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Pakistan Malaria Annual Report 2019
© Directorate of Malaria Control 2019
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Printed in Islamabad, Pakistan
CONTENTS
1. THIS YEAR’S REPORT AT A GLANCE .................................................................................................. 9
1.1. INTRODUCTION ............................................................................................................................................ 9 1.2. DISEASE BURDEN & PROGRAMMATIC ACHIEVEMENTS ............................................................................... 9 1.3. PROVINCIAL FINDINGS (GLOBAL FUND SUPPORTED DISTRICTS) .................................................................. 9 1.4. MALARIA CONTROL & PREVENTION ........................................................................................................... 10
1.4.1. Long Lasting Insecticidal Nets (LLINs) ................................................................................................ 10 1.4.2. Trainings and capacity building activities .......................................................................................... 10 1.4.3. BCC activities ..................................................................................................................................... 10
1.5. ISSUES AND CHALLENGES ........................................................................................................................... 10
2. INTRODUCTION ...................................................................................................................................... 12
2.1. GLOBAL SITUATION .................................................................................................................................... 12 2.2. SITUATION IN PAKISTAN ............................................................................................................................. 12 2.3. PROGRAM GOAL AND OBJECTIVES6 ........................................................................................................... 13
2.3.1. Goal ................................................................................................................................................... 13 2.3.2. Objectives .......................................................................................................................................... 13
3. COUNTRY OVERALL FINDINGS .......................................................................................................... 14
3.1. POPULATION COVERAGE ............................................................................................................................ 14 3.2. OVERALL DISEASE BURDEN IN 2018 ........................................................................................................... 14 3.3. ANNUAL PARASITE INCIDENCE (API) .......................................................................................................... 14 3.4. ANNUAL BLOOD EXAMINATION RATE (ABER) ............................................................................................ 15 3.5. TEST POSITIVITY RATE (TPR) ....................................................................................................................... 15
4. THE GLOBAL FUND (TGF) GRANT SUPPORTED DISTRICTS ........................................................ 16
4.1.1. The Global Fund (TGF) Grant ............................................................................................................. 16 4.1.2. Total number of health facilities under the Global Fund grant ......................................................... 16
4.2. TGF DISTRICTS POPULATION COVERAGE .................................................................................................... 17 4.3. DISEASE BURDEN IN THE GLOBAL FUND SUPPORTED DISTRICTS ............................................................... 17 4.4. ANNUAL PARASITE INCIDENCE (API) .......................................................................................................... 18 4.5. ANNUAL BLOOD EXAMINATION RATE (ABER) ............................................................................................ 19 4.6. TEST POSITIVITY RATE (TPR) ....................................................................................................................... 20 4.7. TREND OF API, ABER AND TPR .................................................................................................................... 20
5. PROVINCIAL ACHIEVEMENTS FOR GLOBAL FUND SUPPORTED DISTRICTS ......................... 22
5.1. KHYBER PAKHTUNKHWA – (GLOBAL FUND SUPPORTED DISTRICTS ONLY) ................................................ 22 5.2. SINDH – (GLOBAL FUND SUPPORTED DISTRICTS ONLY) .............................................................................. 23 5.3. TRIBAL DISTRICTS – (GLOBAL FUND SUPPORTED DISTRICTS ONLY) ............................................................ 25 5.4. BALOCHISTAN – (GLOBAL FUND SUPPORTED DISTRICTS ONLY) ................................................................. 27
6. MALARIA CONTROL INTERVENTIONS ............................................................................................. 29
6.1. LLINS/MOSQUITO NETS DISTRIBTION ........................................................................................................ 29 6.1.1. Mass distribution of LLINs ................................................................................................................. 29 6.1.2. Continuous distribution of LLINs through Antenatal Care (ANC) Clinics ............................................ 30
6.2. TRAINING AND CAPACITY BUILDING OF HEALTHCARE PROVIDERS ............................................................ 30 6.2.1. Malaria case management................................................................................................................ 30 6.2.2. Malaria Diagnosis .............................................................................................................................. 30
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6.2.3. Malaria information system (MIS) and outbreak response ............................................................... 31 6.2.4. Behavior Change Communication (BCC) activities ............................................................................ 31
6.3. UPDATES FROM THE PROCUREMENT AND SUPPLY CHAIN SECTION ............................................................................. 32
7. ISSUES AND CHALLENGES .................................................................................................................. 34
7.1. CASE MANAGEMENT ........................................................................................................................................ 34 7.2. TRAININGS ..................................................................................................................................................... 34 7.3. BEHAVIOR CHANGE COMMUNICATION ................................................................................................................. 34 7.4. LLINS DISTRIBUTION ........................................................................................................................................ 35 7.5. QUALITY ASSURANCE (QA) ............................................................................................................................... 35 7.6. SURVEILLANCE & OUTBREAK RESPONSE ............................................................................................................... 35 7.7. STOCKS MANAGEMENT ..................................................................................................................................... 36
8. SUCCESS STORIES.................................................................................................................................. 37
8.1. ‘A RAY OF HOPE FOR PEOPLE IN NEED’ ................................................................................................................. 37 8.2. ‘STRENGTHENING THE POWER OF POOR COMMUNITIES’ .......................................................................................... 37 8.3. ‘IT’S NOT AN EVIL SPIRIT’ ................................................................................................................................... 38
9. ANNEXURES ............................................................................................................................................ 39
9.1. LIST OF THE GLOBAL FUND GRANT SUPPORTED DISTRICTS ........................................................................................ 39
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LIST OF FIGURES
FIGURE 1 SHARE OF ESTIMATED MALARIA CASES, 2017 ........................................................................................................... 12 FIGURE 2 PROPORTION OF PLASMODIUM SPECIES, 2010 AND 2017 .......................................................................................... 12 FIGURE 3 API, ABER AND TPR IN 2018 .............................................................................................................................. 14 FIGURE 4 TOTAL CONFIRMED MALARIA CASES IN 2018 ............................................................................................................ 14 FIGURE 5 COUNTRY ANNUAL PARASITE INCIDENCE (API) OF 2018 ............................................................................. 14 FIGURE 6 COUNTRY ANNUAL BLOOD EXAMINATION RATE (ABER) FOR 2018 ........................................................... 15 FIGURE 7 COUNTRY TEST POSITIVITY RATE (TPR) FOR 2018 ...................................................................................... 15 FIGURE 8 FUNCTIONAL HEALTH FACILITIES UNDER DOMC AND TIH IN 2018 .............................................................................. 16 FIGURE 9 REPORTED CONFIRMED MALARIA CASES IN 2018 ....................................................................................................... 17 FIGURE 10 CONFIRMED MALARIA CASES REPORTED BY THE PROVINCES IN 2018 ........................................................................... 17 FIGURE 11 MONTHLY TRENDS OF CASES FROM 2014-2018 .......................................................................................... 18 FIGURE 12 ABER, API AND TPR IN 2018 .................................................................................................................... 18 FIGURE 13 ANNUAL PARASITE INCIDENCE (API) OF 2018 ............................................................................................ 18 FIGURE 14 COMPARISON OF API DURING 2012–2018 .................................................................................................. 19 FIGURE 15 ANNUAL BLOOD EXAMINATION RATE (ABER) FOR 2018 .......................................................................... 19 FIGURE 16 COMPARISON OF ABER DURING 2012–2018 .............................................................................................. 20 FIGURE 17 TEST POSITIVITY RATE (TPR) FOR 2018 ..................................................................................................... 20 FIGURE 18 COMPARISON OF TPR DURING 2012–2018 ................................................................................................. 20 FIGURE 19 TRENDS OF API, ABER AND TPR DURING 2012–2018 ............................................................................... 21 FIGURE 20 DISTRICT WISE DISTRIBUTION OF CASES IN KP 2018 ................................................................................... 22 FIGURE 21 BER, API AND TPR COMPARISON DISTRICT WISE OF KP 2018 ................................................................... 22 FIGURE 22 MONTHLY TREND OF CASES REPORTED IN KP IN 2018 ................................................................................ 23 FIGURE 23 YEAR WISE MONTHLY TREND OF CASES IN KP FROM 2014-2018 ................................................................ 23 FIGURE 24 DISTRICT WISE DISTRIBUTION OF CASES IN SINDH 2018 .............................................................................. 24 FIGURE 25 BER, API AND TPR COMPARISON DISTRICT WISE OF SINDH 2018 .............................................................. 24 FIGURE 26 MONTHLY TREND OF CASES REPORTED IN SINDH IN 2018 ........................................................................... 24 FIGURE 27 YEAR WISE MONTHLY TREND OF CASES IN SINDH FROM 2014-2018 ........................................................... 25 FIGURE 28 MONTHLY TREND OF CASES REPORTED FROM TRIBAL DISTRICTS DURING 2018 ......................................... 26 FIGURE 29 YEAR WISE MONTHLY TREND OF CASES FROM 2014-2018 .......................................................................... 26 FIGURE 30 DISTRICT WISE DISTRIBUTION OF CASES IN BALOCHISTAN 2018 ................................................................. 27 FIGURE 313 BER, API AND TPR COMPARISON DISTRICT WISE OF BALOCHISTAN DURING 2018 .................................. 27 FIGURE 32 MONTHLY TREND OF CASES REPORTED IN BALOCHISTAN IN 2018 .............................................................. 28 FIGURE 33 YEAR WISE MONTHLY TREND OF CASES FROM 2014-2018 .......................................................................... 28 FIGURE 34 MASS DISTRIBUTION OF LLINS IN PROVINCES/REGIONS IN 2018 ............................................................... 29 FIGURE 35 DISTRICT WISE MASS DISTRIBUTION OF LLINS IN 2018 .............................................................................. 30 FIGURE 36 LLINS ANC DISTRIBUTION IN 2018 ............................................................................................................ 30 FIGURE 37 MALARIA TRAININGS CONDUCTED IN 2018 ................................................................................................. 31 FIGURE 38 BCC (ADVOCACY AND AWARENESS) SESSIONS CONDUCTED IN 2018 ......................................................... 32
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FOREWORD
Year 2018 has been one of the most successful years for malaria control program
in Pakistan. The achievements for both the malaria case management and
prevention were acknowledged and appreciated at the highest level by World
Health Organization (WHO), Alliance for Malaria Prevention (AMP) and other
partners. The main credit of all these achievement goes to the provincial programs
who are working hard for ensuring the correct execution of the planned
interventions in the best possible manner.
This annual report provides information for the malaria disease burden across Pakistan for 2018. A total of
374,513 confirmed malaria cases have been reported from all the health facilities across Pakistan to the
federal directorate. Around 6.5 million malaria suspects were screened at these health facilities. Highest
numbers of the reported cases were P. Vivax (PV) 84.0% (314,574) followed by P. Falciparum (PF) 14.9%
(55,639) and Mix cases 1.1% (4,300). The situation is more or less same as compared to the last year.
However, now we have more windows of opportunities in the shape of availability of latest updated manuals
and guidelines, and online DHIS-2 reporting system for better case management and surveillance systems.
We have been successful in engaging more private practitioners in the highest malaria endemic districts
and now the overall number of private health facilities providing free of cost malaria diagnostic and
treatment services exceeds 900.
Now our responsibility has been increased many folds where all these achievements have to be sustained
with even more progress. It is our responsibility to ensure that correct and true data is captured and reported
at all levels. We have to assure the highest quality of the diagnostic services. Moreover, we have to
communicate the right message to all stakeholders till the level of a health workers sitting at the facility
level and providing services. We have to build their technical skills and capacity for providing best quality
services. Now is the time to ensure that we all take the responsibility of mobilizing our own domestic
resources for malaria control activities in Pakistan. This will help in sustaining the gains made by the
programs through the Global Fund support. We need to ensure that proper planning is carried out for
appropriate utilization of these resources.
I have firm belief that if all these efforts are continued in the best spirit coupled with dedication and
commitment, we will be able to eliminate malaria from Pakistan very soon.
Dr. Abdul Baseer Khan Achakzai
Director, Directorate of Malaria Control (DOMC)
M/O NHSR&C, Islamabad.
ACKNOWLEDGMENTS
Malaria annual report has been regularly developed by the Directorate of Malaria Control (DOMC) since
2016 onwards. This year report is focused on reporting of the malaria burden from all districts of Pakistan
including those supported by the Global Fund grant. The report has been developed primarily through a
secondary analysis of the programmatic and surveillance data received at the DOMC for the malaria control
activities in Pakistan.
We are extremely thankful to our technical partner, the World Health Organization (WHO), the Provincial
Malaria Control Programs of Balochistan, Khyber Pakhtunkhwa, Tribal Districts (Ex. FATA), Punjab and
Sindh, the Global Fund, and Alliance for Malaria Prevention (AMP) for supporting malaria control
activities in Pakistan.
We would also like to appreciate the private sector Principal Recipient (PR), Indus Health Network
(IHN/TIH) and Sub-Recipients (SRs) of this grant including Association for Community Development
(ACD), Balochistan Rural Support Program (BRSP), Frontier Primary Health Care (FPHC), National Rural
Support Program (NRSP), and Pakistan Lions Youth Council (PLYC) for all their hard work and efforts to
ensure that all the planned activities are timely executed in the best possible manner.
Lastly, we owe pronounced acknowledgements for the needy, deserving and suffering communities living
in the high endemic districts of Pakistan who have been a great source of motivation for us to deliver in the
field and continuously strive for malaria elimination from Pakistan.
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ABBREVIATIONS
ABER Annual blood examination rate
ACD Association for Community Development
ACTs Artemisinin-based combination therapy
AJK Azzad Jammu Kashmir
ANC Ante-natal care
API Annual parasite incidence
BCC Behavior change communication
BHU Basic health unit
BRSP Balochistan Rural Support Program
CD Civil dispensary
CMU Common unit for managing the Global Fund grant
DHIS District health information system
DHQ District headquarter
DOMC Directorate of malaria control
FATA Federally administered tribal areas
FPHC Frontier Primary Health Care
GTS Global Technical Strategy
IHN Indus Health Network
IRS Indoor residual spray
ITN Insecticide treated nets
IVC/MCP Integrated vector control/malaria control programme
IVMP Integrated vector management programme
KP Khyber Pakhtunkhwa
LLINs Long-lasting insecticidal nets
MS Microscopy
MDGs Millennium Development Goals
MIS Malaria information system
NFR New funding request
NRSP National Rural Support Program
PF Plasmodium falciparum
PLYC Pakistan Lions Youth Council
PR Principal recipient
PRL Provincial reference laboratory
PV Plasmodium vivax
RDT Rapid diagnostic test
RHC Rural health center
SDGs Sustainable Development Goals
SPR Slide positivity rate
SR Sub-recipients
TD Tribal Districts
TGF the Global Fund
THQ Tehsil headquarter
TIH The Indus Hospital
TPR Test Positivity Rate
WHO World Health Organization
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1. THIS YEAR’S REPORT AT A GLANCE
1.1. INTRODUCTION
Directorate of Malaria Control (DOMC) in collaboration with the Provincial Malaria Control Programs of
all the provinces has been providing malaria preventive and treatment services all over the country.
1.2. DISEASE BURDEN & PROGRAMMATIC ACHIEVEMENTS
Overall country disease burden
A total of 374,513 confirmed malaria cases have been reported from all the public sector health facilities
across Pakistan and private health clinics in high malaria burden districts to the federal directorate. Around
6.5 million malaria suspects were screened at these health facilities. Highest numbers of the reported cases
were P. Vivax (PV) 84.0% (314,574) followed by P. Falciparum (PF) 14.9 % (55,639) and Mix cases 1.1%
(4,300).
The cumulative API of all the districts/agencies of Pakistan in 2018 was 1.7 with ABER of 3.0 and TPR of
5.7. Provincial breakdown indicates that during 2018 highest number of cases was reported from Sindh
34.5% (129,085), Khyber Pakhtunkhwa 31.0% (115,995) followed by Tribal Districts 17.6% (65,853),
Balochistan 16.4% (61,510), Punjab 0.5% (1,875) and AJK 0.1% (195).
The Global Fund Grant supported districts
The population coverage in the Global Fund supported districts was 56.1 million. A total of 3,818 public
and private diagnostic centers (Microscopy + RDT) were fully functional in 72 districts supported through
the Global Fund grant during 2018. These included 2,867 health facilities in the DOMC supported districts
while 951 health facilities in the TIH/IHN covered districts.
Around 3.4 million suspects were screened for malaria at these health facilities which was around 0.4
million more suspects screened as compared to 2017. A slight increase in the overall number is seen from
0.34 million in 2017 to 0.35 million confirmed malaria cases in 2018. A total of 351,551 confirmed malaria
cases were reported from the Global Fund grant supported health facilities during 2018 as compared to
344,043 cases in 2017; an increase of 7,508 cases. Highest number of the reported cases were P. Vivax (PV)
84% (293,244), followed by P. Falciparum (PF) 15% (54,014) and Mix cases 1% (4,293). It has been seen
that the proportion of P. Vivax cases has increased by 03% and mix cases has decreased by around 03% in
2018 as compared to 2017. This may be attributed to the type of RDT kits (Pf/Pv combo) being used in the
grant supported health facilities which are more specific for detection of the P. Vivax and P. Falciparum
cases.
1.3. PROVINCIAL FINDINGS (GLOBAL FUND SUPPORTED DISTRICTS)
Provincial breakdown shows that during 2018 highest number of cases were reported from KP 32%
(112,224) and Sindh 32% (111,920), followed by Balochistan 17% (60,896), Tribal Districts 19% (65,853)
and Punjab 0.2% (658). This was similar to the last year where Khyber Pakhtunkhwa and Sindh had
reported the highest number of cases. Sindh has reported approx.: 30,700, and Khyber Pakhtunkhwa
approx.: 5,300 more number of cases as compared to last year. Tribal Districts have reported approx.:
15,000, while Balochistan approx.: 12,000 lesser cases as compared to last year.
The average API of these 72 districts during 2018 was 6.3 with ABER of 6.0 and TPR of 10.4 as compared
to the reported API of 6.3, ABER of 5.4 and TPR of 11.6 in 2017 (Figure: 12). It means that there is no
change in the reported API, ABER has slightly improved by 11% and TPR has decreased by 10% as
compared to the last year.
Regarding the trend of peak malaria season, highest number of cases during 2018 were reported with a peak
reaching in the month of September. The trend is almost the same in previous four years with highest
number of cases reported from August to October.
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1.4. MALARIA CONTROL & PREVENTION
1.4.1. Long Lasting Insecticidal Nets (LLINs)
Approximately 2.5 million LLINs were distributed in 11 TGF covered districts in 2018. Highest number of
LLINs (1.2 million) distributed through mass distribution was seen in the Sindh province. Highest number
of LLINs distributed through mass distribution was seen in Mirpurkhas, Sindh (549,215) followed by DI
Khan (434,538).
A total of 360,999 LLINs were distributed in 2018 as compared to 233,398 distributed in 2017 through the
ANC clinics. Highest distribution took place in Khyber Pakhtunkhwa province
1.4.2. Trainings and capacity building activities
A total of 2,823 HCPs were trained on malaria case management, and a total of 1,348 malaria technicians
were trained on malaria diagnosis during 2018. No trainings on MIS were conducted.
1.4.3. BCC activities
Around 59 BCC Coordinators/officers of Balochistan, Sindh, KP and FATA were trained on BCC SOPs
and Flip charts. Additionally, 15 participants from public SR such as M&E coordinators/Officer and
Program officers were also trained from Oct to Dec 2018.
1.5. ISSUES AND CHALLENGES
Following are the main issues and challenges faced during the year:
▪ Blood examination rates remained low in many districts of Balochistan and Khyber Pakhtunkhwa
which may be due to the reason that all fever cases were not tested for malaria.
▪ The private sector is partially covered and their regulation is still a big challenge and many of them do
not follow the national treatment guidelines. The communities in many places have low treatment
seeking behavior.
▪ Non-availability and willingness/interest (due to low per-diems) of the trained master trainers for
executing the step-down trainings in the desired dates, nomination of proper relevant staff to be trained,
shortage and non-availability of medical doctors or relevant staff in remote districts of Balochistan and
Tribal Districts.
▪ Insufficient funds for training greater number of doctors and other relevant staff in the targeted health
facilities, coordination issues with PPHI (in Sindh), frequent transfer and turn-over of trained staff,
training of doctors in non-Global Fund supported districts and preference of Urdu and English language
for the training manual in different settings.
▪ Delivery of the awareness sessions to women and monitoring of these sessions has been challenging in
some areas where LHWs are not willing to work. Other challenges included the provision of CNIC
copy particularly in Tribal Districts, and taking pictures of female sessions.
▪ Lesser distributions of LLINs through ANC clinics in far flung areas of Balochistan due to low
utilization of ANC services, non-availability of CNICs with ANC women, weak control mechanisms
of tracing ANC women getting LLIN from adjacent or multiple ANC centers within a district, and
improper documentation of issued LLINs in the distribution registers.
▪ Regarding mass distribution campaign, weaker coordination was observed amongst various
stakeholders at district level during microplanning process. Compromised quality of trainings for
household registration and distribution of nets, issues with the connectivity and updating of ODK
software, missing areas/villages and population, weaker BCC activities and coverage, and duplication
of coupons during printing process were other major gaps.
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▪ The slides collection from all the microscopy centers and sending these to the provincial reference
laboratories (PRL) in a timely manner has been challenging in many targeted districts except Sindh and
Khyber Pakhtunkhwa.
▪ DHIS-2 is still not fully functional and issues with reporting have been reported. Data punching in
DHIS-2 gets delay due to internet issue in the districts.
▪ Keeping in view the higher number of facilities in many districts, the time is not sufficient to ensure
good quality of data verification on quarterly basis. Due to change in frequency of the monthly meetings
to the quarterly, frequent variances have been noted in the compiled data by the provincial DMU in-
charge and the private SRs. Implementation of online DHIS-2 is expected to address these gaps.
▪ Timely alert generation and outbreak detection remained a big challenge. Weekly watch charts although
installed in almost all public health facilities are not regularly updated and used properly and unusual
rise in cases is not timely reported.
2. INTRODUCTION
2.1. GLOBAL SITUATION
Malaria continues to claim the lives of more than
435 000 people each year. The World malaria report
2018 estimates that there were 219 million cases of
malaria in 2017. The 10 highest burden African
countries saw an estimated 3.5 million more malaria
cases in 2017 compared with the previous year. The
report shows that most of the countries are off
course to meet two critical 2020 milestones of the
WHO Global Technical Strategy for Malaria 2016-
2030: reducing case incidence and death rates by at
least 40% from 2015 levels. However, there are
pockets of progress; more countries are getting
closer to eliminating malaria, and several others
including Ethiopia, India, Pakistan and Rwanda
recorded substantial declines in cases in 2017.
About 82% of estimated vivax malaria cases in 2017
occurred in just five countries (India, Pakistan,
Ethiopia, Afghanistan and Indonesia). In 2018,
Pakistan was one of the countries reporting a
decrease of more than 240,000 cases (20% decrease
as compared to 2016). However, about 82% of
estimated vivax malaria cases in 2017 occurred in
just five countries (India, Pakistan, Ethiopia,
Afghanistan and Indonesia) 1.
2.2. SITUATION IN PAKISTAN
Like in other parts of the world malaria is a leading
cause of morbidity and mortality in Pakistan. It is
one of the 6 priority communicable diseases posing
threat to the health of millions. With one million
estimated and 300,000 confirmed reported cases
each year, Pakistan has been grouped with
Afghanistan, Somalia, Sudan and Yemen
accounting for more than 95% of the total regional
malaria burden2.
Pakistan is among seven countries of the WHO
Eastern Mediterranean Region sharing 98% of the
total regional malaria burden.3 An estimated 98% of
Pakistan population (205 million) is at varying risk
while around 60% (123 million) population at high
risk for malaria. In this country, Malaria with
Plasmodium vivax is more common (88%), while
malaria with Plasmodium falciparum is seen only
during rainy seasons or post rain accounting for
12% of the malaria burden4.
1 WHO, World Malaria Report 2018 2 http://www.emro.who.int/pak/programmes/roll-back-
malaria.html accessed on 20th July 2019 3 EMRO WHO. Country Total reported cases Total confirmed Total reported cases Total confirmed Total
reported cases Total confirmed Afghanistan Djibouti. 2016;1–6 4 Khattak AA, Venkatesan M, Nadeem MF, Satti HS, Yaqoob A, Strauss K, et al. Prevalence and distribution of human Plasmodium infection in Pakistan. Malar J. 2013;12(1):1–8
Figure 1 Share of estimated malaria cases, 2017 Figure 2 Proportion of Plasmodium species, 2010 and 2017
P.falciparum and P.vivax are the only reported
parasite species with later the most predominant one
(>80%). A.culicifacies and A.stephensi are known
primary vectors involved in the transmission of
malaria. Both the vectors are considered to be
essentially endophilic in their diurnal resting and
mainly zoophilic.
Mass population movements within the country and
across international borders, unpredictable
transmission patterns, the low immune status of the
population, climatic changes, poor socioeconomic
conditions, declining health infrastructure, resource
constraints, poor access to preventive and curative
services, and mounting drug and insecticide
resistance in parasites and vectors, all contribute to
this huge disease burden5.
Malaria stratification6 according to the National
Strategic Plan (2015-2020) shows three
epidemiological strata. Stratum-I (API/TPR>5
annually) has the highest significance and includes
72 out of the total 151 districts7. A significant
reduction was observed in the overall incidence of
P. falciparum cases by >80% (73,925 in 2011 to
18,432 in 2015) in TGF supported districts8. This
reduction is attributed mainly to TGF interventions
including ACT and LLINs. Epidemiologically, it is
classified as a moderate malaria endemic country
with a National annual parasite incidence (API)
averaging at 1.8. Annual program data of 2017
shows that there is high variation of API within
different provinces of Pakistan (Sindh 2.0, KP 3.6,
Balochistan 6.3, Tribal Districts 16.2 and Punjab
0.01)9.
2.3. PROGRAM GOAL AND OBJECTIVES6
2.3.1. Goal
By 2020, reduce the malaria burden by 75% in high and moderate endemic districts and eliminate malaria
in low endemic districts of Pakistan.
2.3.2. Objectives
The key objectives of the programme are:
1. To achieve <5 API in high endemic areas of Balochistan, Sindh, KP and Tribal Districts by 2020
2. To achieve <1% API within moderate endemic districts of Balochistan, Sindh, KP and Punjab by 2020
3. To achieve Zero API within low endemic districts of Sindh, KP and Punjab by 2020
Specific Objectives
1) To ensure and sustain the provision of quality assured early diagnosis and prompt treatment services to
>80% at risk population by 2020,
2) To ensure and sustain coverage of multiple prevention interventions (IRS, LLINs & and other
innovative tools and technologies) to 100% in the target high risk population as per national guidelines
and coverage in foci in moderate and low risk districts by 2020,
3) To increase community awareness up to 80% on the benefits of early diagnosis and prompt treatment
and malaria prevention measures using health promotion, advocacy and BCC intervention,
4) To enhance technical and managerial capacity in planning, implementation, management and MEAL
(Monitoring, Evaluation, Accountability and Learning) of malaria prevention and control intervention,
5) To ensure availability of quality assured strategic information (epidemiological, entomological and
operational) for informed decision making and; functional, passive and active case based weekly
surveillance system in all low risk districts, and
6) To ensure provision of malaria prevention, treatment and control services in humanitarian crises,
emergencies and cross-border situation.
5 http://www.emro.who.int/pak/programmes/roll-back-
malaria.html accessed on 20th July 2018 6 Strategic Plan Malaria Control Program Pakistan
(2015-2020)
7 Pakistan Bureau of Statistics;
http://www.pbscensus.gov.pk/content/distribution-
districts-phases 8 Routine malaria information system 2015 9 Unit PM. Malaria Annual Report 2016.
3. COUNTRY OVERALL FINDINGS
3.1. POPULATION COVERAGE
Directorate of Malaria Control (DOMC) in
collaboration with the Provincial Malaria Control
Programs of all the provinces has been providing
malaria preventive and treatment services all over
the country. During 2018, the interventions were
carried out at primary health facilities including
Basic Health Units (BHUs) and Civil Dispensaries
(CDs), secondary level health facilities including
District Headquarter (DHQ) hospitals, Tehsil
Headquarter (THQ) hospitals and Rural Health
Centers (RHC). The catchment population of all
health facilities providing malaria diagnostic and
treatment services in the country was approximately
214,673,566.
3.2. OVERALL DISEASE BURDEN IN 2018
A total of 374,513 confirmed malaria cases have
been reported from all the health facilities across
Pakistan to the federal directorate. Around 6.5
million malaria suspects were screened at these
health facilities. Highest numbers of the reported
cases were P. Vivax (PV) 84.0% (314,574) followed
by P. Falciparum (PF) 14.9% (55,639) and Mix
cases 1.1% (4,300). (Figure: 3) The cumulative API
of all the districts/agencies of Pakistan in 2018 was
1.7 with ABER of 3.0 and TPR of 5.7. Provincial
breakdown indicates that during 2018 highest
number of cases was reported from Sindh 34.5%
(129,085), Khyber Pakhtunkhwa 31.0% (115,995)
followed by Tribal Districts 17.6% (65,853),
Balochistan 16.4% (61,510), Punjab 0.5% (1,875)
and AJK 0.1% (192).
3.3. ANNUAL PARASITE INCIDENCE (API)
The overall API of country was 1.7. Highest API was reported by Tribal Districts (12.9) followed by
Balochistan, Khyber Pakhtunkhwa and Sindh while lowest was reported by Punjab and AJK. (Figure:5)
Figure 5 Country Annual Parasite Incidence (API) of 2018
0.0 0.0
2.63.7 4.1
12.9
1.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
AJK Punjab Sindh KhyberPakhtunkhwa
Balochistan TribalDistricts
Overall
Figure 3 API, ABER and TPR in 2018 Figure 4 Total confirmed malaria cases in 2018
3.0
5.7
1.7
0.0
2.0
4.0
6.0
8.0
ABER TPR API
314,575
55,6394,300
374,513
P. Vivax P.Falciparum
Mix Confirmedcases
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3.4. ANNUAL BLOOD EXAMINATION RATE (ABER)
The overall ABER10 for all country was 3.0. Tribal Districts (9.2) reported the highest ABER followed by
Balochistan (4.9). (Figure: 6)
Figure 6 Country Annual Blood Examination Rate (ABER) for 2018
3.5. TEST POSITIVITY RATE (TPR)
The reported cumulative TPR was 5.7. Tribal Districts reported the highest TPR of 14.0 followed by
Khyber Pakhtunkhwa (11.2), and Balochistan (8.2) as shown in Figure: 7.
Figure 7 Country Test Positivity Rate (TPR) for 2018
10 Annual Blood Examination Rate (ABER) = The number of patients receiving a parasitological test for
malaria (blood slide for microscopy or malaria rapid diagnostic test) per 100 population per year
2.23.3 3.6
4.9
9.2
3.0
0.0
2.0
4.0
6.0
8.0
10.0
Punjab KhyberPakhtunkhwa
Sindh Balochistan Tribal-Districts Overall
ABER
0.1 0.3
7.3 8.2
11.2
14.0
5.7
0
5
10
15
Punjab AJK Sindh Balochistan KhyberPakhtunkhwa
Tribal-Districts
TPR
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4. THE GLOBAL FUND (TGF) GRANT SUPPORTED DISTRICTS
4.1.1. The Global Fund (TGF) Grant
Since 2002, The Global Fund has been supporting the Government of Pakistan malaria control interventions
in the malaria highest endemic districts. The support
is focused for strengthening the malaria diagnostic,
treatment and preventive services. The facility level
services include screening of the suspects for
malaria through microscopy and rapid diagnostic
test (RDT), and confirmation followed by the
treatment of malaria cases as per the national
treatment guidelines. The preventive services
include the distribution of Insecticide Treated Nets
(ITNs) and Indoor Residual Spray (IRS)11.
Directorate of Malaria Control Program (DOMC) is
the public sector Principal Recipient (PR) for the
Global Fund current grant while Indus Health
Network (IHN/TIH) is the private sector PR for the
duration of 2018-2020. In 2018, DOMC
implemented Malaria Control interventions in
overall 53 highly endemic districts (Table 1)
through eight public and private Sub-Recipients
(SRs). These districts include 19 from Balochistan,
13 from Tribal Districts, seven from Khyber
Pakhtunkhwa, 13 from Sindh and one from Punjab.
Public sector SRs for DOMC are Integrated Vector
Control / Malaria Control Program (IVC/MCP)
Khyber Pakhtunkhwa (KP), Integrated Vector
Management Program (IVMP) Tribal Districts,
Directorate of Malaria Control (DOMC) Sindh and
Directorate of Malaria/ Vector Borne Diseases
(VBD) Balochistan. Private sector SRs were
Association for Community Development (ACD),
Balochistan Rural Supports Programme (BRSP),
National Rural Support Program (NRSP), and
Pakistan Lions Youth Council (PLYC).
TIH/IHN is implementing similar interventions in
overall 19 districts including seven in KP and 12 in
Balochistan through two SRs namely Balochistan
Rural Support Program (BRSP) and Frontier
Primary Health Care (FPHC).
4.1.2. Total number of health facilities under the Global Fund grant
A total of 3,818 public and private diagnostic
centers (Microscopy + RDT) were fully functional
in 72 districts supported through the Global Fund
grant during 2018. These included 2,867 health
facilities in the DOMC supported districts while 951
health facilities in the TIH/IHN covered districts.
(Figure: 8) There is an increase of around 422 health
facilities during 2018 as compared to 2017.
11 The Global Fund. Pakistan - Country Overview [Internet]. [cited 2018 Mar 30]. Available from:
https://www.theglobalfund.org/en/portfolio/country/
184502
265
951452
1762
653
2867
0500
100015002000250030003500
Public Public Private
Microscopy RDT Total
TIH DOMC
Figure 8 Functional Health Facilities under DOMC and TIH in 2018
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4.2. TGF DISTRICTS POPULATION COVERAGE
The population coverage in the Global Fund supported districts increased from 54.4 million in 2017 to 56.1
million in 2018 in four provinces12.
4.3. DISEASE BURDEN IN THE GLOBAL FUND SUPPORTED DISTRICTS
The number of reporting grant supported districts from all over Pakistan was 72 in 2018. The number of
functional health facilities providing malaria diagnostic services by the end of the year was 3,818. Around
3.4 million suspects were screened for malaria at these health facilities which was around 0.4 million more
suspects screened as compared to 2017.
A slight increase in the overall number is seen
from 0.34 million in 2017 to 0.35 million
confirmed malaria cases in 2018. A total of
351,551 confirmed malaria cases were
reported from the Global Fund grant
supported health facilities during 2018 as
compared to 344,043 cases in 2017; an
increase of 7,508 cases. Highest number of
the reported cases were P. Vivax (PV) 84%
(293,244), followed by P. Falciparum (PF)
15% (54,014) and Mix cases 1% (4,293); as
shown in Figure: 9. It has been seen that the
proportion of P. Vivax cases has increased by
03% and mix cases has decreased by around 03% in 2018 as compared to 2017. This may be attributed to
the type of RDT kits (Pf/Pv combo) being used in the grant supported health facilities which are more
specific for detection of the P. Vivax and P. Falciparum cases.
Provincial breakdown shows that during 2018
highest number of cases were reported from
KP 32% (112,224) and Sindh 32% (111,920),
followed by Balochistan 17% (60,896), Tribal
Districts 19% (65,853) and Punjab 0.2%
(658). This was similar to the last year where
Khyber Pakhtunkhwa and Sindh had reported
the highest number of cases. Sindh has
reported approx.: 30,700, and Khyber
Pakhtunkhwa approx.: 5,300 more number of
cases as compared to last year. Tribal
Districts have reported approx.: 15,000, while
Balochistan approx.: 12,000 lesser cases as
compared to last year.
Regarding the trend of peak malaria season, highest number of cases during 2018 were reported with a peak
reaching in the month of September (Figure: 11). The trend is almost the same in previous four years with
highest number of cases reported from August to October.
12 Population has been estimated based on 2017 census population with actual district wise growth rates
Figure 9 Reported confirmed malaria cases in 2018
Figure 10 Confirmed malaria cases reported by the Provinces in 2018
MIX, 4,293, 1%
PF, 54,014, 15%
PV, 293,244,
84%
MIX PF PV
Khyber
Pakhunkh
wa,
112,224,
32%
Sindh,
111,920,
32%
Balochista
n , 60,896,
17%
Tribal
Districts,
65,853,
19%
Punjab,
658, 0%
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Figure 11 Monthly trends of cases from 2014-2018
The average API of these 72 districts during 2018
was 6.3 with ABER of 6.0 and TPR of 10.4 as
compared to the reported API of 6.3, ABER of 5.4
and TPR of 11.6 in 2017 (Figure: 12). It means that
there is no change in the reported API, ABER has
slightly improved by 11% and TPR has decreased
by 10% as compared to the last year.
Figure 12 ABER, API and TPR in 2018
4.4. ANNUAL PARASITE INCIDENCE (API)
The average API for TGF supported districts was
6.3. Highest API was reported by Tribal Districts
(12.9) followed by Khyber Pakhtunkhwa, Sindh and
Balochistan while the lowest was reported by
Punjab (0.7). (Figure: 13).
Figure 13 Annual Parasite Incidence (API) of 2018
11,3368,925
13,309
21,051
30,73529,959
35,632
48,496
58,119
49,989
27,544
16,456
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2018 2017 2016 2015 2014
6.0 6.3
10.4
0.0
5.0
10.0
15.0
ABER API TPR
0.2
5.06.2 6.3
12.9
6.3
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Punjab Balochistan Sindh KhyberPakhtunkhwa
Tribal Districts Overall
Under the Global Fund grant, the number of
targeted districts for intervention has been varying
over the period of time. API declined from 7.8 per
1000 per year in 2012 to 5.5 in 2015. The 2016 API
showed an increase in malaria incidence which
could be attributed to the increase in coverage of the
malaria diagnostic and case management services.
However, API estimates for year 2017 showed a
decline as compared to 2016 due to the inclusion of
many new districts under the grant as the TGF
support was enhanced from 43 districts in 2016 to
72 districts in 2017 and the population was
increased by around 164% for the grant supported
districts. The reported API during 2018 was same as
reported the last year. The year-wise comparison of
the APIs from 2012–2018 is shown in the graph
below: (Figure: 14)
Figure 14 Comparison of API during 2012–2018
4.5. ANNUAL BLOOD EXAMINATION RATE (ABER)
The ABER13 for TGF supported districts during
2018 was reported to be 6.0. Tribal Districts (9.2)
reported the highest ABER followed Sindh,
Balochistan and Khyber Pakhtunkhwa. Punjab (0.9)
reported the lowest ABER. (Figure: 15)
Figure 15 Annual Blood Examination Rate (ABER) for 2018
The blood screening rate has shown slight
improvement of approx.: 11% during 2018 (6.0) as
13 Annual Blood Examination Rate (ABER) = The
number of patients receiving a parasitological test for
compared to 2017 (5.4). Year wise comparison
since 2012 is shown in Figure: 16.
malaria (blood slide for microscopy or malaria rapid
diagnostic test) per 100 population per year
7.8 7.9 7.3
5.5
10.3
6.3 6.3
0.0
2.0
4.0
6.0
8.0
10.0
12.0
2012 2013 2014 2015 2016 2017 2018
0.9
5.4 6.0 6.5
9.2
6.0
0.0
2.0
4.0
6.0
8.0
10.0
Punjab KhyberPakhtunkhwa
Balochistan Sindh Tribal Districts Overall
Figure 16 Comparison of ABER during 2012–2018
4.6. TEST POSITIVITY RATE (TPR)
The reported cumulative TPR was 10.4 for the year
2018. Tribal Districts reported the highest TPR of
14.0 followed by Khyber Pakhtunkhwa reporting
11.6. (Figure: 17) Sindh and Khyber Pakhtunkhwa
have reported an increase in TPR by around 12%
and 08% respectively as compared to the last year.
Punjab, Balochistan and Tribal Districts reported a
decline in TPR by approx:69%, 38%, and 13%
respectively as compared to the last year.
Figure 17 Test Positivity Rate (TPR) for 2018
The yearly trends show that TPR in cumulative TPR in 2018 (10.4) has slightly declined by approx.: 10%
as compared to 2017 (11.6). (Figure: 18).
Figure 18 Comparison of TPR during 2012–2018
4.7. TREND OF API, ABER AND TPR
The trends analysis for API, ABER and TPR for the
last seven years is shown in the graph below.
(Figure: 19) The reported API during 2018 is same
as reported last year. The ABER has shown slight
improvement of around 11% while the TPR has
decreased by approx.: 10% during 2018 as
compared to 2017. Due to ABER still just around
6.0 in the grant supported districts, the TPR may not
be true reflective of the malaria endemicity.
5.9 6.27.1
6.0
8.4
5.46.0
0.0
2.0
4.0
6.0
8.0
10.0
2012 2013 2014 2015 2016 2017 2018
2.5
8.3 9.511.6
14.0
10.4
0
5
10
15
Punjab Balochistan Sindh KhyberPakhtunkhwa
Tribal Districts Overall
16.613.2
10.6 10.512.2 11.6 10.4
0.0
5.0
10.0
15.0
20.0
2012 2013 2014 2015 2016 2017 2018
Figure 19 Trends of API, ABER and TPR during 2012–2018
7.8 7.97.3 5.5
10.36.3 6.35.9 6.2
7.1 6.0
8.45.4 6.0
16.6
13.210.6 10.5
12.2 11.6 10.4
0.0
5.0
10.0
15.0
20.0
2012 2013 2014 2015 2016 2017 2018
API ABER TPR
5. PROVINCIAL ACHIEVEMENTS FOR GLOBAL FUND SUPPORTED DISTRICTS
5.1. KHYBER PAKHTUNKHWA – (GLOBAL FUND SUPPORTED DISTRICTS ONLY)
A total of 112,224 confirmed malaria positive cases
including 108,829 Pv (97%), 2,994 Pf (3%) and 401
Mix (0.4%) cases were reported from 14 GF grant
supported districts of KP during 2018. Last year the
total positive cases reported were 106,915 with
almost a similar proportion of Pv, Pf and Mix cases.
The reported API was 6.3, ABER was 5.4 and TPR
was 11.6 as compared to API of 6.2, ABER of 4.6
and TPR of 13.4 during the last year. Hence, the
percent change in ABER was 17% (increased) and
TPR was 13% (decreased) as compared to the last
year. Considering district wise situation, the highest
number of cases were reported from Mardan
(18,043) followed by Lower Dir (14,455) and DIK
(12,145). (Figure: 20) Last year, DIK had reported
the highest number of malaria positive cases
(13,182).
Figure 20 District wise distribution of cases in KP 2018
The highest API was reported from district Tank (12.0) followed by Buner (11.4) and Lakki Marwat (10.2).
(Figure: 21)
Figure 21 BER, API and TPR comparison district wise of KP 2018
Monthly trends indicate a peak rise of reported positive cases from August to October. Minimal cases have
been reported from January to March and in the month of Dec. (Figure: 22)
27523984 4549 4666 4821 5165
63247736 7792
925110541
12145
14455
18043
02000400060008000
100001200014000160001800020000
2.23.9 4.7 4.9 5.2 5.3 6.0 6.3 7.2 7.4
9.7 10.2 11.4 12.0
0
5
10
15
20
25
API ABER TPR
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Figure 22 Monthly trend of cases reported in KP in 2018
A yearly comparison of the cases reported from 2014-2018 also indicates a peak season of August – October
followed by a decline (Figure: 23).
Figure 23 Year wise monthly trend of cases in KP from 2014-2018
5.2. SINDH – (GLOBAL FUND SUPPORTED DISTRICTS ONLY)
A total of 111,920 confirmed malaria positive cases
including 84,070 Pv (75%), 26,402 Pf (24%) and
1,448 Mix (01%) cases were reported from 13 GF
grant supported districts of Sindh during 2018. Last
year the total positive cases reported were 81,216
with 71% Pv, 25% Pf and 04% Mix cases. The
reported API was 6.2, ABER was 6.5 and TPR was
9.5 as compared to API of 4.6, ABER of 5.4 and
TPR of 8.5 during the last year. Hence, the percent
change in API was 35% (increased), ABER was
20% (increased) and TPR was 12% (increased) as
compared to the last year. Considering district wise
situation, the highest number of cases were reported
from Thatta (27,187) followed by Sujawal (11,724)
and Mirpur Khas (11,424). (Figure: 24) Last year
also, Thatta had reported the highest number of
malaria positive cases (15,515).
36722664
3941
6152
1014711667
13386
16503
18889
14460
6948
3795
0
5000
10000
15000
20000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
3672 26643941
6152
1014711667
13386
1650318889
14460
6948
3795
0
5000
10000
15000
20000
25000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2018 2017 2016 2015 2014
Figure 24 District wise distribution of cases in Sindh 2018
The highest API was reported from district Thatta (27.0) followed by TMK (15.4) and Sujawal (14.7).
(Figure: 25)
Figure 25 BER, API and TPR comparison district wise of Sindh 2018
Monthly trends indicate a peak rise of reported positive cases from August to October. Minimal cases have
been reported from January to March. (Figure: 26)
Figure 26 Monthly trend of cases reported in Sindh in 2018
2207 2615 2963 4010 5369 6493 74549424 10364 10686 11424 11724
27187
0
5000
10000
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25000
30000
1.7 2.2 2.4 2.6 3.0 3.2 4.2 5.67.4 8.6
14.7 15.4
27.0
0
5
10
15
20
25
30
API ABER TPR
2838 21453484
55647669 6871
9091
16930
2150219681
10631
5514
0
5000
10000
15000
20000
25000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
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A yearly comparison of the cases reported from 2014-2018 also indicates a peak season of August – October
followed by a decline (Figure: 27).
Figure 27 Year wise monthly trend of cases in Sindh from 2014-2018
5.3. TRIBAL DISTRICTS – (GLOBAL FUND SUPPORTED DISTRICTS ONLY)
A total of 65,853 confirmed malaria positive cases
including 60,258 Pv (92%), 5,010 Pf (08%) and 585
Mix (01%) cases were reported from 13 GF grant
supported Tribal Districts during 2018. Last year the
total positive cases reported were 80,924 with 89%
Pv, 08% Pf and 02% Mix cases. The reported API
was 12.9, ABER was 9.2 and TPR was 14.0 as
compared to API of 16.2, ABER of 10.1 and TPR
of 16.1 during the last year. Hence, the percent
change in API was 20% (decreased), ABER was
09% (decreased) and TPR was 13% (decreased) as
compared to the last year. Considering district wise
situation, the highest number of cases were reported
from Khyber (13,922) followed by South
Waziristan (11,321) and Mohmand (7,423).
(Figure: 28) Last year also, Khyber had reported the
highest number of malaria positive cases (21,068).
Figure 28 Agency wise distribution of cases in Tribal Districts during 2018
2838 21453484
55647669 6871
9091
16930
2150219681
10631
5514
0
5000
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15000
20000
25000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2018 2017 2016 2015 2014
10232158 2261 2603 2482 2723
3475 3739
58196904 7423
11321
13922
0
2000
4000
6000
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14000
16000
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The highest API was reported from sub-district (FR) Lakki Marwat (92.1) followed by sub-district (FR)
Tank (67.2) and sub-district (FR) DIK (49.2). (Figure: 29)
Figure 29 BER, API and TPR comparison agency wise of Tribal Districts during 2018
Monthly trends indicate a peak rise of reported positive cases from July to September. This is different as
compared to the last year where the peak season was seen from August to October. Minimal cases have
been reported from Jan to March and in the month of Dec. (Figure: 30)
Figure 28 Monthly trend of cases reported from Tribal Districts during 2018
A yearly comparison of the cases reported from 2014-2018 also indicates a peak season of July–October
followed by a decline (Figure: 31).
Figure 29 Year wise monthly trend of cases from 2014-2018
5.2 5.9 10.6 12.4 13.7 15.6 15.7 16.4 18.8
48.0 49.267.2
92.1
-40.0
10.0
60.0
110.0
160.0
Bajaur Kurram Orakzai NorthWaziristan
Khyber Mohmand FRPeshawar
SouthWaziristan
FR Kohat FR Bannu FRD.I.Khan
FR Tank FR LakkiMarwat
API ABER TPR
2545 22353084
4367
6731 67968171
88489580
6982
4075
2439
0
2000
4000
6000
8000
10000
12000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2545 22353084
4367
6731 67968171 8848
9580
6982
40752439
0
5000
10000
15000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2018 2017 2016 2015 2014
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5.4. BALOCHISTAN – (GLOBAL FUND SUPPORTED DISTRICTS ONLY)
A total of 60,896 confirmed malaria positive cases
including 39,670 Pv (65%), 19,382 Pf (32%) and
1,844 Mix (03%) cases were reported from 31 GF
grant supported districts of Balochistan during
2018. Last year the total positive cases reported
were 72,867 with 61% Pv, 27% Pf and 12% Mix
cases. There is a remarkable decrease in the
proportion of reported Mix cases. The reported API
was 5.0, ABER was 6.0 and TPR was 8.3 as
compared to API of 6.3, ABER of 5.8 and TPR of
10.7 during the last year. Hence, the percent change
in API was 21% (decreased), ABER was 03%
(increased) and TPR was 22% (decreased) as
compared to the last year. Considering district wise
situation, the highest number of cases were reported
from Zhob (6,342) followed by Lasbela (6,133) and
Jaffarabad (6,106). (Figure: 32) Last year,
Jaffarabad had reported the highest number of
malaria positive cases (7,912).
Figure 30 District wise distribution of cases in Balochistan 2018
The highest API was reported from district Sherani (22.2) followed by Zhob (19.9) and Musa Khel (18.8).
(Figure: 33)
Figure 313 BER, API and TPR comparison district wise of Balochistan during 2018
135 175 188 238 292 321 555 580 624 839 87012131242134415261665178320032012
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0.1 0.2 0.6 0.7 1.0 1.3 1.3 1.63.2 3.6 3.8 4.1 4.2 4.5
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0.0
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40.0
API ABER TPR
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Monthly trends indicate a peak rise of reported positive cases from August to October. Minimal cases have
been reported from Jan to March. (Figure: 34)
Figure 32 Monthly trend of cases reported in Balochistan in 2018
A yearly comparison of the cases reported from 2014-2018 also indicates a peak season of August–October
followed by a decline (Figure: 35).
Figure 33 Year wise monthly trend of cases from 2014-2018
22091805
2704
4897
6166
4601 4930
6164
80998820
5851
4650
0
2000
4000
6000
8000
10000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2209 18052704
4897
6166
4601 4930
6164
80998820
58514650
0
2000
4000
6000
8000
10000
12000
Jan Feb Mar April May June July Aug Sept Oct Nov Dec2018 2017 2016 2015 2014
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6. MALARIA CONTROL INTERVENTIONS
Various interventions for malaria control in Pakistan include:
a. Malaria case management: Early diagnosis, treatment as per national guidelines
b. Long Lasting Insecticidal Nets (LLINs)/Mosquito nets distribution
c. Training and capacity building of healthcare providers on:
i. Malaria case management,
ii. Malaria diagnosis through microscopy and RDT,
iii. Malaria microscopy quality assurance, and
iv. Malaria information system (MIS)
d. Behavior Change Communication (BCC), and
e. Malaria surveillance and outbreak response.
A review of malaria control activities that took place in 2017 is discussed below:
6.1. LLINS/MOSQUITO NETS DISTRIBTION
The long-lasting insecticidal nets (LLINs) or simply mosquito nets distribution during 2018 has been
conducted through the mass and ANC distribution channels.
6.1.1. Mass distribution of LLINs
Aligning to the best recommended practices for
LLINs distribution, DOMC and TIH in partnership
with the World Food Programme (WFP) and
Pakistan Red Crescent Society (PRCS) with the
financial support of the Global Fund, for the first
time, successfully executed mass distribution
campaign for distribution of approximately 2.5
million LLINs in 11 districts of Balochistan, Sindh,
Khyber Pakhtunkhwa and Tribal Districts during
2018. The goal was to achieve universal coverage
with LLINs in the rural areas of the malaria high
burden sharing districts. The districts for mass
distribution campaign were selected based on the
malaria endemicity as per the latest available
surveillance data. All rural households in the
targeted districts were identified as the LLINs’
“beneficiaries”. The strategy was to distributed one
LLIN to every two persons capped at a maximum of
three LLINs per household.
Highest number of LLINs (1.2 million) distributed through mass distribution was seen in the Sindh province
as shown in the figure below:
Figure 34 Mass distribution of LLINs in Provinces/Regions in 2018
285,242 399,216 537,562
1,286,196
2,508,216
Balochistan Tribal Districts KhyberPakhtunkhwa
Sindh Total
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District-wise, highest number of LLINs distributed through mass distribution was seen in Mirpurkhas,
Sindh (549,215) followed by DI Khan (434,538). District wise LLINs distribution is shown below:
Figure 35 District wise mass distribution of LLINS in 2018
6.1.2. Continuous distribution of LLINs through Antenatal Care (ANC) Clinics
A total of 360,999 LLINs were distributed in 2018 as compared to 233,398 distributed in 2017 through the
ANC clinics. Highest distribution took place in Khyber Pakhtunkhwa province as shown below:
Figure 36 LLINs ANC distribution in 2018
6.2. TRAINING AND CAPACITY BUILDING OF HEALTHCARE PROVIDERS
6.2.1. Malaria case management
The target for 2018 was to train a total of 3,122 health care providers on malaria case management. A total
of 2,823 HCPs were trained thus achieving the target by 90%.
6.2.2. Malaria Diagnosis
The target for 2018 was to train 1,392 technicians on malaria diagnosis. A total of 1,348 malaria technicians
were trained thus achieving the target by 97%.
30,645 47,614 52,298 62,321 92,364 103,024
344,142 392,839 399,216 434,538
549,215
19,300 30,983 62490
107,703 140,523
360,999
Punjab Tribal Districts Balochistan Sindh KhyberPakhtunkhwa
Total
6.2.3. Malaria information system (MIS) and outbreak response
During 2018, no MIS trainings were conducted.
The details of DOMC, IHN/TIH and total achievements vs the targets for trainings is shown below:
Figure 37 Malaria trainings conducted in 2018
6.2.4. Behavior Change Communication (BCC) activities
Advocacy and awareness sessions are the tools of
BCC through which masses are reached and are
given awareness about malaria prevention,
diagnosis and treatment. The BCC officers are
supposed to replicate same messages with
advocates of malaria truly called “agents of change”
through advocacy sessions in the targeted
community. These advocates further engage the
people of the community (primary target). In this
top down information dissemination process, the
content, the methodology, facilitation and
management of the sessions are maintained in a
manner that all the relevant information about
malaria i.e. prevention, diagnosis and treatment as
per the national treatment guidelines etc., reaches
the beneficiaries of this interventions. Capacity
Building on BCC Standard Operating Procedures
(SOPs) & IEC material has been carried out by
DOMC-Islamabad for SR BCC Officers,
Coordinators and M&E Officers in all four regions
(Balochistan, FATA, KP and Sindh) of the NFR
grant.
The main objectives of the BCC Capacity building trainings were as under:
▪ To develop an understanding among BCC officers to roll out different components of training
▪ To improve trainees’ skills and enhance their capacity to conduct the BCC awareness sessions in the
community
▪ To improve coordination and planning skills of trainees
▪ To develop the skills of trainees for Project implementation and quality assurance of BCC activities.
Private Sector SR Public SR Total
BCC Officers/ Coordinators M&E/Program Officers
59 15 74
Around 59 BCC Coordinators/officers of Balochistan, Sindh, KP and FATA were trained on BCC SOPs
and Flip charts. Additionally, 15 participants from public SR such as M&E coordinators/Officer and
Program officers were also trained from Oct to Dec 2018.
2,1
79
1,1
211
,82
5
1,0
79
94
3
27
1
99
8
26
9
3,1
22
1,3
92
2,8
23
1,3
48
C A S E M A N A G E M E N T H C P M A L A R I A D I A G N O S I S
DOMC-Target DOMC-Ach: IHN-Target IHN-Ach: Total-Target Total-Ach:
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Figure 38 BCC (Advocacy and awareness) sessions conducted in 2018
6.3. Updates from the procurement and supply chain section
Supply chain section of common management unit
(CMU) is responsible for the quantification,
procurements, supply chain management and
distribution of AMDS and Health products. Supply
chain section is headed by Manger Supply chain and
assisted by deputy manager supply chain + supply
chain officer. Overall the PSCM unit is headed by
Chief procurement officer.
PSM working group for DOMC
Supply chain section conduct the supply chain review on the quarterly basis at central and regional levels.
Considering the supply chain situations, the procurement orders are planned.
Quantification:
Supply chain section completed the two reviews of quantification in 2018 on biannual basis with the support
of DOMC technical team and LFA. Following procurements were made based on review:
Procurement of AMDs and Heath Products in 2018:
S# Anti Malaria Drugs (AMDs) Procurement Distribution
1 Anti Malaria Drugs (AMDs) - -
a ACT/SP 3+1 - -
b ACT/SP 6+2 Children - 2,600
c ACT/SP 6+3 Adult - 32,860
d ACT/ AL 6 - -
e ACT/ AL 12 14,100 11,984
f ACT/ AL 18 25,590 21,600
g ACT/ AL 24 48,210 33,415
h Inj Artesunate 60 mg 5,000 4,221
i Tab Chloroquine Phosphate 150mg (base) 2,736,700 3,508,750
j Tab Primaquin 7.5 mg 8,036,700 6,053,874
k Tab Primaquin 15 mg - 260,237
l Tab. Quinine Sulphate 300mg 20,000 123,400
2 Rapid Diagnostic Tests (RDTs) 2,839,175 2,584,675
3 G6PD Screening Kit -
4 Long Lasting Insecticide bed Nets (LLINs) -
5 Microscopes (Head Office) -
6 Deltamethrine Sachet 6,000
14404
229581
13651
214465
888 9050886 780915292
238631
14537
222274
Advocacy sessions Awareness sessions
DOMC-Target DOMC-Ach: IHN-Target IHN-Ach: Total-Target Total-Achieved
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7 IRS Pumps -
Stock Availability:
With improved coordination and planning there were no any stocks outs at central level, regional levels and
district levels. DOMC managed the stock availability in more than 4000 health facility with more than 96%
during the 2018 at facility levels.
LLINs Mass campaign 2018:
Supply chain section of CMU manage the all logistics activities of Mass campaign of 2018 with the
coordination of stakeholders as below:
• Development of Logistics Plan of Action
• Macro And Micro Planning
• Assessments and development of warehouses at regional and district levels.
• Transport plans and implementations
In 2018 mass campaign selected WH were pumped with LLINs starting as per quantities finalized by WFP/
PRCS with DoMC & TIH. Based on the request from World Food Programme (WFP) following quantities
were issued to WFP by DOMC.
Warehouse Supported
District
Quantities Total Shipment 1 shipment 2 Shipment 3
Peshawar WH 1 South Waziristan 227,100
227,100
Peshawar WH 1 Tank 115,100
115,100
Peshawar WH 1 Bajaur 115,100 42,700
157,800
Peshawar WH 2 Bajaur 258,000
258,000
Sub Total for KPK/FATA 758,000
Quetta WH Barkhan 75,000
75,000
Quetta WH Kohlu 77,150
77,150
Quetta WH Harnai 39,500
39,500
Quetta WH Sheerani 65,750
65,750
Sub Total for
Baluchistan
257,400
Sindh Thatta 106,100 298,100
404,200
Sindh Mirpurlkhas DPs 540,300 13,600
553,900
Sindh Sujjawal Dps 344,900
344,900+
8000
Sub Total for Sind
1,311,000
Grand Total
2,326,400
Successful Supply Chain management of LLINs through overall campaign helped to achieve the desired
objectives.
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7. ISSUES AND CHALLENGES
The main challenges for implementation of grant activities during 2018 were as under:
7.1. Case management
It has been seen that still 100% coverage of health
facilities has not been done in all the grant supported
districts. In few cases the treatment of malaria
confirmed cases was not in accordance to the
national treatment guidelines due to multiple
reasons including non-availability of AMDs in
syrup form for children, preferences of doctors and
patients for one form of anti-malarial drug (AMD)
over another, non-availability of injection
artesunate in all the health facilities, non-
availability of the updated or revised treatment
guidelines, non-compliance to primaquine (PQ) 14
days course by the patients, non-functional centers
in far flung areas, training needs for newly inducted
doctors and evening shift staff, and frequent transfer
and turnover of the trained staff in PPHI, IHS,
MERF and IHN managed health facilities in the
districts. G6PD testing is not available in any of
these districts and physicians have hesitation in
prescribing PQ tablets without G6PD testing. Blood
examination rates also remained low in many
districts of Balochistan and Khyber Pakhtunkhwa
which may be due to the reason that all fever cases
were not tested for malaria. The private sector is
partially covered and their regulation is still a big
challenge and many of them do not follow the
national treatment guidelines. The communities in
many places have low treatment seeking behavior.
7.2. Trainings
Main issues include the non-availability and
willingness/interest (due to low per-diems) of the
trained master trainers for executing the step-down
trainings in the desired dates, nomination of proper
relevant staff to be trained, shortage and non-
availability of medical doctors or relevant staff in
remote districts of Balochistan and Tribal Districts.
Other challenges included frequent polio
campaigns, delays in printing of the training
manuals based on the revised treatment guidelines
resulting in delayed approval of the training plans,
insufficient funds for training huge number of
doctors and other relevant staff in the targeted health
facilities, coordination issues with PPHI (in Sindh)
and frequent transfer and turnover of the trained
staff in PPHI,IHS , MERF and IHN managed health
facilities in the districts, transfer of trained staff, and
preference of Urdu and English language for the
training manual in different settings. More trainings
on Malaria Case Management are required for new
induction of the doctors in the provinces and
frequent turnover of trained staff in health facilities
are managed by PPHI, IHS, MERF and IHN in the
provinces. Due to scarcity of funds under the NFR
grant, there is a big gap in the number of health care
providers who can be trained through the Global
Fund resources for malaria case management. The
health care providers in the non-Global Fund
supported districts also need to be trained on
updated malaria case management guidelines
through Provincial Malaria Control Programs as
counterpart financing.
7.3. Behavior change communication
Delivery of the awareness sessions to women and
monitoring of these sessions has been challenging
in some areas where LHWs are not willing to work.
There should be a mechanism to engage women
activists to provide awareness to women at
household level. It has been suggested that the
strategy should be updated to include the radio
programs, walks, wall chalking, bill boards, theater
performances, IEC material, malaria day
celebration, and provincial level advocacy events by
SRs. Other challenges included the provision of
CNIC copy or information particularly in Tribal
Districts, taking the pictures of female sessions,
proper monitoring of sessions, school and college
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student not targeted for BCC, approval of the
workplans from the DHOs, and timely
communication of the change in BCC plans.
7.4. LLINs distribution
Major challenges for distribution of bed nets
through the ANC clinics included lesser
distributions in far flung areas of Balochistan due to
low utilization of ANC services, non-availability of
CNICs with ANC women, weak control
mechanisms of tracing ANC women getting LLIN
from adjacent or multiple ANC centers within a
district, and improper documentation of issued
LLINs in the distribution registers by lady health
visitors or female health technicians creating
difficulties in data entry and compilation.
Regarding mass distribution campaign, weaker
coordination was observed amongst various
stakeholders at district level during microplanning
process, compromised quality of trainings for
household registration and distribution of nets,
issues with the connectivity and updating of ODK
software, missing areas/villages and population,
weaker BCC activities and coverage, and
duplication of coupons during printing process, etc.
7.5. Quality assurance (QA)
Although new QA guidelines are now available, still
the implementation of these remained a major
challenge. The slides collection from all the
microscopy centers and sending these to the
provincial reference laboratories (PRL) in a timely
manner has been challenging in many targeted
districts except Sindh and Khyber Pakhtunkhwa.
This has mainly been contributed by shifting of the
monthly coordination meetings to quarterly. Issues
were also reported regarding the arrangements and
cost associated with transportation of slides for QA
from districts to the PRL. Issues have also been
reported with the quality of reagents being procured
for the microscopy centers. Poor quality of staining
was reported from Sujawal and Kamber Shahdad
Kot. QA of testing through the RDT kits is more
complex and remain neglected in many districts
mainly due to limited resources. Issue were reported
regarding the QA slide bank and disposal of used
Microscopy slides and used RDTs.
7.6. Surveillance & outbreak response
More focus was observed on improving the
surveillance systems during 2018. DHIS-2 was
implemented across all districts for reporting in
parallel to the manual excel based reporting.
However, DHIS-2 is still not fully functional and
issues with reporting have been reported. Data
punching in DHIS-2 gets delay due to internet issue
in the districts. Due to multiple and fragmented
surveillance system, the true Malaria burden is not
known. It will be better if the MIS (FM tools) are
implemented throughout the province. Monthly
data reporting with a quarterly review, verification
or validation mechanism is very challenging.
Keeping in view the higher number of facilities in
many districts, the time is not sufficient to ensure
good quality of data verification on quarterly basis.
Due to change in frequency of the monthly meetings
to the quarterly, frequent variances have been noted
in the compiled data by the provincial DMU in-
charge and the private SRs. Implementation of
online DHIS-2 is expected to address these gaps.
Timely alert generation and outbreak detection
remained a big challenge. Weekly watch charts
although installed in almost all public health
facilities are not regularly updated and used
properly and unusual rise in cases is not timely
reported. Many times, the outbreak alert is
generated from Provincial office and not from
health facility level. The roles and responsibilities
were not clear at SR and PR level. There were no
defined standard criteria for conformation of
outbreak. Capacity building on outbreak detection
and response is needed for better results. Vector
surveillance remained a weak area; entomological
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kits are needed. Moreover, the technical and
administrative approval of a response to a
confirmed outbreak usually takes too long which
affects the appropriate response on time.
7.7. Stocks management
The maintenance of cold chain was affected at the
health facilities level due to electricity load
shedding. The proper record keeping in the stock
registers is compromised due to the burden on
facility focal persons as different programs have
different stock registers to be updated by a single
person. There are no proper guidelines for disposal
of the expired medicines. It has been reported that
short expiry medicines were procured which made
it difficult for the logistic team to ensure proper
utilization before expiry. Private SRs’ one district
logistic officer in looking after two districts which
makes his task difficult.
8. SUCCESS STORIES
8.1. ‘A ray of hope for people in need’
Jamal, 27 years old resident of village Nek Nohri
Taluka Pithoro, District Umerkot, runs a small flour
mill. He was suffering from high grade fever for a
week or so, but was given medicines by a general
practitioner without any test and was not getting
well. His father then took him to the Taluka Hospital
Pithoro, where a doctor trained on malaria case
management, advised malarial parasite (MP) test.
He was confirmed as P.falciparum positive, a lethal
type of malaria which possibly can result in severe
malaria. Jamal shared, ‘I got tested and medicine
total free of cost and now am feeling very good. I
am thankful to all facility staff
for the quality services they
are providing’.
The free of cost malaria
diagnostic and treatment
services are being provided by
the National Rural Support
Programme (NRSP) with the support of the
Directorate of Malaria Control (DOMC) under the
Global Fund grant are a blessing for many families
in remote areas of Sindh and other areas.
8.2. ‘Strengthening the power of poor communities’
Behavior change is one of the most difficult tasks.
It starts with awareness raising. Seeta, a housewife
from village Mandrai Farm, UC Mir Wali
Mohammad Talpur, Umerkot, came to know about
malaria causes and prevention after participating in
BCC Session at Mandrai
Farm in Sep-2017. She
said, ‘we filled digs,
started using the mosquito
nets and other measures
for protecting ourselves
from mosquito bites after
attending that session’.
Seeta suggested that such sessions should target
male members of society including husbands, father
in law, teachers, munshi and kamdars as these are
all influential.
NRSP with the support of Mehran Education Health
& Welfare Association (MEHWA) a local NGO is
conducting awareness sessions through the support
of the Directorate of Malaria Control (DOMC)
under the Global Fund grant in district Umerkot and
many others districts of Sindh and Balochistan.
Slowly and gradually these efforts are changing
community behaviors.
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8.3. ‘It’s not an evil spirit’
Nabi Bakhsh, a poor villager from village Khan
Jamali of Sibi town, has three daughters and a son.
His main source of income is farming and livestock
rearing. Few months ago, his son suffered with high
grade fever that deteriorated his health condition
rapidly. Due to customary practices, Nabi Bakhsh
took him to a shrine in a nearby village. The saint,
after seeing his son, revealed that he was attacked
by an evil spirit which immediately required holy
treatment otherwise his life would have been at risk.
By remembering those days, Nabi Bakhsh
mumbled, “When I heard that, I lost my nerves and
straightaway decided to keep him in the shrine till
his complete recovery. My son’s week-long
treatment cost me more than Rs. 25,000 because the
saint initially asked for 10 black hens to be
sacrificed for him which didn’t work at all. Then he
ordered me to bring three black goats that resulted
in a failure as well. I was so worried for my son’s
life and couldn’t think of any other solution because
his condition was getting worse day by day. I even
thought that perhaps I was going to lose him soon.”
Nabi Bakhsh added, “one day when I was
planning to take my son to another sacred shrine, I
came across BRSP team that was conducting a
session on malaria in our village. When I heard the
symptoms of malaria, I was surprised because that
was the exact condition, my son had been suffering
from fever for the last few weeks. The facilitator
further told us about free of cost malaria diagnosis
and treatment in Government health facilities.” He
instantly took his son to the nearest health facility
where he was diagnosed with severe form of
malaria. The doctor right away started his treatment
and provided free medicines. In next few days, after
regular use of prescribed medicines, his son got
much better as his condition improved.
“Undoubtedly, BRSP is a ray of hope for the
poor and needy people. Had I not met them, I would
have lost my son”, Nabi Bakhsh showed gratitude
with tears in his eyes.
BRSP with the support of DOMC under the
Global Fund grant is providing free treatment and
diagnostic facilities in 25 districts of Balochistan.
BCC sessions have resulted in increased utilization
of LLINs and encouraged communities for instant
malarial testing that has certainly contributed in
reduction of Malaria cases, particularly in high risk
districts
.
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9. ANNEXURES
9.1. List of the Global Fund grant supported districts
Names and details of the grant supported districts with PRs and SRs is given in the table below:
The Global Fund grant supported districts of Pakistan during 2017
S# Districts
(alphabetically)
Province Principal Recipient
(PR)
Sub-Recipient
(SR)
1. Awaran Balochistan DOMC NRSP
2. Badin Sindh DOMC NRSP
3. Bajaur Tribal Districts DOMC ACD
4. Bannu KP IHN/TIH FPHC
5. Barkhan Balochistan DOMC BRSP-DOMC
6. Buner KP DOMC ACD
7. Chagai Balochistan DOMC BRSP-DOMC
8. Charsadda KP IHN/TIH FPHC
9. Dera Bugti Balochistan DOMC BRSP-DOMC
10. Dera Ghazi Khan Punjab DOMC PLYC
11. Dera Ismail Khan KP IHN/TIH FPHC
12. Dukki Balochistan IHN/TIH BRSP-TIH
13. FR Bannu Tribal Districts DOMC ACD
14. FR DI Khan Tribal Districts DOMC ACD
15. FR Kohat Tribal Districts DOMC ACD
16. FR Lakki Marwat Tribal Districts DOMC ACD
17. FR Peshawar Tribal Districts DOMC ACD
18. FR Tank Tribal Districts DOMC ACD
19. Gwadar Balochistan DOMC NRSP
20. Hangu KP DOMC ACD
21. Harnai Balochistan IHN/TIH BRSP-TIH
22. Jaffarabad Balochistan DOMC BRSP-DOMC
23. Jhal Magsi Balochistan DOMC BRSP-DOMC
24. Kachhi/Bolan Balochistan DOMC BRSP-DOMC
25. Kambar Shahdad Kot Sindh DOMC PLYC
26. Karak KP DOMC ACD
27. Kech Balochistan DOMC NRSP
28. Khairpur Sindh DOMC PLYC
29. Kharan Balochistan DOMC BRSP-DOMC
30. Khuzdar Balochistan DOMC BRSP-DOMC
31. Khyber KP-TD DOMC ACD
32. Killa Abdullah Balochistan DOMC BRSP-DOMC
33. Killa Saifullah Balochistan IHN/TIH BRSP-TIH
34. Kohat KP DOMC ACD
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35. Kohlu Balochistan DOMC BRSP-DOMC
36. Kurram KP-TD DOMC ACD
37. Lakki Marwat KP IHN/TIH FPHC
38. Larkana Sindh DOMC PLYC
39. Lasbela Balochistan DOMC NRSP
40. Loralai Balochistan IHN/TIH BRSP-TIH
41. Lower Dir KP DOMC ACD
42. Mastung Balochistan IHN/TIH BRSP-TIH
43. Mardan KP IHN/TIH FPHC
44. Mirpur Khas Sindh DOMC PLYC
45. Mohmand KP-TD DOMC ACD
46. Musa Khal Balochistan IHN/TIH BRSP-TIH
47. Nasirabad Balochistan IHN/TIH BRSP-TIH
48. Naushahro Feroze Sindh DOMC PLYC
49. North Waziristan KP-TD DOMC ACD
50. Nushki Balochistan IHN/TIH BRSP-TIH
51. Nowshera KP IHN/TIH IHN/TIH
52. Orakzai KP-TD DOMC ACD
53. Panjgur Balochistan DOMC NRSP
54. Pishin Balochistan IHN/TIH BRSP-TIH
55. Quetta Balochistan DOMC BRSP-DOMC
56. Shangla KP DOMC ACD
57. Sherani Balochistan IHN/TIH BRSP-TIH
58. Sibi Balochistan IHN/TIH BRSP-TIH
59. Sohbatpur Balochistan DOMC BRSP-DOMC
60. South Waziristan KP-TD DOMC ACD
61. Sujawal Sindh DOMC NRSP
62. Sukkur Sindh DOMC PLYC
63. Swat KP DOMC ACD
64. Tando Allahyar Sindh DOMC PLYC
65. Tando Mohammad Khan Sindh DOMC NRSP
66. Tank KP IHN/TIH FPHC
67. Tharparkar Sindh DOMC PLYC
68. Thatta Sindh DOMC NRSP
69. Umer Kot Sindh DOMC NRSP
70. Washuk Balochistan DOMC BRSP-DOMC
71. Zhob Balochistan IHN/TIH BRSP-TIH
72. Ziarat Balochistan DOMC BRSP-DOMC