustained universal access and coverage.

9. Updating of provincial and federal malaria and IVBD strategic plans by end of April 2015 aligned

to health strategic plans and PHC and MHSP based on need and demand for acceleration and

intensification towards universal malaria intervention coverage by 2015 and post MDG

Procurement and supply system

1. PMCP. DMCP need to ensure the PPRA, PPHI, LHI and all malaria partners procure all malaria

commodities (ant malarial, insecticides and vector control equipment for IRS) according to the

WHO/WHOPES specifications.

2. Urgently align DRAP registration for malaria combination therapy with national malaria treatment

policy and to support production/import of Primaquine and de-registration and ban on use of mono-

therapeutic formulation for all malaria treatment.

3. To prepare quarterly updates on malaria commodities used and in stock and forecast urgent need

4. Establish a system for RDT quality assurance (QA) using WHO accredited international laboratory

and quality control using a national malaria microscopy laboratory.

5. Annual updating of the malaria commodities specification list based on WHO recommendations

6. Annual updating of estimates of malaria commodities based on need and demand to achieve and

sustain universal access and coverage

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7. Conduct a review of the current stores and potential need for malaria combination drugs, RDT,

LLIN, IRS and LSM chemicals in district and provinces

1. Introduction

1.1 Background Given the concerns for malaria burden and implementation of the new arrangements for the programme,

malaria control and elimination unit, in coordination with Directorate of Malaria Control, WHO country

office and GFTAM, requested for a rapid assessment of the current situation of malaria control

programme in Pakistan. The findings of rapid assessment strongly suggested and recommended an in

depth program review to identify gaps and issues with programs especially in wake of devolution and a

national and provincial strategic document can be made as a way forward and mobilize resources on new

funding model

1.2 Objectives of the MPR

1. To review the epidemiological outlook of malaria disease in each province of Pakistan with

particular reference to disease trends, Slide positivity rate, Species wise distribution, Blood Exam

Rate (BER), Severe Malaria and Outcome of the managed cases at health facility with particular

reference on disease specific mortality.

2. To review the Malaria program structure, capacity and management in each province and at national

level (DOMC), in view of its new roles after devolution and identify issues and challenges arising

post devolution.

3. To assess the current programme performance by intervention thematic areas and review progress,

challenges and towards achievement of targets in each province and progress towards achieving

national and regional goals.

4. To identify way forward, priority needs and gaps for improving programme performance and

coordination at provincial and federal level.

5. Define steps to improve programme performance and redefine the strategic direction and focus,

including revision of policies and strategic plans at provincial levels which can help tapping the

available funds from various sources including the public sector and donors e.g. Global Fund from

R10 malaria grant phase II and from the new funding model.

6. To assess the effectiveness of Global Fund grants supported projects in highly endemic regions of

the country and to suggest ways and means for quality assured interventions following the

principals of transparency, accountability and value for money.

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7. To develop the post MDG strategic plan at provincial and national level for Pakistan for 2015-2020,

based on the results of PRM, which will help mobilize resources based on new funding model.

1.2 Methodology of the MPR Malaria programme review will involve a mixture of methods, including desk reviews of technical

thematic areas based on programme data, reports, documents and published literature; updating

country databases and country profiles; mapping of populations at risk; estimating burden and making

projections; policy and management analyses; special studies; and group work, individual

consultations and provincial and district field visits with interviews and observations.

The programmatic review will be conducted in four phases which will include

Phase I:

Planning Phase- It will involve:

1. Needs assessment for a programme review

2. Building consensus to conduct a review

3. Appointment of a review coordinator and establish an internal review secretariat and steering Committee

4. Constitution of Provincial Teams

5. Identify and agree on the terms of references of the internal and external review teams

6. Send an official request to WHO for technical support

7. Select and prepare central, provincial and district sites for field visits

8. Define the objectives and outputs of the review

9. Plan administration and logistics

10. Develop a review proposal, with a budget, and identify funding sources

11. Design a checklist for tracking activities

12. Collecting and summarizing all the available data including technical reports and PC1s

13. Review of available data and preparation of thematic area overviews;

Phase II:

Thematic desk review- This will involve:

1. Assembling information from reports and documents,

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2. Conducting a technical thematic desk review,

3. Compiling a thematic desk review and

4. Score achievement by thematic areas

5. Selecting and adapting data collection methods for the field review.

Phase-III:

Field review- This will involve

1. Briefing and team-building between internal and external review teams

2. Building consensus on the findings of the internal thematic desk reviews

3. Becoming familiar with the data collection methods for field visits

4. Briefing and forming the teams for field visits

5. Visiting national institutions and organizations (Central level)

6. Making district, provincial, state and regional field visits

7. Sharing reports and presentations from field visits

8. Preparing a draft review report

9. Preparing the executive summary, aide-memoire and slide presentation

10. Presenting the review findings and recommendations

11. Meeting with senior management of the ministry of health,

12. High-level meeting and signing of aide-memoire and stakeholder workshop

13. Media events (press release and press conference) and

14. Completing the final draft of the review report

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Phase-IV:

Final report and follow-up on recommendations. This phase will include:

1. Finalize and publish the report.

2. Disseminate the report.

3. Implement the recommendations.

4. Monitor implementation of the recommendations.

5. Update policies and plans and redesign the programme, if necessary.

1.4 Outline of the document

This report is structured to cover all the thematic areas mentioned below. The following thematic

areas are discussed along with its SWOT analysis followed by recommendations.

Program Management

Malaria Diagnosis and Case Management

Malaria Vector Control

Malaria Commodities, Procurement and Supply Chain management

Advocacy, Information, Education, Communication and Community Mobilization

Epidemiology, Surveillance, Monitoring, Evaluation and Operational Research

Epidemic and Emergency Preparedness and Response

2. Context of malaria control

2.1 Historical milestones in malaria control

Year Activities

1952-56 A five year plan to extend the malaria control activities to other

areas aside from selected areas since 1950.

The main strategy was vector control using blanket spraying of DDT.

The results were encouraging and marked decrease in the spleen rate was

observed in children below 10 years.

1960 In 1960s, a pre-eradication malaria survey was completed.

Results indicated highest malaria prevalence in Punjab, due to the network of

irrigation canals and the extension of flooded areas.

1961-69 A nation-wide malaria eradication program was launched under the auspices

of WHO and with the help of USAID and UNICEF.

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Strategy

The main strategy was vector control using blanket spraying of DDT, with a

transient temporary relief during late 60s & early 70s

Results

As a result of this campaign the malaria was nearly eradicated from the

country and a marked reduction in malaria cases was observed from an

estimated 7 million cases in 1961 to 9,500 cases in 1967. An overall

reduction from 15% to less than 0.01% was observed in the slide positivity

rate.

1969-74 The malarial infection began resurgence in 1969 & 1970s and included the

increase of malaria in urban areas (a quarter of million cases were reported

from Karachi alone). All this resulted in the program collapse, subsequently

followed by explosive resurgence of malaria assuming epidemic proportion

in 1972-73.

Results

USAID reports in Pakistan, there were 9,500 cases in 1968. In 1971 there

108,000 cases which rose to 10 million in 1974.

The reasons of resurgence were : the onset of vector resistance to

Organochlorines (DDT & Dieldrin/BHC), under estimation of A. stephensi in

maintenance of urban malaria together with financial and administrative

constraints, inadequate administration of programs, inadequate research,

training, and supplies of chemicals and drugs, inadequate health services

infrastructure, the lack of malaria control components in hydraulic

development projects, and underdeveloped socioeconomic conditions

generally. Premature withdrawal of donor support was also an important

factor.

1975-85 The Malaria Program switched from Eradication to Control Program.

Initiation of Five years National Malaria Control Program with support of

WHO and USAID. Implementation handed over to provincial government

and malaria control program was integrated with general health services.

The main objective of the MCP was to reduce the disease incidence to less

than 500 cases per million population.

Strategy Vector control by indoor residual spraying was the main strategy.

In 1976 DDT (Organochlorines) was replace with Malathion

(Organophosphate) insecticide with two rounds of spraying in most areas.

Results

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Malaria decreased significantly in 1977-78. There has been a sharp decline in

the slide positivity rate from 14% to 0.62% and API from 13 per 1000

population to 0.3 per 1000 population in 1978. Malaria Control programme

continued till 1985.

1985-2002 In 1985, Malaria Control program was merged with Health Department.

In 2000-20012, Devolution of health and other services

The execution and implementation of the Program went directly under the

control of Executive District Officers (H).

Under devolution the malaria staff were declared dying cadre and the MCP

directorate was abolished, which further deteriorated the malaria situation in

province.

Same Malaria Control Policies and strategies continued.

2003 RBM Strategy adopted in Pakistan as a signatory with Global partners

The key objective was to reduce the disease burden by 50% by 2010.

2004 GF and strategic plans and rounds

2007-13 PC-1 of 329.954 million rupees.

Main strategies:

Early Diagnosis and Rapid treatment, Multiple Prevention, Epidemic

Preparedness, Monitoring, Evaluation and Surveillance, BCC, Operational

research besides staff component.

Results

Fail to achieve the targets because of lack of financial and

administrative constraints

2013-15 A total of 90.0 million were calculated as KP share of National RBM Program fund. (PSDP GRANT NO; 23 (2012-13)

Rs.8.025 million was utilized in FY 2011-12 on purchase of goods. The remaining Rs.81.975 million are available as capital cost for this PC-I.

The Project Cost Estimates have been prepared in January, 2013 and will continue till 2015.

Strategies

The main components include Early Diagnosis and Rapid treatment, Multiple

Prevention, Institutionalization and Monitoring, Evaluation and Surveillance.

2.2 Malaria control within the national development agenda/national health policy

23

In the national policy (2009) of Pakistan , The burden of diseases (BoD) is heavily dominated by

communicable diseases,reproductive health and malnutrition issues accounting for 50% of the total

burden of diseases. This is further complicated by burden due to non-communicable disease group

dominated by cardiovascular diseases, diabetes, injuries and neuro-psychological diseases.

This double burden of disease is a major challenge in the health sector of Pakistan

Among the BoD, Pakistan is considered as a malaria endemic country with little

change in the status over past five years. Punjab, NWFP and Sindh have low endemicity of

malaria but Balochistan and FATA are high endemic areas

The overall goal of the 2009 policy is to improve health status of the people of

Pakistan.The National Health policy aims to improve health status of people of Pakistan by achieving the

policy objectives mentioned below and it is envisaged that it will also help Pakistan to make

progress towards health related MDGs.

i. Enhancing coverage and access of essential health services especially for the poor;

ii. Measurable reduction in the burden of diseases especially among vulnerable segments

of population;

iii. Protecting to the poor and under privileged population subgroups against catastrophic

health expenditures and risk factors;

iv. Strengthening health system with focus on resources;

v. Strengthening stewardship functions in the sector to ensure service provision,

equitable financing and promoting accountability;

vi. Improving evidence based policy making and strategic planning in the health sector.

The specific Objective 2 of the policy aims to achieve : Measurable reduction in the burden of diseases

especially among vulnerable segments of population. In response to the endemic Malaria burden in

Pakistan, the programme will continueto implement the Roll Back strategy with effective implementation

in high risk districts, using rapid diagnostic kits, expanding the use of impregnated treated nets

(ITNs) and using updated treatment protocols. In addition, a comprehensive strategy

will to be developed to respond to other vector borne diseases especially dengue

fever.

In reviewing the Human and Social Capital Development , working group report for Vision 2025 ( first

draft, December 2013) , Malaria control program is not mentioned as such. However , it is mentioned that

:Strengthening of primary care with necessary back up support in rural areas where all health outlets

will function as focal point for control of Communicable diseases, family planning services and

improvement of surveillance and the diseases early warning system will be addressed through the

different national health programs. DOMC should take the opportunity of the recent MPR to advocate

for inclusion of malaria control / elimination among the strategic priorities of the Vision 2025.

2-3 Malaria control in National health strategic plans

In pursuance to 18th Amendment of the Constitution, health & population sectors have been devolved to

the provinces with all administrative and financial autonomy. Most of the province are finalizing their

health sector strategies.

24

Sindh for example consider as a key issue the rise of Malaria incidence witch has coincided with

outbreaks of dengue fever needing a proper vector control. The special area of focus in Sindh will be to

Establish links for integrated control at community based, MSDP and ESDP levels, and evidence based

intervention enhancements (Strategy 3.6: Establishing links between TB, Malaria and Hepatitis for

integrated control at community based, MSDP and ESDP levels, and evidence based intervention

enhancements.)

In Pundjab, The key emphasis of the Strategy is on integrating health services supported by a strong

monitoring and evaluation system. The health sector Strategy has been devised with a vision to enhance

health status and productive lives of the people of Punjab by improving maternal and child health,

nutrition, control of communicable and

non-communicable diseases .

2-4 Health services organization and management

The health delivery system in Pakistan is a mix of public and private sector services. There is

considerable inequity in access to services between rural and urban areas. One estimate indicates that

more than two thirds of the population consult private sector health providers as compared to only a third

of the population utilizing public sector health facilities1.

Thus the government is the main provider of rural health services and also the only substantial provider of

preventive care throughout the country. Little information is available about the semi-regulated private

sector.

The public health services are provided through the health care delivery systems and public health

intervention. The health system has a well defined pyramidal structure, with Basic Health Units (BHUs)

at the base (approximate catchment areas of 15-20,000 people), Rural health centres (RHCs) forming the

core of primary health care with a catchment population of approximately 80-100,000 people. Tehsil

Headquarters (THQ) hospitals provide in-patients services as the secondary level of the health system

followed by District HQ providing an upper secondary level of hospital services. There are also major

teaching hospitals and specialist centres, provided by a mixture of public and private sectors, The system

is supported by Government financing and through the support or Civil Society Organisations with a

range of donors, including the Government (using a sub-contracting mechanism) and international

bilateral donors such as USAID, DFID and many others including World Bank and Asian Development

Bank, Islamic Development Bank and numerous others.

Vertical Public health interventions include a number of public health programs which are federally led

with provincial implementation and institutional mechanisms. The list of the main vertical public health

programs is as follows;

Expanded Program on Immunization (EPI) National Program for Family Planning and Primary Health Care (NP for FP&PHC) National Maternal, Newborn and Child Health Program (MNCHP) National AIDS Control Program (NACP) National Program for Malaria Control (MCP) National T.B. Control Programme (NTCP) Prime Minister Program for Prevention and Control of Hepatitis in Pakistan Cancer Treatment Programme

1 Pakistan Social and Living Standards Measurement Survey (Provincial-District) 2004-05

25

National Blindness Control Programme

There are 948 hospitals in 2008 with over 133,956 registered physicians and over 65,387 registered

Nurses, 9,012 Dentists and approximately 100,000 Lady Health Workers. The population to facilities

ratio in respect of a doctor is 1 per 1,212 persons; a dentist 1 per 18,010 persons and availability of one

hospital bed for 1,575 persons2.

2.5 Organizational structure for malaria control

The programme is implemented countrywide with an established organisational set-up at federal,

provincial and district level. At the federal level there is a Directorate of Malaria Control, which is an

attached Department of the Ministry of Health. The Director Malaria Control is assisted by a team of

professionals (i.e. Epidemiologist, Entomologist, and Health Education Officer) and support staff. The

Directorate is responsible for overall leadership role including strategic direction & policy design (detail

described in Annex II). The Directorate of Malaria Control has a separate budget for development and

non-development activities, which falls under the Federal Ministry of Health.

At the Provincial level there is a complete administrative set-up for malaria control Programme, although

the structure may differ by province for example; In Punjab the Director (CDC) is the overall in-charge

with Additional Director of Malaria being directly responsible for malaria control activities. These

officers assist the Director General Health Services. There are separate Directorates of Malaria Control in

the Provinces of Sindh & Balochistan working under the provincial Health Departments. In KPK

(formerly NWFP) the Malaria Control Programme is under the Deputy Director Public Health, with an

Assistant Director (PH) being the focal person for malaria control activities.

The Provincial Malaria Control Programmes are primarily responsible for co-ordinating and facilitating

malaria planning and implementation activities in their respective districts. Each province earmark

separate budgets to co-ordinate/facilitate malaria control interventions

The Executive District Officer Health (EDO) has overall responsibility for malaria control activities at the

district level. The DOH/DDOH (preventive) is the focal person for malaria control activities in the

district. The delivery and management of malaria care has been integrated with district healthcare services

so that continuing care can be provided close to the patients home. The DOH also has two malaria

officers i.e. a Communicable Disease Control Officer and an Assistant Entomologist, who assist him in

looking after the malaria control activities in the district.

At Tehsil level the Deputy or Assistant DOH would be designated as sub-district/tehsil focal person for

malaria control activities in the tehsil. They would be responsible for operations of malaria control

activities in their respective tehsils. DDOH also has one CDC Inspector (CDCI) to assist in malaria

control work in the tehsil.

The district and sub-district hospitals and rural health centres (and few selected basic health units) work

as microscopy centres. A microscopy centre has a laboratory with laboratory staff and a doctor who is

trained to diagnose and treat malaria. The primary health care facilities such as basic health units and

dispensaries, where laboratory is not available, work as treatment centres. The district headquarters

hospitals also provide specialist care to complicated/severe malaria cases. The CDC Supervisors at the

union council level, associated with primary health care facility, carries out community-based activities

for the control of malaria.

2 Economic Survey of Pakistan-Health & Nutrition, 2008-09

26

2.6 Key strategies for malaria control

Goal: In line with MDG 6, the strategy aims to reduce the burden of malaria by 75% percent (from 2000

levels) by 2015.

Objectives: This proposed 5-year strategy aims to provide the basis for achieving universal coverage of

malaria control interventions to the most at-risk populations in highly endemic districts by 2015. The

objectives of the strategy are:

1. To enhance access by the population at risk to quality assured early diagnosis and prompt, effective treatment services.

2. To scale-up coverage of multiple prevention interventions (especially LLINS & Indoor Residual Spraying [IRS]) to the level of universal coverage in the target population in high-risk districts.

3. To strengthen existing Malaria Control Programme management capacity to coordinate, plan, implement and monitor effective curative and preventive interventions nationwide.

4. To strengthen programme capacity in enhanced epidemiological surveillance for timely detection and curtailment of malaria outbreaks.

5. To improve public sector health facility utilization for early diagnosis, effective treatment and preventive measures through enhanced community awareness and participation.

Targets: These targets cover the 38 highly endemic:

The proportion of malaria cases diagnosed and provided correct treatment within 24 hours of the onset of symptoms (at facility or community) will be 80% (baseline NA).

The proportion of cases diagnosed as P. falciparum malaria in public sector health facilities being treated with ACTs will be 100% (baseline 8.2%)

3.

The proportion of private sector health care providers providing malaria case management according to the national treatment guidelines will be raised to 50% (baseline 34%)

3.

Universal coverage of freely distributed LLINs in highly endemic districts in the country.

The proportion of women and children having access and availability of community & facility based malaria control services will be raised to 80% (baseline TBE).

All MCPs at federal and provincial level are capable of planning, implementing and monitoring malaria control interventions through long and short term technical assistance.

All provinces (05), regions (03) and districts will have quality assurance mechanisms in place.

All endemic districts will have the capacity to detect, report and respond appropriately to malaria epidemics.

All endemic districts will have provision of malaria control services for population of humanitarian concern (IDPs, refugees, nomads etc).

100% target population in highly endemic districts reached through behavior change communication interventions. (baseline 0%)

3 Malariometric Survey 2009

27

Strategic Elements of Malaria Control Programme:

The National Strategic Plan for Malaria Control 2011-15 is based on the following key elements:

Case management: Early diagnosis, rapid and appropriate treatment.

Prevention through multiple strategies

Epidemic preparedness

Building capacity at national and sub-national levels.

Advocacy, communication and social mobilization.

Partnerships with private and informal sector

Focused operational research.

Additional elements include a focus on geographical areas of importance (such as those with manmade or

natural disasters) and on populations of humanitarian importance, such as IDPs and refugees, as well as

those with restricted access to health services. Gender issues will be addressed through combining efforts

with relevant stakeholders in mother and child health initiatives, including antenatal care and community

health workers.

This strategy will provide the basis and guidance for malaria control from 2010-2015 in Pakistan.

Crucially, elements of this plan will be used to support applications for donor funding to support the

already substantial Government contributions.

2.7 Key players in malaria control Save the Children and Department of Malaria Control (DOMC-Islamabad) are Principal Recipients

while Merlin and ACD are sub recipients. Since inception, the World Health Organization is

providing technical assistance and has recently provided National Professional Officers stationed at

MCP in Balochistan, Sindh, FATA, Punjab and KPK.

The Principal Recipients and Sub Recipient working with IVM in FATA:

Districts Sub Recipient Principal Recipient

FR Peshawar, Kohat, Bannu, DI Khan,

Lakki, Tank, North Waziristan

Merlin Save the Children

Khyber Merlin DOMC

South Waziristan, Orakzai, Mohmand ACD Save the Children

Bajaur, Kurram ACD DOMC

28

The Principal Recipients and Sub Recipient working with MCP in KP:

Districts Sub Recipient Principal Recipient

Bannu, Lakki Marwat Merlin Save the Children

DI Khan, Tank Merlin DOMC

Mardan, ACD Save the Children

Charsadda, Nowshera ACD DOMC

The partners of Malaria Control Program Sindh include WHO, GFATM and NGOs implementing

activities in six selected districts of Sindh as Sub Recipient (SR) and Principal Recipients (PR) under

GFATM grant. During floods and heavy rains in Sindh in 2010 and 2011 additional partners such as

MERLIN and Islamic Relief also supported Malaria Control Program Sindh.

2.8 Resource Mobilization

2.9 Linkages and coordination

The MCP does not collaborate with other DOH departments including MNCH Program and NP for

FP&PHC and AIDS Control Program. The MNCH Program implements the Integrated

Management of Childhood Illness (IMNCI) strategy and PCPNC as part of the focused antenatal

care package. There are no joint plans with several line ministries that include Agriculture,

Tourism, Environment, Education, Public Works, Housing, Fisheries, etc. These sectors have

access to populations that are affected by malaria but are usually not targeted by interventions

delivered through the health sector.

2.10 Conclusions and Recommendations

The program should devise mechanisms for malaria control issues to be discussed on a regular basis

at the Federal, Provincial and District level using already planned and instituted partnership

coordination mechanisms.

Recommendations:

There is coordination between partners and MCP, but not the Program Managers therefore coordination among stakeholders need to formalized and improved.

Unavailability of guidelines and manuals reflects weak coordination between Province and Federal Directorate of Malaria.

PCPNC guidelines need to be updated.

3. Epidemiology of malaria

Today Pakistan has an estimated population of 173.5 million people, out of which, according to the 2012

national malaria disease surveillance annual report, 9% are living in high transmission districts (34) with

an annual parasitic index (API) ranging from 5 to 28, 20% are living in moderately endemic districts (41

districts) with API ranging from 1 to 5, and 71% living in low endemic districts with an API below

1/1000 population. The national API for the entire country is averaging 1.69, which classifies Pakistan as

a moderate malaria endemic country. Malaria mappings demonstrate clearly the highly endemic districts

29

are located mainly in the provinces of Baluchistan, FATA, Sindh, and KPK. The lowest malaria incidence

was reported in two provinces Punjab and AJK with combined population of more than 56% of total

population of the country.

Figure 1: Proportion of PV to Pf (2008-2012)

The primary malaria vectors are A.culicifacies and A.stephensi. A number of secondary vectors have

been reported and their contribution to malaria transmission is being investigated. The last nationwide

vector surveillance was in 2009 and a recent survey has been conducted in 2013 and data is being

analysed and the report under preparation.

The predominant malaria parasite is P. Vivax with P. falciparum being the secondary parasite. In 2012,

Annual Blood Examination Rate (ABER) varied between 1.78% in Punjab to 7.09% in Baluchistan. Out

of the 289,759 malaria cases confirmed positive in 2012, 249,504 were identified by microscopy (86.1

%), while 40,255(13.89%) by rapid diagnostic test. Majority of cases were considered as P.vivax (74.39

%) and 23.95 % as P.falciparum and 1.65 % as mixed infections.

Proportion of P falciparum varies widely with a range of 2.4% - 44% respectively. Maximum proportion

of falciparum cases (i.e. 44%) has been reported from Baluchistan province followed by 27% in Sindh,

11% in FATA, 9% in KPK and 6% in Punjab province. Proportion of PV to Pf over last five years (2008-

2012) is shown in Figure-1. Certain areas of Sindh and Baluchistan have year round transmission with

falciparum predominance.

Table 1: Malaria Data Pakistan 2012

Province Population TOTAL Indicators

30

Slides/RDT Positive P.V PF Mix

SPR API BER %

P.F Examined

Punjab

91,943,208 1636079 17522 16426 1008 88

1.07 0.19 - 5.75

Sindh

39,231,406 1785499 114651 79511 31083 4057 5.56 2.9 - 27.1

KPK

22,985,802 534516 63494 57402 5804 288 12.4 2.76 - 9.14

FATA

4,382,727 197571 29926 26432 3232 262 16.2 6.82 - 10.79

Baluchistan

8,295,628 588558 63733 35372 28248 113 12.85 7.68 - 44.32

AJK

4,160,025 146744 433 421 11 1 0.29 0.10 - 2.54

TOTAL 170,998,796 4888967 289759 215564 69386 4809

(1.6) 5.57 1.69 - 23.9

Malaria indicator survey of 2009 showed malaria prevalence rates in Baluchistan 6.2% (Pf 2.4% Pv 3.8%

), FATA 13.9% (Pf 0.6%:Pv13.3%),Khyber Pakhtunkhwa 3.8% (Pf0.9%:Pv2.9%) and Sind 0.7% (Pf

0.7%: Pv0.4%).

The provincial prevalence is consistent with the reported incidence from the malaria surveillance system.

The 2013 prevalence survey is being analyzed and report will be available in early 2014.

Age- and sex-wise distribution of cases indicates malaria is confined to the age group above 15 years. In

the 19 priority districts the % of confirmed malaria cases among children below 5 years was 17.82 % of

confirmed cases

31

Transmission Patterns

P. Vivax P.Falciparum

Seasonal Transmission May October

Usually two peaks of vivax malaria each year First Peak (Spring) resulting from delayed attacks or relapses

second peak after monsoon. (Rowland 1997 a)

PF shows a single peak after summer because of summer case to case incubation interval of PF (Bouma 1996a)

0

20

40

60

80

100

120

140

160

1 3 5 7 9

11

13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

YEARLY WEEK NUMBER

# C

ASE

S

0

10

20

30

40

50

60

1 3 5 7 9

11 13 15 17 19

21

23

25 27 29 31 33 35 37 39 41 43 45

47

49

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# C

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S

Figure 2: Typical seasonal transmission patterns of P vivax and P falciparum seen in most of malaria endemic

Pakistan.

Transmission of malaria in most parts of the country is highly seasonal and unstable with peaks of

transmission in the summer (June-Sept) for P.vivax and relapse episodes are observed in the early summer

(April-June) resulting from transmission in the previous year. Falciparum malaria occurs in the late-

summer and winter months (August-November).

The historical malaria trends in Pakistan from the malaria surveillance system between 1973 and 2012

shows clearly the following:

1) The Annual Parasitic Index (API) decreased rapidly from 1973 (API 13.18) to below 1/1000 in 1977 (

API 0.93) with a sharp decline in the slide positivity rate from 14% to 0.62% with malaria eradication

campaigns in less than 5 years;

2) An upsurge of positive cases was observed from approximately 130.000 cases /year (malaria strategic

plan) between the years 2005 and 2009 to almost 300,000 positive cases in 2012 ( National malaria

disease surveillance report 2012)., The annual parasitic incidence increased from 0.74 in 2009 to 1.46 in

2010 and 1.88 in 2011. Similar trends were observed in low transmission areas of Punjab province which

experienced floods, malaria cases escalated from 3,432 cases in 2009 to approximately 30,000 cases in

2010 (table 1);

3) The blood examination rate ( indicator for malaria surveillance ) decreased from 9.36 in 1973 to 5.46

in 1980 and remained quasi stable approximately 2-3 / 1000 inhabitants between 1983 and 2013 ,

reflecting a poor case detection the past 30 years.;

4) Given the variety of ecotypes in the country (valleys with rivers at various altitudes, agriculture-related

malaria, peri-urban type, migrant malaria) the epidemiology of malaria varies considerably between

provinces / districts and union councils. More detailed spatial analysis with micro-stratification by

districts is critical for malaria control/elimination monitoring

32

Figure 3: Malaria trend 1973-2012

Malaria epidemics are a common occurrence in Pakistan which has a history of unstable transmission.

Between 2010 and 2013, Disease Early Warning System (DEWS) reported majority of malaria alerts and

outbreaks from Baluchistan followed by Sindh, The alerts and outbreaks in both provinces peaked in

2011 and 2012 which was partially attributed to floods and the assignment of DEWS surveillance

officers, thereby making the alerts and outbreaks detection system more efficient. Incidentally,

Baluchistan province comprised of the majority of alerts and outbreaks during 2010-13 (7 out of the 15

districts) with the highest numbers reported from Jaffarabad (44 alerts and 32 outbreaks).

The new malaria information system launched in 2009 in 19 priority districts and managed by the DOMC

observed an increase of API from 7.13 in 2009 to 10.13 in 2012 mainly due to the increased malaria risk

associated with major flood emergency and increased access to RDT and Microscopy. Control measures

whic