Malaria related morbidity and mortality constitute a major public health problem in many regions of the world.  Based on 2006 data, an estimated 3.3 billion people or about 40% of the world population are at risk of malaria and, of an estimated 247 million episodes of malaria, 86 percent are in the African region (WHO 2008). Young children and pregnant women are at greatest risk, especially in areas of stable (high) transmission. Malaria in pregnancy (MIP) is associated with increased risk for poor maternal and infant health outcomes including maternal anemia, low birth weight (LBW), infant parasitemia, spontaneous abortions, stillbirths, and death of the mother.  It has been estimated that MIP is responsible for 5 to 12 percent of all LBW, 35 percent of preventable LBW, and contributes to 75 to 200 thousand infant deaths each year (WHO, 2007). The risks for poor pregnancy outcomes are even higher among women with dual HIV and malaria infection and women with first pregnancies.

In 1998, the Roll Back Malaria (RBM) international partnership established the goal of cutting in half the burden of malaria by 2010.  The World Health Assembly in 2005 extended the goal to reducing the burden by at least 75 percent by 2015. The UN Millennium Development Goals (MDG) most directly related to malaria include: #4 Reduce child mortality, specifically under age 5; #5 Improve maternal health; and #6 Combat HIV/AIDS, malaria and other diseases.  MDG Target 6C calls for halting by 2015 and then reversing the incidence of malaria and other major diseases.  Additional partners involved in the effort to reduce the medical, public health, and economic burden of malaria range from The Global Fund, the World Bank’s Malarial Control Booster Program, the U.S. President’s Malaria Initiative (PMI), and the Global Health Initiative, to the Bill and Melinda Gates Foundation.  While there have been successes in working toward the international goals in some regions and countries, routine surveillance data in a wide majority of the African countries (37 out of 41) from 2000 to 2007 did not show the expected reductions. For the 25 reporting countries outside of Africa, 22 countries met 50 percent reduction levels during the same time interval (WHO 2008).

Key approaches to preventing and controlling malaria include: (1) planning and implementing sustainable preventive measures, such as vector control and malaria prevention in vulnerable groups; (2) providing prompt diagnosis and treatment; (3) detecting early, containing or preventing epidemics; and (4) strengthening local capacity for monitoring and evaluation (M&E) and applied research permitting regular assessment of a country’s malaria situation (Global Fund, 2009). Prevention and treatment of MIP are of particular importance and the WHO package of recommended interventions for controlling MIP in stable transmission areas includes the use of insecticide treated mosquito nets (ITNs), intermittent preventative treatment in pregnancy (IPTp), and effective case management of malaria and anemia (WHO, 2007).

Progress in prevention and control has been uneven with relatively high estimated coverage with ITNs of the at-risk general population in countries outside of Africa, whereas only six countries in Africa had sufficient nets to cover at least 50 percent of the at-risk population. From a subset of 16 African countries where surveys measured pregnant women’s use of IPTp, on average only 18 percent of the women had the recommended two or more doses during pregnancy (WHO, 2008).  Effective implementation of the WHO strategy to combat MIP requires close collaboration between malaria control and reproductive health programs at all levels.

Given the rapid global expansion of funding and interventions targeting malaria over the past decade, particularly in Africa where some areas with high endemic levels are receiving intensive coverage, the changing patterns of transmission, infection and disease burden are further increasing the need for effective M&E. A framework (Global Fund, 2009) for monitoring malaria control programs has been developed that details various inputs, activities, outputs, outcomes and impacts, all linked to the process of assessment and planning. Ideally program inputs (e.g., funding and standards of practice) result in outputs, such as improved supplies and services and clients served, which can then lead to positive short-term outcomes (e.g., increased use of ITNs, adherence to IPTp, and treatment of malaria cases during pregnancy).  Improving birth and maternal health outcomes, measured by reduced levels of LBW and severe anemia in pregnant women, contributes to the impact goals of preventing and treating MIP. The five core indicators selected for this database are from the WHO (2007) Malaria in Pregnancy guidelines and measure key outputs, i.e., staff training and availability of supplies, and short-term outcome indicators measuring client use of ITNs, IPTp, and malaria treatment during pregnancy. Longer term impact indicators (percent LBW and percent pregnant women with severe anemia) can be adapted from the parallel database indicators in technical areas for Newborn Health and Women’s Nutrition, respectively.

Indicator Selection

The full set of WHO (2007) MIP indicators were designed by a WHO sponsored expert technical group to be measurable through existing health management systems and routine or regular household surveys (i.e., DHS, UNICEF MICS, and supplemental malaria indicator surveys).  The indicators were pilot tested in three malaria endemic countries (Kenya, Nigeria, and Uganda) to test the feasibility of collecting the data through these routine systems and surveys. The use of standard indicators provides country and regional programs with measures that allow comparison of subpopulations, endemic and high verses low transmission areas, and the ability to track progress of intervention programs over time.  This information helps direct resources to the areas of most need and improve effectiveness of country and local level programs.  The standardized indicators also ensure comparability of information across countries and regions for surveillance and for intervention planning and evaluation purposes.  Successful M&E requires strengthening health management information systems where needed and ensuring systems are in place for supervision and quality control at all levels of health care.

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References:

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, Geneva. https://www.measureevaluation.org/resources/training/capacity-building-resources/m-e-of-hiv-aids-programs-in-india-english/session-1/GFATM%20M_E_Toolkit.pdf

Roll Back Malaria, MEASURE Evaluation, USAID, UNICEF, World Health Organization, MACEPA, CDC. 2009. Guidelines for Core Population-Based Indicators. MEASURE Evaluation: Calverton, MD: Roll Back Malaria Working Group. https://reliefweb.int/sites/reliefweb.int/files/resources/AC719D00E5DE6F5D492575B3001BE5A3-RMB-guideline-20009.pdf

USAID. 2009. Monitoring and Evaluation Indicators to be Used within the President’s Malaria Initiative, Washington, DC: USAID.

WHO. 2007. Malaria in Pregnancy:  Guidelines for measuring key monitoring and evaluation indicators, Geneva: WHO. http://whqlibdoc.who.int/publications/2007/9789241595636_eng.pdf

WHO. 2008. World Malaria Report 2008. Geneva: WHO. http://whqlibdoc.who.int/publications/2008/9789241563697_eng.pdf