World Malaria Day 2020: Two countries

On this World Malaria Day there is a new urgency to maintain and build on recent progress made in malaria control. The World Health Organization (WHO) noted recently that interruptions of supply chains brought about by the COVID-19 pandemic may reverse some of the recent progress. Let us note, then, what has been achieved recently in two projects—MEASURE Evaluation and PMI Measure Malaria—and what they can sustain.

We talked to three experts about the ongoing malaria surveillance, monitoring, and evaluation (SME) work in two countries at different stages of intervention: Olivier Kakesa in Cameroon, and Maurice Yé and Fanor Joseph in Madagascar.

Two Settings at Different Stages

Madagascar is moving from control to elimination in the fight against malaria. MEASURE Evaluation has worked in Madagascar since 2015, and that work is transitioning to the PMI Measure Malaria project. The chief task now is to incorporate malaria surveillance into the country’s health information system (HIS), aligned with its health strategy and focused on elimination. The HIS in Madagascar is managed on the District Health Information Software, version 2 (DHIS2) platform. Yé and Joseph are focused on a transition plan to migrate malaria data from a parallel digital information system into DHIS2. That also means supporting PMI partners to align their technical assistance with this effort, train key personnel in malaria SME, and coordinate the malaria technical working group. The result will be the transition of malaria surveillance from a discrete program to a disease managed routinely as part of the country’s health strategy.

“A big jump from the beginning to now [in Madagascar] is the malaria bulletin,” Yé says. “It gives the field a single document summarizing all the data: the use of mosquito nets, the number of cases reported, the availability of drugs. This gives [everyone] useful information.” Joseph adds that Madagascar plans to expand distribution of the bulletin to the district level. “Already, 50 districts of 140 have that. We are trying for 100 percent.”

Additionally, Madagascar has succeeded in setting up a pool of SME professionals, taking the number of skilled staff from “two people skilled to more than 200,” says Yé.

In contrast, Cameroon—also using DHIS2—is working toward malaria control rather than elimination. MEASURE Evaluation’s work there began in 2018. Its main tasks now are to establish a baseline for measuring progress against malaria, to train health workers in malaria surveillance and data quality, and to finalize the SME plan to be incorporated into Cameroon’s health strategy for 2019–2023. In Cameroon there are challenges in data quality. “The [data] quality is OK for areas we support, with 80 percent accuracy,” Kakesa says. “Our big challenge is the timeliness of data reported to DHIS2. In collaboration [with stakeholders] we are making it better.”

Applying Learning Across Settings

Cameroon, which started malaria SME interventions later than Madagascar, was able to benefit from a tool recently developed to address in-country capacity for malaria SME—the Monitoring and Evaluation Capacity Assessment Toolkit (MECAT). Although the Madagascar team conducted a rigorous assessment as their work began, Yé says he’s somewhat envious of the tool Kakesa had in hand: “I’m proud of how Olivier handled the MECAT [in Cameroon]. Madagascar didn’t get to use that tool.”

But the learning is in both directions. Cameroon has seen the benefit of Madagascar’s malaria bulletin and is now producing one themselves.

Adapting to a New Environment: COVID-19

In the midst of COVID-19, WHO underlines the importance of sustaining efforts to prevent, detect, and treat malaria, while protecting health workers and communities from COVID-19 [1]. Our experts say this means they are working remotely and adapting as they can.

Already, says Yé, the impacts are being felt. “We can’t do the district and regional [malaria SME] training because it can’t be done remotely. For the past week, we haven’t been able to hold data quality meetings, where our expertise is needed at district and regional levels,” says Yé. He also worries about how COVID-19 may affect health-seeking behavior. “[There’s a] general fear about visiting health facilities, which may suppress our ability to determine the people who have malaria.” However, PMI Measure Malaria is monitoring data being reported and will analyze them when there are at least three months of data. Decreased accessing of health facilities would result in under-reporting of malaria cases and would affect global estimates.

In Cameroon, says Kakesa, “there are 820 confirmed COVID-19 cases (as of April 13). Given the lack of mass testing, I believe there are many more. And because of social isolation, most of our [scheduled] activities for March and April will not be completed.”

Even as work shifts and travel is restricted, however, PMI Measure Malaria continues to expand upon and support ongoing work and respond to emerging needs.

“We [in Madagascar] have been working remotely since March 30 to continue implementing malaria SME activities,” says Joseph. “We are also providing remote technical support to the ministry to adapt the DHIS2 COVID-19 module developed by the University of Oslo for tracking cases.” In Cameroon, PMI Measure Malaria provides remote technical assistance for malaria data analysis to help the country deal with COVID-related social distancing restrictions.

As countries mobilize their COVID-19 response, the PMI Measure Malaria team will coordinate with their efforts. If supplemental funds become available, we will work with disease surveillance stakeholders to adapt current information systems to accommodate COVID-19 data, improve contact tracing of suspect cases at the community levels, and monitor and assess the response system. To ensure COVID data are integrated with other data in the HIS, the team will facilitate the analysis and dissemination both of malaria indicators and COVID-19 data through the production of daily briefs and a weekly bulletin.

The work of MEASURE Evaluation and PMI Measure Malaria on the collection and use of data is being disrupted to an extent by COVID-19, but by interacting remotely with our colleagues, we are able to hold onto and even build on some of our recent accomplishments. And, we will also be able to use our systems and expertise to benefit the global response to COVID-19.

For more information about PMI Measure Malaria’s work, visit https://www.measuremalaria.org/ and to view a curricullum for SME of malaria programs visit www.measuremalaria.org/publications/surveillance-monitoring-and-evaluation-of-malaria-programs-online-course/

Olivier Kakesa, is a resident advisor in Cameroon with PMI Measure Malaria

Maurice Yé, is a Malaria Surveillance, Monitoring and Evaluation Advisor in Madagascar with PMI Measure Malaria

Fanor Joseph, is an HMIS resident advisor in Madagascar with PMI Measure Malaria