President’s Malaria Initiative: Malawi - Malaria Operational Plan FY 2017



When it was launched in 2005, the goal of the President’s Malaria Initiative (PMI) was to reduce malaria-related mortality by 50% 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 malaria-free 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 RBM Partnership’s second generation global malaria action plan, Action and Investment to defeat Malaria (AIM) 2016-2030: for a Malaria-Free World and 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. Malawi was selected as a PMI focus country in FY 2006. This FY 2017 Malaria Operational Plan presents a detailed implementation plan for Malawi, 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 Malawi, 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 FY 2017 funding. The proposed FY 2017 PMI budget for Malawi is $22 million. PMI will support the following intervention areas with these funds:

Entomologic monitoring and insecticide resistance management: The Malawi Vector Control Strategy 2015-2019 promotes integrated resistance monitoring and implementation of a resistance management plan, collection of entomological data to monitor impact and capacity building for implementation. Over the past five years, PMI-supported entomological monitoring has documented increasing vector insecticide resistance, including the rise and spread of pyrethroid and carbamate resistance in An. funestus, which is the primary malaria vector across most of the country. As of 2015, all An. funestus populations tested against the organophosphates malathion and pirimiphos-methyl have been fully susceptible. These data indicate organophosphates are the only technically sound options for IRS in Malawi. PMI supports entomological surveillance in seven districts, including measurements of mosquito density and insecticide resistance. Additionally, the team conducted a comparison of the effectiveness of pyrethrum spray catches vs. CDC light traps, and measured sporozoite rates in routine collections for the first time in several years. With FY 2017 funding, PMI will continue to support entomological monitoring in targeted districts. In past years, the entomology team has had difficulty collecting enough An. funestus to carry out resistance assays in all districts. Because the GoM has no firm plans to conduct IRS in the previously sampled districts, PMI plans to reduce the number of districts from seven to five, while intensifying collections in these districts to ensure adequate mosquito sample sizes are collected for all resistance assays. PMI will continue to support insecticide resistance monitoring, including measurement of resistance intensity and synergist assays, measurement of species distribution and abundance, and mosquito behavior. PMI will also continue to provide technical assistance to the NMCP for its entomological monitoring program, which aims to map insecticide resistance in all districts on a rotating annual basis, and which will cover any potential IRS districts.

Insecticide-treated nets (ITNs): The NMCP developed the Malawi Vector Control Strategy 2015-2019 and implementation plan, in which the distribution and promotion of ITN use are the primary malaria prevention interventions in the country. PMI has consistently supported NMCP efforts through the procurement and distribution of ITNs for continuous distribution to pregnant women and children under the age of one year at antenatal care clinics and delivery or expanded program on immunization visits. Over the past six years, an estimated 7 million ITNs have been distributed countrywide in Malawi through routine channels. In addition, PMI has supported Malawi with technical support for planning and management of routine and mass distribution mechanisms, as well as support for social and behavior change communication and community mobilization efforts to improve the uptake and utilization of ITNs. With FY 2017 funding, PMI will continue to support the NMCP’s efforts to ensure high coverage of pregnant women and children through the procurement and distribution of ITNs through routine channels (1.2 million ITNs), and support management, oversight, and distribution of PMI-procured nets to health facilities for routine distribution. FY 2017 activities will also include technical assistance to the NMCP for ITN quantification and distribution planning, and supportive supervision of ANC staff. PMI will continue support for Year 2 of ITN durability monitoring. Based on lessons learned, PMI will provide technical assistance to facilitate planning and preparation for the mass distribution campaign expected in 2018 – 2019.

Indoor residual spraying (IRS): The 2011-2016 Malawi Malaria Strategic Plan incorporates IRS as part of an integrated vector management strategy. Depending on available resources, the plan proposes resuming IRS with long-acting organophosphates in three high-burden districts in 2016, with the goal of expanding to eight high transmission districts. In 2007, PMI piloted IRS with a pyrethroid insecticide in part of one high transmission district in Malawi, eventually scaling up to cover two districts. In 2010, the Government of Malawi (GoM) began supporting IRS in an additional five districts in 2010. However, high levels of pyrethroid and carbamate resistance in An. funestus necessitated a shift to organophosphate insecticides. Given the high cost and short duration of residual efficacy of short-acting organophosphate, the only alternative available at the time, PMI suspended direct support for IRS in Malawi after the 2011 spray season. Although the future of the IRS program is uncertain due to resource challenges, the NMCP has expressed their intent to pursue GoM funding for IRS with organophosphates in 2017 in up to three high-risk districts. The NMCP has requested technical assistance from PMI to ensure that the campaign is implemented in a timely and effective manner and in compliance with accepted environmental and worker safety standards. Therefore, with FY 2017 funding, PMI plans to fund activities to catalyze the IRS campaign, including support for microplanning, geocoding, training, environmental compliance, worker safety, and other logistical activities.

Malaria in pregnancy (MIP): Through focused antenatal care (FANC), PMI supports all aspects of the Ministry of Health’s three-pronged approach to reducing the burden of malaria in pregnancy: use of intermittent preventive treatment in pregnant women (IPTp) during antenatal care (ANC), distribution of ITNs to pregnant women, and effective case management of malarial illness and anemia. PMI, in conjunction with the NMCP and Reproductive Health Directorate, has worked to increase uptake of IPTp through training and supervision of providers and assistance with directly observed treatment. With support from PMI, the Ministry of Health (MoH) updated the national policy on IPTp to reflect the new World Health Organization (WHO) guidelines, and trained nearly all health workers in these new guidelines in 2014-15. The revised policy removes previous barriers to IPTp uptake, under which women were only to receive IPTp at specific intervals during pregnancy. Nevertheless, despite two decades of IPTp policy in Malawi, coverage goals have yet to be met. There are still systemic barriers to seeking ANC in the first trimester and increasing sulfadoxine-pyrimethamine (SP) resistance represents another significant threat to IPTp in Malawi. With FY 2017 funding, PMI will continue integrated and malaria-specific social and behavior change communication activities in support of IPTp, case management, and ITN use at national and community levels; provide free ITNs for routine distribution at ANC visits and at labor and delivery for newborns; procure sulfadoxine-pyrimethamine (2.4 million treatments) and supplies to ensure directly observed therapy and IPTp uptake at ANC; support supervision activities for malaria in pregnancy interventions as part of the focused antenatal care package; and help improve the collection of data on IPTp through support to strengthen the Health Management Information System (HMIS) system.

Case management: Increasing capacity to ensure prompt and effective case management and reduce the presumptive use of antimalarial medications was a key priority in Malawi’s Malaria Strategic Plan. PMI has supported the Government of Malawi through procurement of malaria commodities including rapid diagnostic tests (RDTs), artemisinin-based combination therapy (ACT) treatments, injectable artesunate, and artesunate suppositories; training of health facility workers; outreach training and supportive supervision (OTSS) to laboratory and clinical supervisors; and support to village health clinics. Supply chain issues are a key concern in Malawi. Due to issues of leakage and general mismanagement, a parallel supply chain was created in 2010 to distribute donor-procured malaria commodities. In 2012, representatives from the GoM, Central Medical Stores Trust (CMST), and partners, including World Health Organization, the Global Fund, DFID, and PMI, conducted a review of the supply chain management system and developed a Joint Strategy for Supply Chain Integration in Malawi. In addition to support for Central Medical Store (CMS) reform, the USG has supported efforts to improve the overall supply chain through continued support to the MoH to strengthen commodity management and planning at all levels of the system. At the zonal, district, facility, and community levels, PMI will continue to focus on improving provider behavior, accountability for medicines, and improved data management. PMI and other USAID health elements plan to support a supply chain technical advisory group within the newly formed Drug Theft Investigation Unit (DTIU). ACT consumption has continued to outpace reported malaria cases, with approximately 10 million ACTs consumed compared to approximately 6 million malaria cases (per HMIS data) in 2015. Investigations have identified the facility level—as opposed to central or district levels—as the most problematic. The consensus is that the problem is multifactorial, with continued presumptive treatment, poor record-keeping, and theft as the likely main contributors. Other contributing factors include stock mismanagement, inadequate facilities for commodity storage, and patients often receiving a diagnosis and treatment at different locations within the facility, which leads to additional record-keeping challenges. An action plan has been created with input from the NMCP, HTSS, and other stakeholders to improve commodity oversight and management – including improved supervision at the district, facility, and community levels, better use of data for decision-making, and audits of facilities with discrepancies between consumption and reported cases. Additionally, the recent training of health workers in malaria case management included an emphasis on compliance with RDTs and appropriate use of ACTs, which, when coupled with appropriate follow-up and supervision, should improve provider behavior. With FY 2017 funding, PMI will focus on improving community and facility-based case management services in ten priority districts, those with the highest malaria burden in the country. Case management commodities, specifically RDTs and ACTs, will still be supplied nationwide and supply chain technical assistance will be provided to all districts through zonal supply chain staff. Parenteral and rectal artesunate for severe malaria treatment will not be procured with PMI funds because other donors provide support for these commodities. PMI will continue to provide diagnostic technical assistance in ten focus districts, concentrating on quality improvement/quality control for diagnostics in facility and community settings. Support will also

include improving RDT use and adherence to results, appropriate severe malaria case management and referral from community and lower health facility levels, and supervision and mentorship in facility and community settings. Based on support from other donors, PMI will not support biannual therapeutic efficacy monitoring with FY 2017 funding.

Health systems strengthening and capacity building: PMI supports targeted health system strengthening activities which cut across intervention areas, such as training of health workers, supply chain management and health information systems strengthening, drug quality monitoring, and NMCP capacity building. Through its implementing partners, PMI provides technical support to the MoH to help improve policies, management and leadership, and fiscal responsibility. PMI promotes evidence-based policies, strengthens the management and technical capacity of the NMCP and other MoH divisions, supports development and strengthening of electronic data systems, strengthens the zonal supervision structures, bolsters decentralized management of health services at the district level, and strengthens the government’s capacity for financial planning and management and budget execution. With FY 2017 funding, PMI Malawi plans to focus and concentrate its service delivery strengthening efforts in ten high malaria burden districts, building government capacity for facility-based case management, FANC and delivery of IPTp, community mobilization and integrated community case management (iCCM), and surveillance monitoring and evaluation at the district level. These capacity building efforts will include training and expanded supportive supervision and mentoring to relevant cadres (e.g., district and zonal health officers, facility and community health care workers, etc.). PMI plans to continue to provide pre-service training to pharmacy assistants so that this cadre will enter the workforce with the stock management skills necessary to help ensure commodity security at the facility level. Simultaneously, at the central level, PMI will provide technical and operational support to the NMCP and other key parts of the MoH (such as the Central Monitoring and Evaluation Department (CMED) and the Integrated Management of Childhood Illness Unit), support policy development and dissemination, strengthen pharmaceutical supply chain management, and reinforce the HMIS and monitoring and evaluation.

Social and behavior change communication (SBCC): The NMCP put in place a Malaria Communication Strategy (2015-2020), whose goal is to improve behavioral change interventions through advocacy and social mobilization, and has established a technical committee to support and guide the implementation of this strategy. PMI Malawi’s SBCC efforts are in line with this national strategy and support an integrated approach focused on ITNs, MIP, and case management. SBCC activities have included national campaigns and door-to-door visits to promote year-round ITN use; large-scale campaigns to emphasize ANC attendance to improve IPTp uptake; and community-based campaigns that emphasize ITN utilization, as well as improved case management through the promotion of early care-seeking behavior. SBCC strategies have been employed from the national to the community level to target policy makers, health care providers, and community members. In promoting malaria interventions, PMI has utilized a variety of SBCC approaches, including educational meetings, mass media, print media, community drama, and interpersonal communication activities.

With FY 2017 funding, PMI plans to support an integrated SBCC approach at the national level and at the community level in ten focus districts with ITN, IPTp, and case management messaging. National level efforts will focus on advocacy, mass media communication, and materials development, while community level efforts will focus on interpersonal and small group interventions and strategies to engage traditional authorities to support and promote the importance of malaria prevention activities.

Surveillance, monitoring, and evaluation (SM&E): The NMCP’s 2011-2016 Malaria Strategic Plan calls for strengthening of surveillance, monitoring, and evaluation systems through routine health management information systems, malaria-specific surveillance and special surveys to gather entomologic, epidemiologic, and coverage indicator data. PMI has supported numerous monitoring and evaluation activities in Malawi, including household surveys (Demographic Health Survey [DHS], Malaria Indicator Survey [MIS]), health facility surveys (service provision assessment, end-use verification survey), malaria surveillance and routine system support (sentinel surveillance, HMIS), and an impact evaluation. With FY 2017 funding, PMI plans to continue to support strengthening of routine health management information systems and malaria-specific surveillance, as well as assessing the availability of commodities at health facilities. For district-level activities in the ten PMI focus districts, PMI will work closely with the central level and other malaria partners to ensure activities are in-line with the priorities of the GoM, support national level initiatives and ensure coordination of activities with other partners working in the non-focus districts. PMI will support an impact evaluation of the integrated district-level service delivery and systems strengthening activities to provide evidence of impact of the project on the availability and quality of health services and health system performance in the ten PMI focus districts.

Operational research (OR): The NMCP’s 2011-2015 Malaria Strategic Plan calls for strengthening OR through the support of local capacity building and the creation of stronger coordination between the NMCP and researchers to harmonize and prioritize operational research efforts. PMI-funded OR has provided important data for decision-making, including studies measuring the durability of long-lasting ITNs, the impact of IRS, the effectiveness of the IPTp strategy, the quality of health facility case management practices for uncomplicated and severe malaria, the ability of patients to complete recommended first-line treatment for malaria, the distribution of potentially drug-resistant parasites and mosquitoes and the effectiveness of ITNs in an area with significant pyrethroid resistance. In early 2015, a PMI-funded evaluation of mobile-telephone text messaging to improve health worker performance was initiated. End-line surveys were conducted in November 2015 and May 2016 to assess the impact of the intervention. Analysis of these end-line data revealed no significant improvement in health care worker performance in the intervention group (based on these results, the May 2016 end-line survey was not conducted). In 2015, PMI supported a repeat evaluation of the effectiveness of IPTp focusing on the effect of the sextuple (dhps581) mutation, which is associated with extremely high levels of resistance. Preliminary data suggest that SP remains effective in preventing patent, but not subpatent parasitemia, and was associated with increased birthweight in women who received at least three doses compared to women who received fewer than three doses. PMI has been supporting the NMCP to develop a research agenda and data dissemination platform to better coordinate and share research among partners in Malawi. Funding from previous years continues to support two studies. The first assesses the efficacy of IPTp with dihydroartemisinin-piperaquine compared to SP to help determine whether this might be an alternative to IPTp-SP. The second is a pilot assessment of the effect of community delivery of IPTp-SP on IPTp uptake and ANC attendance. There are no OR studies planned with FY 2017 funds.