I. EXECUTIVE SUMMARY
When it was launched in 2005, the goal of the U.S. President’s Malaria Initiative (PMI) was to reduce malaria-related mortality by 50 percent across 15 high-burden countries in sub-Saharan Africa through a rapid scale-up of four proven and highly effective malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs); indoor residual spraying (IRS); accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs); and intermittent preventive treatment of pregnant women (IPTp). With the passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act in 2008, PMI developed a U.S. Government Malaria Strategy for 2009–2014. This strategy included a long-term vision for malaria control in which sustained high coverage with malaria prevention and treatment interventions would progressively lead to malariafree zones in Africa, with the ultimate goal of worldwide malaria eradication by 2040-2050. Consistent with this strategy and the increase in annual appropriations supporting PMI, four new sub-Saharan African countries and one regional program in the Greater Mekong Subregion of Southeast Asia were added in 2011. The contributions of PMI, together with those of other partners, have led to dramatic improvements in the coverage of malaria control interventions in PMI-supported countries, and all 15 original countries have documented substantial declines in all-cause mortality rates among children less than five years of age.
In 2015, PMI launched the next six-year strategy, setting forth a bold and ambitious goal and objectives.
The PMI Strategy for 2015-2020 takes into account the progress over the past decade and the new challenges that have arisen. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s Strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and ending extreme poverty. It is also in line with the goals articulated in the Roll Back Malaria (RBM) Partnership’s second generation global malaria action plan, Action and Investment to Defeat Malaria (AIM) 2016-2030: For a Malaria-Free World and the World Health Organization’s (WHO’s) updated Global Technical Strategy: 2016-2030. Under the PMI Strategy 2015-2020, the U.S.
Government’s goal is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.
In 2017, consistent with an increase in annual appropriations, PMI again launched new country programs in Cameroon, Côte d'Ivoire, Niger, and Sierra Leone, and expanded an existing program in Burkina Faso to PMI focus country status. With the addition of these new focus countries, PMI now has programs in 24 countries in sub-Saharan Africa, in addition to two bilateral programs and targeted support in the Greater Mekong Subregion in Asia.
Liberia began implementation as a PMI focus country in FY 2008. This FY 2019 Malaria Operational Plan (MOP) presents a detailed implementation plan for Liberia, based on the strategies of PMI and the National Malaria Control Program (NMCP). It was developed in consultation with the NMCP and with the participation of national and international partners involved in malaria prevention and control in the country. The activities that PMI is proposing to support fit in well with the national malaria control strategy and plan and build on investments made by PMI and other partners to improve and expand malaria-related services, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) malaria grants. This document briefly reviews the current status of malaria control policies and interventions in Liberia, describes progress to date, identifies challenges and unmet needs to achieving the targets of the NMCP and PMI, and provides a description of activities that are planned with fiscal year (FY) 2019 funding.
The proposed FY 2019 PMI budget for Liberia is $14 million. PMI will support the following intervention areas with these funds:
Entomologic monitoring and insecticide resistance management: Liberia’s 2016–2020 National Malaria Strategic Plan (NMSP) includes the objective of institutionalizing entomological and insecticide resistance monitoring with a plan to produce a vector prevalence map of the country, highlighting vector behavior, susceptibility to insecticides, and location, as well as to use the NMCP’s insectary as a testing site for studies of malaria vectors. Over the past year, PMI expanded support for the NMCP to conduct entomological monitoring at four established surveillance sites plus an additional ten sites along a transect from Nimba to Montserrado County. PMI further supported nationwide insecticide susceptibility testing, and initiated pyrethroid resistance intensity and synergist assays at select sites.
PMI has continued to support an entomologist embedded within the NMCP to help build capacity for entomological surveillance, supported on-site training for insecticide resistance, and established collaboration between the NMCP and the Liberian Institute of Biomedical Research (LIBR) for laboratory analyses of entomological samples. This has enabled the NMCP to begin testing mosquito specimens for Plasmodium sporozoites.
With FY 2019 funds, PMI will continue to build the capacity of the NMCP to maintain a functional insectary; conduct entomological surveillance in areas with limited or no data on vector species composition, abundance, or behavior; conduct insecticide resistance monitoring, with a focus on new insecticides, pyrethroids, and synergists; and perform laboratory analyses for vector species identifications and sporozoite infection rates.
Insecticide-treated nets: Liberia’s 2016–2020 NMSP includes the objective of ensuring that 80 percent of the country’s population is protected by malaria prevention measures. Under this objective, Liberia aims to ensure universal access to ITNs by reaching 100 percent of households through mass campaigns conducted every three years. Currently, mass campaigns are the main distribution method, reinforced by continuous distribution of ITNs during the first antenatal care (ANC) visit and at the time of delivery in a registered health care institution to encourage delivery in facilities. Between 2008–2018, approximately 11 million ITNs were distributed in Liberia through campaigns, ANC services, and at institutional deliveries, including approximately 2.9 million ITNs purchased by PMI.
With FY 2019 funds, PMI will continue to support routine distribution of ITNs by procuring ITNs to cover ANC and institutional delivery needs, and transporting the nets down to the county level. In addition, PMI will continue to provide technical support for (IPTp2) increased from 45 percent in the 2009 MIS to 55 percent in the 2016 MIS, and three doses of IPTp (IPTp3) doubled from 10 percent in the 2009 MIS to 22 percent in the 2016 MIS.
PMI assisted the NMCP in finalizing and printing updated MIP protocols and treatment guidelines based on WHO 2012 guidance. These new guidelines were harmonized across all MIP and case management related documents, including the national pre-service curriculum, in-service community training materials, social and behavior change communication (SBCC) module materials, and surveillance, monitoring, and evaluation (SM&E) tools, and were revised for nationwide use. In 2016, PMI supported the update, printing, and distribution of ANC and MIP training manuals and guidelines for ANC and MIP for pre-service and in-service health workers and community level service providers like community health assistants (CHAs), community health volunteers (CHVs), and trained traditional midwives. More than 900 trained traditional midwives of 927 certified midwives and traditional midwives in all 15 counties were trained on the updated ANC and MIP protocols and guidelines. The health management information system (HMIS) registers and forms were revised to capture the IPTp3, IPTp3 plus doses, and ITNs given during ANC and institutional deliveries.
With FY 2019 funding, PMI will continue to provide technical assistance to support the NMCP in the implementation, scale-up, and monitoring of MIP, including implementation of routine ITN distribution, the new IPTp guidelines, and proper management of malaria in pregnancy. PMI will procure SP and support ANC service providers to improve quality of care and adherence to standards for MIP, capacity building of health providers, in-service training and supervision for health care workers, support for County Health Teams and technical assistance to strengthen the distribution and availability of antenatal care commodities including SP and ITNs.
Case management: By 2020, the Liberia Ministry of Health (MoH) strategy for malaria case management aims to reach 85 percent of patients suspected of malaria in the public and private sector with a diagnostic test, and for all positive cases to be appropriately treated with an antimalarial medication. Malaria testing services have been fully restored in all facilities and at the community level since March 2016 when WHO lifted the ban on testing imposed during the EVD outbreak. PMI continues to work with the NMCP/MoH to scale up high-quality prevention services in the community, including testing by CHAs.
With FY 2019 funding, PMI will procure 2.4 million rapid diagnostic test (RDTs) for parasitological testing of suspected malaria cases in health facilities and the community, as well as approximately one million doses of artesunate-amodiaquine (AS/AQ) for treatment of uncomplicated malaria. PMI will also procure injectable artesunate for treatment of severe malaria in facilities and rectal artesunate for pre-referral treatment of children with severe illness seeking care in lower level facilities and in the community. In addition, PMI will expand its support to all 15 counties for the provision and improvement of quality malaria case management, including testing through training and supportive supervision. PMI will also continue to support the extension of malaria case management to the community level and refresher training for facility-level case management. Together with the Global Fund and other partners, PMI expects to fill all ACT and RDT needs for Liberia. PMI will support training and capacity building of MoH staff at both the central and county level, including in the community through support of activities conducted by CHAs (previously called general community heath volunteers; gCHVs) and Community Health Service Supervisors (CHSS).
Pharmaceutical management: The NMCP’s objective in the 2016–2020 NMSP is to strengthen the supply chain system for effective quantification and prompt distribution of commodities under a universal system by 2020. PMI supported the MoH to develop (2010) and revise (2015) its Supply Chain Master Plan. PMI has assisted the MoH to consolidate all health commodities in a Central Medical Store, thereby increasing transparency and accountability across the supply chain.
With FY 2019 funding, PMI will continue to strengthen the capacity of the Central Medical Store to manage the storage and integrated distribution of commodities and strengthen the Liberia Medicines and Health Products Regulatory Authority for regulation of malaria commodity registration and post-market surveillance of antimalarial drugs. PMI will also continue to support quarterly implementation of an end-use verification survey to monitor the availability of malaria commodities and the quality of malaria case management at the health facility level.
Social and behavior change communication: In 2016, the NMCP, in partnership with the MoH National Health Promotion Division, the Community Health Services Division, and malaria partners, revised its Malaria Communication Strategy for 2016–2020 and developed a Malaria Communication Implementation Plan for 2016–2020. The SBCC strategy addresses knowledge, practice, and perception gaps in malaria prevention and treatment, including use of IPTp for pregnant women. PMI supported the development of the SBCC strategy, materials, and tools, provided training to facility-based staff and CHAs, and supported the media to broadcast radio messages on ITN use, IPTp, test and treat, and the use of ACTs. The collective effort of the NMCP and its partners has successfully raised the population’s awareness of malaria. The 2016 MIS indicated that 99 percent of women of reproductive age have heard of malaria. Of those who have heard of malaria, 95 percent know that the illness can be avoided and 90 percent know that mosquitos transmit the parasite from person-to-person. Almost all women (99 percent) who have heard of malaria state that malaria is treatable, with the majority (81 percent) citing the recommended ACTs. However, the 2016 MIS showed knowledge-practice gaps, with high use of monotherapies to treat malaria and misconceptions about the use of SP for IPTp.
With FY 2019 funds, PMI will continue to support the NMCP to implement their Malaria Communication Implementation Plan for 2016–2020. At the facility level, service providers will be trained on counseling skills and standard practices in adhering to national case management and MIP guidelines and protocols. Facility health workers will provide counseling services to clients on all aspect of malaria SBCC, including: prompt care-seeking behavior, the importance of malaria testing for all cases presenting with fever, completion of ACT treatment course, IPTp uptake for pregnant women, and sleeping under ITNs. At the community level, CHV will encourage pregnant women to seek prompt care and attend ANC services regularly at the health facilities. Other SBCC activities will include regular mass media campaigns, community meetings, and drama/theatre.
Surveillance, monitoring, and evaluation: The NMCP has finalized its 2016–2020 SM&E plan to accompany the 2016–2020 NMSP. The Global Fund and PMI provide the bulk of the funding for SM&E activities, while WHO provides technical support. The MoH has a fully integrated computerized HMIS that serves all public facilities and those private clinical facilities that receive malaria medications and diagnostic support from the MoH. The District Health Information System 2 (DHIS2) platform also includes a community-based information system (CBIS). Personnel have been trained and the system is operational nationwide; however, reporting is not uniform and data are underutilized at all levels. PMI will use FY 2017 funding to support the malaria module in the 2018 DHS.
With FY 2019 funding, PMI will work to improve the collection, reporting, and use of HMIS and CBIS malaria data, as well as household survey and implementing partner data through supportive supervision of SM&E activities from the national level, and for malaria data collection and use at the county level across all counties, as well as embedded technical assistance at the MoH, NMCP, and in select counties.
PMI will also support training at the national and county level on malaria SM&E. 8
Operational research: The NMCP Research, Monitoring, and Evaluation Department is responsible for planning and conducting operational research studies in collaboration with other NMCP focal points and partners. Liberia had one PMI-supported operational research (OR) study that was completed in 2013, which examined using a dried blood tube sample as a stable source of quality control samples for RDTs in an external quality assurance system in the field.
With FY 2019 funds, PMI in collaboration with the NMCP will support an operational research study to assess the barriers to IPTp2+ services uptake at ANC settings in Liberia.
Other health systems strengthening: PMI supports a range of targeted health system strengthening activities that cut across intervention areas but bolster achievement of malaria program results, such as training of health workers, supply chain management, health information systems strengthening, drug quality monitoring, and NMCP capacity building. To encourage integration of malaria prevention and control activities into routine health care in ways that are sustainable, PMI has supported the NMCP to more actively engage with other parts of the MoH involved in malaria-related activities, as well as broader health system strengthening efforts that can benefit the malaria program. For instance, PMI support combined with funding from other USAID program elements will help to strengthen management and leadership of county health teams to oversee and monitor malaria service delivery through updated national clinical standards, support for quality improvement interventions, including regular supervision as well as clinical training, strengthening of the health information system, and improved human resource management.
With FY 2019 funds, PMI will provide support to the central MoH/NMCP and county health teams to strengthen crosscutting health systems functions to improve management and governance of the health system and support decentralization. PMI will continue to support the NMCP to strengthen their linkages with the other MoH units including the Family Health Services Department, Community Health Services Unit, National Health Promotion Unit, the National Diagnostic Unit, and HMIS Monitoring Evaluation and Research Unit, as well as the newly established National Public Health Institute. PMI will also support Peace Corps to strengthen malaria messaging in schools by supporting two third-year malaria Peace Corps volunteers and malaria education activities carried out by the network of Peace Corps volunteers throughout the country.