National Strategy for Community-based Management of Malaria (CBMM) in Afghanistan

National Strategy for Community-based Management of Malaria (CBMM) in Afghanistan

(2011-2015)

Table of Contents

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.

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

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

1. BACKGROUND

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.

Afghanistan

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.