Islamic Republic of Afghanistan
Ministry of Public Health
General Directorate of Preventive Medicine
Communicable Diseases Control Directorate
National Malaria and Leishmaniasis Control Programme
National Strategy for Community-based Management of Malaria (CBMM) in Afghanistan
(2011-2015)
Table of Contents
ACKNOWLEDGMENT:
Acronyms:
1.BACKGROUND
2.SITUATION ANALYSIS:
Malaria Stratification
Health Care System
Review of National Policies
Community-based health care
Malaria treatment guidelines and management of fever
Challenges
Ongoing Community-Based Initiatives in Afghanistan
Pilot Community-Based Management of Malaria in Badkhshan, Kunduz, and Takhar Provinces
5.STRATEGIC OBJECTIVES:
6.Strategic Components:
6.1Case Management; prompt and reliable diagnosis and effective treatment
6.2 Capacity Building (Training of health workers and supervisors)
6.3Advocacy, community sensitization and education
6.4Risk Management Strategy
Strategic Component #1: Case Management; prompt and reliable diagnosis and effective treatment
Strategic Component #2: Capacity Building (Training of health workers and supervisors)
Strategic Component #3: Advocacy, community sensitization and education
Strategic Component #4: Risk Management Strategy
Procurement, storage and distribution
Stock management
7.INSTITUTIONAL FRAMEWORK
8.MECHANISM FOR COORDINATION
8.1 The National Vector Born Disease Control Task Force (VBDCTF)
8.2 The Provincial Vector Born Disease Control Task Force (VBDCTF)
9.IMPLEMENTATION PLAN
Priorities areas and phased implementation
10.MONITORING AND EVALUATION
10.1Integrated supervision
10.2 Quality control at point of care
ANNEX 1 - Stratification of districts of Afghanistan based on reported malaria incidence rate (2009 data)
ANNEX 2 - Current contents of CHW kit (2009)
ANNEX 3 - Tally Sheets for CBMM developed in the pilot RDT and ACT community-based project
ANNEX 4 - Supervision Check List on ACTs and RDTs for Community Health Supervisors
ANNEX 5 Timetable of activities
ANNEX 6 Budget components and financial gaps (USD)
ANNEX 7: CBMM training Curriculum
ACKNOWLEDGMENT:
The Ministry of Public Health would like to acknowledge the contribution made by all stakeholders working in the first National Community Based Malaria Management Strategic Planning Workshop, which provided a forum for deliberations of this plan.
The National Malaria & Leishmaniasis Control Task force experts, CBHC directorate,World Health Organization EMRO, BRAC, HN-TPO and other partners deserve special gratitude for their invaluable technical guidance and ensuring thatAfghanistan’s National Community Based Malaria Management Strategic Plan is comprehensive, effective and will have a significant impact in terms of rolling back malaria.
Finally, it is important to note that this Strategic Plan should be regarded as a working document. All comments, feedback and additional case materials will be considered in future reviews in order to make it more relevant.
Dr. M.Sami Nahzat
NMLCP Manager
Acronyms:
ACTs Artemisinin Combination Therapy
AMS Afghanistan Mortality Survey 2010
BHCs Basic Health Centres
BRAC Bangladesh Rural Accreditation Committee
CBHC Community Based Health Centre
CDC Communicable Disease Control
CIMCI Community Integrated Management of Childhood Illness
CHS Community Health Supervisor
CHWs Community Health Workers
CQ Chloroquine
EMRO East Mediterranean Regional Office
EPHS Essential Package of Hospital Services
GF R8 Global Fund Round 8
GFATM Global Fund fight against AIDS, TB and Malaria
HMIS Health Management Information System
HN-TPO Health Net- Trans cultural Psycho-social organisation
HPRO Health Protection Research Organisation
HSC Health Sub Center
IEC Information, Education and Communication
IM Intramuscular
IMCI Integrated Management of Childhood Illness
LLIN Long Lasting Insecticidal Nets
MoPH Ministry of Public Health
MHT Mobile Health Team
NGOs Non- Governmental Organisation
NMCLP National Malaria and Leishmaniasis Control Programme
NMSP National Malaria Strategic Plan
ORS Oral Rehydration Salts
PHC Primary Healthcare
PHD Provincial Health Directorate
PR Principal Recipient
RDT Rapid Diagnostic Test
HSC Health Sub centres
TB Tuberculosis
TDR Tropical Disease Research
UN United Nations
UNICEF United Nations Childrens Fund
USAID US Agency for International Development
WHO World Health Organisation
1.BACKGROUND
It is estimated that the number of cases of malaria rose from 233 million in 2000 to 244 million in 2005 but decreased to 225 million in 2009. The number of deaths due to malaria is estimated to have decreased from 985000 in 2000 to 781000 in 2009. Decreases in malaria burden have been observed in all WHO Regions, with the largest proportional decreases noted in the European Region, followed by the Region of the Americas. The largest absoluteDecreases in deaths were observed in Africa. The percentage of reported suspected malaria cases receiving a parasitological test has increased between 2005 and 2009, particularly in the African Region (from 26% to 35%), Eastern Mediterranean Region (47% to 68%) and South-East Asia Region excluding India (from 58% to 95%). Data from a limited number of countries suggest that both microscopy and RDTs are less widely available in the private sector than the public sector.A small number of countries, including the Lao People’s Democratic Republic and Senegal, have shown that it is possible to scale up rapidly the availability of malaria diagnostic testing nationwide, provided that attention is given to adequate preparation, training, monitoring, supervision and quality control (world malaria report 2010). Among females, the leading causes of death are infectious and parasitic diseases 18.3 percent and between men 16.2 percent (Afghanistan Mortality survey, 2010 - Chapter 8 causes of death by age and sex Page: 136)
Malaria is an endemic disease and a major public health problem in many Provinces of Afghanistan. It causes a great burden on the health and economic development of individuals, families and communities living in endemic areas. The total number of reported malaria cases were 414407 in 2006, 390729 in 2009 and 392463 in 2010. Majority of these cases were clinically diagnosed: 79.8%, 83.4 % and 82.0% respectively(HMIS 2010). The Government of Afghanistan remains committed to the control of this disease. For this purpose the Government developed the National Malaria Strategy Plan 2008-2013 with a vision of a malaria free Afghanistan.
The main quality-of-care challenge posed by the recent decline in malaria is now in identifying those cases of fever which are in fact caused by malaria and amongst those malaria cases, identifying and treating the correct species of infection. Most fever in Afghanistan is not caused by malaria (even in the most endemic areas, slide positivity rate is rarely above 30%). Most malaria, in turn, is not caused by P. falciparum, but by P. vivax. Because treatment for these two diseases differs, identification of the species is important for treatment outcomes. In summary, the context for deployment of RDTs should be in improving the treatment of fever at community level and ensuring that those with malaria are a) parasitologically confirmed cases and b) treated appropriately. Appropriate treatment, in this context, means that those with parasites are treated with an effective antimalarial, and those without malaria parasites are appropriately treated with non-antimalarial drugs.
The need to identify the presence or absence of malaria parasites (at species level) in providing treatment lends itself to mixture of diagnostic methods each of which is appropriate to the setting. The choice is between microscopy and RDTs. Microscopy is the preferred method in clinic settings with a relatively high throughput of patients, but is also difficult and expensive to maintain because of the need to monitor quality of the microscopists and relatively high fixed costs (such as microscopes and salaries). RDTs may also play a role at clinic level, in areas where microcopy is hard to maintain, where patient throughput is low, or at times when the laboratory is closed.
RDTs can also be deployed at community level, through CHWs, which may improve access to effective treatments for both malarial and non-malarial causes of fever at community level. Programs to increase access to RDTs also encounter challenges, such as maintenance and monitoring of quality, supply and storage of the RDTs (which are heat sensitive), and in training of CHWs. Despite these challenges, there is hope that RDTs have a role to play in improving diagnosis of malaria and non-malarial causes of fever and through accurate diagnosis, to improve the targeting of effective treatments.
Accurate diagnosis of malaria (using RDTs and micrsocopy) is also providing more accurate and higher resolution surveillance data in most settings where they have been deployed (either through clinics to communities). Until now, most data has been based on suspected malaria cases (i.e. where there has been no parasite based diagnosis), which results in a persistent over estimate of malaria burden – for example in Takhar province, in 2009, around 13,000 suspected cases were reported through the HMIS system. In clinics which have microscopy (in the most endemic districts of Takhar) slide positivity rate was <1%. If this figure is applied to the number of suspected cases identified, the true number of cases amongst those suspected cases is of the order of 100-200 cases – 2 full orders of magnitude below the estimates based on suspected cases.
This improved accuracy in surveillance can result in the directing of resources more effectively and in earlier detection of outbreaks and epidemics. It has additional advantages in enhancing the type of intensive surveillance that will be required if Afghanistan officially declares the goal of elimination.
The National Strategy for Community-based Management of Malaria (CBMM) in Afghanistan outlines the basic approach to increase access to diagnostic testing of malaria and effective treatment at the community level in all malaria endemic areas of Afghanistan. It aims at mobilising commitment and resources from the Government of Afghanistan, the implementing agencies and the community themselves, providing a common strategy for concerted action.The development of this Strategy builds on the key policy elements of the National Malaria Strategy (NMSP) of Afghanistan (2009-2013), the Basic Package of Health Services (BPHS) for Afghanistan (2009/1388), and the Community-Based Health Care Policy and Strategy (2009-2013). Currently Afghanistan enjoys a strong partnership amongst Government, UN agencies, funding agencies, and national and international NGOs, which creates an enabling environment for successful malaria control.
The CBMM Strategy aim to progressively expand access to highly effective antimalarial treatment with Artesunate + SP (Sulfadoxine-Pyrimethamine) for the treatment of parasite confirmed falciparum malaria and with chloroquine for treatment of parasite confirmed vivax malaria, guided by the use of combination RDTs at peripheral clinics and at community level. The Phase I (first two years of the project) will focus on consolidation of work in the pilot districts of Northern provinces of Badkhshan, Kunduz, and Takhar involved in the community-based deployment of ACTs and RDTs, and will extend in the districts with the highest reported incidence of malaria, while during its Phase II (years 3, 4 and and 5) the programme will extend to the remaining parts of the country . Within each phase, the first year of implementation will focus on the peripheral health facilities which do not currently have microscopy (BHCs and HSC) and the second year will extend the interventions to Heath Posts at community level. The year 5 (Phase III) will aim at consolidation of the results, with focus on refresher training and improving on the coverage targets.
2.SITUATION ANALYSIS:
Malaria Stratification
Malaria is endemic in large areas of Afghanistan below 2,000 meters above the sea level and is highly prevalent in river valleys. Major determinates of malaria transmission in the country are altitude and agricultural practices, especially rice cultivation.
The risk of malaria transmission in each of the provinces is not homogeneous, and, for this reason, a more accurate stratification of malaria based on incidence of reported clinical malaria per district by BHC and CHC has been used in this document, based on HIMS 2009 data. District in which the reported malaria cases exceeded the median of reported annual malaria incidence rate, i.e. >10/1000, were classified as Stratum 1, those with reported annual malaria incidence rate between 1 and 10/1000 were classified as Stratum 2 and those with reported annual malaria incidence rate of 0-1/1000 cases were classified as Stratum 3. The stratification of malaria at district level using these thresholds is shown in Figure 1 below.
Figure 1.Stratification of malaria in Afghanistan at District level.
The detailed list of reported malaria incidence rate per district in all the 34 Provinces of the country and their classification in the three malaria Strata defined as indicated in Figure 1, is presented in Annex 1.
Health Care System
Owing to the protracted war, poverty, loss of livelihoods, and the breakdown of health structures, estimates from the AMS 2010 indicate that male and female life expectancies at birth are 62-64 years. For every 1,000 live births, about 3-5 women die during pregnancy, in childbirth, or in the two months after delivery Child mortality continues to be high in Afghanistan although there has been a marked decline in the last decade.The under-5 mortality rate for Afghanistan excluding the South zone for the 2-6 years prior to the survey is 97 deaths per 1,000 births, and the infant mortality rate is 77 deaths per 1,000 births.
The national health policy of Afghanistan aims at providing a standardized package of basic services in all primary health care facilities, as described in the Basic Package of Health Services (BPHS)The Basic Package of Health Servicesincludes six standard types of health facilities, ranging from community outreach provided by CHWs at Health Posts, through outpatient care at Health Sub Centers and Basic Health Centers and provided by Mobile Health Teams, to inpatient services at Comprehensive Health Centers, district hospitals and regional hospital.The section below summarizes the services provided by each type of facility.
Health Posts: At the community level, basic health services are delivered by CHWs from their own homes, which function as community health posts. A health post, ideally staffed by one female and one male CHW, cover a catchments area of 1,000– 1,500 people, which is equivalent to 100–150 families. The CHWs offer basic curative services, including differential diagnosis and treatment of fever as well as a wide array of communicable diseases. Currently no malaria RDTsare available at health post level Except USAID pilot project in North east provinces (Kunduz, Takhar and Badakhshan.
Health Sub Centers: The extremely challenging geography, especially in some parts of the country, the scattered pockets of population, the absence of basic infrastructure such as roads and bridges, ethnic and security issues, etc. all pose difficult questions regarding the establishment of BPHS health facilities based on the number of people covered.A HSC is intended to cover a population of about 3,000-7,000, often residing in remote underserved areas. The HSC is staffed by two technical staff (a male nurse and a community midwife), as well as a cleaner/guard. The HSC provides most of the BPHS services that are available in BHCs. HSCs will refer severe and complicated cases to higher level facilities. The HSCs are not equipped with adequate malaria diagnostic facilities.
Mobile Health Teams: Given all the challenges coupled with the scarcity of trained health workers (particularly females), it may not be feasible to establish staffed fixed centers in some remote areas, where the population is scattered and live in small communities. The principal idea of mobile health services is to establish a limited number of mobile health teams in each province by dividing the province into clusters of districts. The MHT ideally has the following staff, male health provider (doctor or nurse), female health provider (community midwife or nurse), vaccinator and driver. The MHTs are unable to offer just clinical malaria diagnostic services.
Basic Health Center: The BHC is a small facility offering primary outpatient care, immunizations and Maternal and Newborn care. The services of the BHC cover a population of about 15,000–30,000, depending on the local geographic conditions and the population density (can be less than 15,000 where the population is very isolated). The minimal staffing requirements for a BHC are a nurse, a community midwife, and two vaccinators. Mainly BHC offer clinical malaria diagnostic services but some health facilities are equipped with supplies and equipment for malaria microscopy through GF R5, R8 Project.
Comprehensive Health Centers: The CHC covers a catchment area of about 30,000–60,000 people and offer a wider range of services than does the BHC. The facility usually has limited beds inpatient care, and a laboratory equipped with microscopes. The staff of a CHC comprises of doctors (male and female), nurses (male and female), midwives, one (male or female) psychosocialcounsellor and pharmacy and laboratory technicians. Irregular attendance by the laboratory technicians due to trainings, illness, commitment to other programme related activities, results weakened laboratory diagnostic services. Furthermore, high patient burden and long waiting lists may also limit access to malaria microscopy at CHCs level.
District Hospitals: Each district hospital covers a population of about 100,000–300,000. The district hospital is staffed with a number of doctors, including female obstetricians/gynecologists; a surgeon, an anesthetist, a pediatrician, a doctor who serves as a focal point for mental health: psychosocial counsellors/supervisors; midwives; laboratory and X-ray technicians; a pharmacist; a dentist and dental technician; and two physiotherapists (male and female).HMIS data shows some proportion of malaria cases are diagnosed clinically despite the District Hospitals are equipped with microscopy due to high patient burdens and long waiting lists in the outpatient departments.
Review of National Policies
Community-based health care
The full description of the Community-based Health Care Policy of Afghanistan is provided in other documents[1], from only some key elements have been extracted and presented. Community-based health care (CBHC) is the basic strategy of the BPHS, providing the context for the comprehensive interaction between the health system and the communities it serves. Its success depends upon community participation and partnership between the community and the health staff.