Inception Report of the Project : Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Region, Chang Mai, Thailand, July 2006

(WP)MVPIICP/MAL/l.2/00l-E RS/2006/GE137(THA)

English only

,,}NCEPfION REPORT OF THE PROJECT: STRENGTHENING MALARIA CONTROL FOR ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION

Convened by:

WORLD HEALTH ORGANIZATION WESTERN PACIFIC REGION Chiang Mai, Thailand July 2006

WHO/wPRO LiBRARY '1,'[\1'.'TT <\.

PHHJPPINES

1 2 ~1AR 2009 Not for sale Printed and distributed by: World Health Organization Western Pac:ific: Region Manila, Philippines August 2006

NOTE The views expressed in this report are those of the participants in the Inception Report of the Project: Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Subregion and do not necessarily reflect the policies of the Organization

This report has been prepared by the World Health Organization Western Pacific Region for governments of Member States in the Region and for those who participated in the Inception Report of the Project: Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Subregion held in Chiang Mai, Thailand, July 2006.

TABLE OF CONTENTS

ABBREVIATIONS .................................................................................................................... i SUMMARy ............................................................................................................................... ii 1. PROJECT BACKGROUND ................................................................................................. 1 1.1 1.2 Introduction ................................................................................................... 1 Project goal, objectives and expected outcomes ................................................. 1

2. A SUMMARY OF MALARIA CONTROL FOR ETHNIC MINORITIES IN THE GMS AND LESSONS LEARNT ................................................................................ 2 2.1 2.2 2.3 Review ofthe ADBIWHO Mekong Roll Back Malaria IEC Proj ect... ................... 2 GMS country review of malaria control for ethnic minority groups ..................... .4 Proposed activities and identification of target populations .................................. 6

3. PROJECT DESIGN AND COUNTRY PLANS ................................................................... 9 3.1 3.2 The second advisory committee meeting ........................................................... 9 Country pilot proj ects ................................................................................... 10 Cambodia project plan ................................................................................... 11 China-Yunnan province project plan ............................................................. 12 Lao People's Democratic Republic project plan ............................................ 13 Thailand project plan ..................................................................................... 14 Viet Nam project plan .................................................................................... 15 Myanmar project plan (pending approval} ..................................................... 16

3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6

4. CAPACITY BUILDING AND MONITORING AND EVALUATION ........................... 17 4.1 4.2 4.3 4.4 Capacity building ..................................................................................................... 17 Regional training workshop on quantitative and qualitative assessment of country pilot intervention studies ............................................................................ 18 Monitoring and evaluation ....................................................................................... 19 Project cost analysis ................................................................................................. 19

5. PROJECT IMPLEMENTATION SCHEDULE, BUDGET AND STRUCTURE ............. 20 5.1 5.2 Project implementation schedule and budget .......................................................... 20 Project structure ....................................................................................................... 21

6. CHALLENGES FOR PROJECT IMPLEMENTATION ................................................... 23 7. CONCLUSIONS ................................................................................................................. 24 ANNEXES: Annex 1 Annex 2 Annex 3 CAMBODIA PROJECT IMPLEMENTATION AND BUDGET PLAN CHINA PROJECT IMPLEMENTATION AND BUDGET PLAN LAO PEOPLE'S DEMOCRATIC REPUBLIC PROJECT IMPLEMENTATION AND BUDGET PLAN

THAILAND PROJECT IMPLEMENTATION AND BUDGET PLAN VIET NAM PROJECT IMPLEMENTATION AND BUDGET PLAN DRAFT MYANMAR PROJECT IMPLEMENTATION AND BUDGET PLAN PROJECT TECHNICAL ASSISTANCE AND SUPERVISION SUPPORT PLAN Annex 8 - TECHNICAL REPORT ON TRAINING WORKSHOP AND M&E INDICATORS Annex 9 - PROJECT IMPLEMENTATION PLAN Annex 10 - PROJECT BUDGET PLAN Annex 11 - PROJECT STRUCTURE Annex 12 - PROJECT COSTING TABLES

Annex 4 Annex 5 Annex 6 Annex 7 -

ABBREVIATIONS

ACT ACTMaiaria ADB AusAiD BVBD CDC CHC CMPE CNM DOTS EC EDAT EMG GFATM GMS HU IEC IMPE ITN LLIN MCNV M&E NGO NIMPE NMCP NMI NIPD PSI

RDT RETA RBM TB UNICEF VBDC VHV VHW VMW YIPD WHO

Artemisinin-based combination therapy Asian Collaborative Training Network for Malaria Asian Development Bank Australian Agency for International Development Bureau of Vector Borne Disease Centers for Disease Control and Prevention Commune health centres Centre for Malariology, Parasitology and Entomology, Lao People's Democratic Republic National Malaria Center, Cambodia Directly observed treatment, short-course European Commission Early diagnosis and treatment Ethnic minority groups Global Fund to Fight AIDS, Tuberculosis and Malaria Greater Mekong Subregion Health Unlimited Information, education and communication Institute of Malariology, Parasitology and Entomology, Qui Nhon, Viet Nam Insecticide-treated net Long lasting insecticide-treated net Medical Committee Netherlands-Viet Nam Monitoring and evaluation Nongovernmental organization National Institute of Malariology, Parasitology and Entomology, Ha Noi, Viet Nam National Malaria Control Programme National Malaria Institute National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China Population Services International Rapid diagnostic test Regional Technical Assistance, ADB Roll Back Malaria Tuberculosis United Nations Children's Fund Vector-Borne Disease Control Village health volunteer Village health worker Village malaria worker Yunnan Institute of Parasitic Diseases, Simao, China World Health Organization

SUMMARY

Malaria control is a health priority in the Greater Mekong Subregion (GMS). Over the past several years the malaria situation in this region has improved. In some areas, rates of malaria-related mortality and morbidity have been reduced by more than half. All the GMS member countries have promoted the use of insecticide-treated nets (ITNs) and encouraged people to seek early diagnosis and appropriate treatment. Rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) are being introduced in most member countries. While these interventions have improved the health of easy-to-reach populations, others who live in remote areas, particularly ethnic minorities, migrants and forest workers, remain at risk for malaria. In 2005, the Asian Development Bank (ADB) agreed to provide financial support, through the World Health Organization (WHO) Regional Office for the Western Pacific, for the project entitled: "Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Subregion". The goal ofthis project is to reduce the malaria burden among poor ethnic minority groups living in malaria-prone areas, thereby helping to reduce child and maternal mortality. The project started in October 2005 and will end in September 2007. Project objectives are: (I) to build capacity of national malaria institutions to develop acceptable, affordable and effective strategies for malaria control for ethnic minorities; (2) to scale up malaria control efforts for these populations through national malaria control programmes (NMCPs); and (3) to promote regional collaboration for malaria control. A two-day Project Inception Meeting, combined with the First Advisory Committee Meeting, was held from 25 to 26 November 2005 in Vientiane, Lao People's Democratic Republic, to introduce and adopt the "Strengthening Malaria Control for Ethnic Minorities in the GMS" project. 1 The malaria control programme managers from the member countries discussed the expected project outcomes and the project implementation schedule. They also shared and discussed 'lessons leamt' from their respective control programmes. The Project was designed to apply information, education and communication (lEC) materials from a previously funded ADB project/ in order to implement a range of malaria control interventions with selected vulnerable populations. Monitoring and evaluation would be done throughout the project, including gathering baseline data from which changes in behaviour and adaptation of malaria-control interventions could be assessed. Due to limitations in time, capacity and resources, a proper economic analysis of the project was not feasible. Countries were asked to gather rudimentary costing data to help with programmatic planning for future scale-up of successful interventions. A regional approach to malaria control among ethnic minorities and other vulnerable populations, based on 'lessons learnt' from the Project, is expected to be developed. ADB, which serves as the executing agency, will allocate US$ 750000 for project implementation. As the implementing agency, the WHO Regional Office for the Western Pacific will contribute US$ 130 000 for technical assistance, workshops and other support, while the national malaria control institutions of the six member countries will provide

I See the report, Strengthening Malaria Control for Ethnic Minorities in the GMS - Project Inception and First Advisory Committee Meeting, Vientiane, Lao People's Democratic Republic, 25-26 November 2005. Manila, WHO, 2006. 2 Funded by ADB and initiated in 2002, the project was entitled: "ADBIWHO Mekong Roll Back Malaria IEC Projecf'. See Final Project Report, WHO, 2005.

US$ 100 000 in kind, for office accommodation and utilities, remuneration and per diem of counterpart staff and other support. The OMS country teams have identified challenges in malaria control for ethnic minorities. Low bednet re-treatment rates, inconsistent use ofbednets and low bednet coverage among vulnerable groups, delays in seeking diagnosis and treatment and failures to complete a full treatment course are seen as main challenges for malaria prevention in all OMS countries. There are multiple factors that account for the identified problems. The targeted communities live in very poor, geographically hard-to-access areas, which often have limited access to health care facilities. Culturally, treatment is often sought from traditional healers first. Few can afford the costs of a full malaria treatment course purchased from a shop. There is little awareness of the link between incomplete treatment courses and the potential for the development of antimalarial drug resistance. Delays in treatment might also result from a lack of trust and perceptions of poor health care services from local health care providers. The respective countries plan to address these challenges through community-based interventions focusing on increasing bednet coverage, usage and re-treatment rates; strengthening village health volunteers' capacities to implement malaria prevention and control strategies; improving rates of malaria diagnoses and treatments obtained from trained personnel through promoting utilization oflocal health facilities, and stressing the importance of correctly adhering to complete doses of artemisinin-based combination therapy (ACT). These interventions aim to be achieved through using health education and social mobilization, training local health providers including village volunteers, strengthening collaboration among malaria partners and improving logistic and management. A Second Advisory Committee Meeting was held in Chiang Mai, Thailand, from 8 to 10 March 2006 to finalize and approve the pilot studies in the six member countries, the budget for project implementation, as well as monitoring and evaluation (M&E) tools and plans. During this meeting, the member countries refined project plans to include expected results, indicators, activities and timeframes. All of the countries focused on similar outcomes, such as: (1) increased knowledge of the target population regarding malaria prevention and control; (2) improved correct usage ofITNs; (3) enhanced local capacity to provide effective malaria control interventions so that scale-up can occur, and (4) expanded advocacy nationally and regionally for continued attention to the vulnerable, targeted ethnic minority groups. Indicators for meeting project objectives were identified, with examples such as: (1) at least 90% of the population in the target villages know prevention strategies and from where they can obtain treatment for malaria (Cambodia); (2) 80% of target population re-treat their bednets with insecticide (China); and (3) all children under five years of age and pregnant women sleep under insecticide-treated bednets (Lao People's Democratic Republic). Some countries have indicated clear outcomes of the project, for example: (I) strategy on malaria control for ethnic minority groups developed (Viet Nam); and (2) report on the results and lessons learnt on pilot interventions for malaria prevention and control distributed and published on the Internet (Myanmar). The Project Coordinator introduced the overall project implementation schedule and budget breakdown. The member countries then summarized their respective country plans. All countries agreed that the budgets as planned were sufficient. They also agreed that all member countries would collaborate with the NMCPs and their available resources for necessary district training, procurement of supplies and implementation of ITNs, RDTs and ACT. Only China and Myanmar would need to procure such commodities for the pilot project target population using project funds. The following decisions were reached during the Second Advisory Committee Meeting: (I) the country project plans Qfthe Cambodia, Lao People's Democratic Republic, Thailand and Viet Nam were approved; (2) China's plan was tentatively approved with final approval after revision and resubmission of plan and budget; (3) approval of Myanmar's plan would be withheld until full proposal was available,

including budget, additional clarification on sample specifics and timeline; and (4) overall Project budget and implementation plan was approved. The China-Yunnan and Myanmar country plans would be revised and resubmitted to all committee members after the meeting. Based on their approved country project plans, each member country then would submit an implementation plan of the first year for funding to the WHO Regional Office for the Western Pacific. Directly following the Second Advisory Committee Meeting, a training workshop on "Quantitative and Qualitative Assessment of the Country Pilot Intervention Studies" was conducted at the same site from 13 to 18 March 2006. Facilitators and faculty for this workshop included: Dr Jo Lines (malaria expert for the Project, London School of Hygiene and Tropical Medicine [LSHTMJ), Dr Holly Ann Williams (United States Centers for Disease Control and Prevention [US CDC), malaria and qualitative methods expertise), Ms Jane Bruce (LSHTM, survey methodology expertise) and Mr Pricha Petlueng (Technical Coordinator for the Project). The course consisted of research methodology content and principles of M&E including economic analysis, plus gave classroom and field practice for qualitative and quantitative methods. All teams produced an initial M&E plan (including specific indicators, budgets and tools) by the end ofthe workshop, although refinements to the plans would be necessary in their respective home countries. The workshop was not long enough to adequately cover the material in a manner that allowed participants to feel comfortable with the subject matter, but it gave all participants a framework to use as a guide in their projects. The respective countries' sets of indicators were finalized during the training workshop. The workshop time was devoted to developing and refining M&E plans, budget and tools. Initial M&E budget and plans and survey protocol and qualitative research guides were in the beginning of the development stage. All member teams sent edited plans and tools for review by the technical experts. Most teams also identified the need to obtain technical support through email and supervisory country visits during field implementation and data analysis. Although a proper economic analysis would be beneficial for future activities, it was agreed during the meeting and the training workshop that this was not feasible due to factors mentioned above. Sending information through the course facilitators, Dr Eve Worrell (Economist, LSHTM) provided expertise to help guide the development of a simple cost calculation matrix for a costing analysis. If obtainable, the information would be used to plan for expansion of the intervention into other areas. While it was hoped that project costing would include direct and indirect costs at both the provider (Ministry of Health) and community level, it is doubtful that such information will be forthcoming. It was clear at the end of the workshop that the country-level teams had minimal understanding of what was needed for costing, as the time of the workshop was exceedingly brief and did not allow for full discussion of this topic. Capacity-building for the respective project teams, including local personnel, is an important objective of this project. The project aims to strengthen national and local capacity through regional trainings, consultation workshops, supervisory country visits on a routine basis and provision of long-distance technical support. Training workshops are planned to focus on the proper techniques for impregnating bednets, conducting rapid diagnostic tests (RDTs), prescribing and dispensing ACT correctly, and improving communication skills. Education and communication training manuals and guidelines will be revised and adapted to suit the current needs of village volunteers and local health staff. Besides providing technical support for strengthening local capacity to implement the interventions, providing essential equipment and training people how to utilize them properly are also important issues for sustaining control interventions. For example, the Cambodia team plans to provide loudspeaker systems to the targeted villages, in which village health

volunteers would be trained in how to utilize them effectively for health education. The team in the Lao People's Democratic Republic plans to provide bicycles to village volunteers to help them reach the ethnic minorities and monitor the progress of their interventions. The Technical Assistance Agreement between ADB and WHO (signed 3 October 2005) defines the following requirements for the Project Inception Report: (1) a summary of malaria control for ethnic minorities in the OMS and lessons learnt; (2) plans for capacity-building and field studies; and (3) project implementation schedule and arrangements. While the first requirement had already been covered by the First Advisory Committee Meeting, the latter requirements were an outcome of the Second Advisory Committee Meeting, which was delayed due to a number of factors. Although the current project was building upon the previous ADB/WHO IEC project, there were administrative changes that caused delays in early project set-up and implementation. Both National Malaria Institutes (NMIs) and WHO country offices needed to nominate focal points and technical persons for the Project; due to the change in most personnel time was needed to inform the new personnel about the previous project. Most importantly, there was the desire to combine the Second Advisory Meeting with the capacity-building workshop on monitoring and evaluation; therefore it had to be scheduled in March in order to accommodate previously arranged commitments of the course facilitators. This Inception Report contains all project implementation details and documents.

1. PROJECT BACKOROUND

1.1

Introduction

Malaria control is a health priority in the Greater Mekong Subregion (OMS). Over the past several years the malaria situation in this region has improved. In some areas, rates of malaria-related mortality and morbidity have been reduced by more than half. All the OMS member countries have promoted the use of insecticide-treated nets (ITNs) and encouraged people to seek early diagnosis and appropriate treatment. Rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) are being introduced in most member countries. Although these interventions have improved the health of some of the national populations, others who live in remote areas, particularly ethnic minorities, migrants and forest workers, remain at risk for malaria. The Asian Development Bank (ADB), a key malaria stakeholder for the OMS, recognized the importance of controlling malaria among the most vulnerable risk groups in these countries. In November 2002, ADB and WHO teamed up to establish a •communication for behaviour change' initiative for malaria control. The "ADB/WHO Mekong Roll Back Malaria (RBM) Information, Education and Communication (IEC) Project" was implemented by the national malaria control programmes (NMCPs) and various partners in the six OMS countries: Cambodia, China, the Lao People's Democratic Republic, Myanmar, Thailand and Viet Nam. By the end of 2004, the following objectives were achieved: (1) user-friendly IEC materials and guidelines to use with ethnic minority groups were developed using a participatory approach; (2) NMCPs' capacity in community-based activities was enhanced through formal and informal training and project implementation; and (3) a draft regional IEC strategy for ethnic minority groups was developed, and experiences and lessons learnt were shared among the OMS countries in order to increase the responsiveness of national programmes to the needs of the target communities. In 2005, ADB agreed to provide further financial support for malaria control among vulnerable ethnic minorities in the OMS through a project entitled: "Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Subregion." The WHO Regional Office for the Western Pacific assumed responsibility for implementation, along with NMCPs and various partners. The Project started in October 2005 and is expected to finish in September 2007 (24-month duration). The overall goal of the project is to reduce the malaria burden among poor and vulnerable ethnic minority groups living in malaria-prone areas. The Technical Assistance Agreement between ADB and WHO (4 October 2005) requires a project inception report with the following components, which will be provided below: (1) a summary of malaria control for ethnic minorities in the OMS and lessons learnt; (2) plans for capacity-building and field studies; and (3) project implementation schedule and arrangements. 1.2 Project goal. objectives and expected outcomes

The goal of the Project is to reduce the burden of malaria among poor ethnic minority groups living in malaria-prone locations in the OMS, thereby helping to reduce child and maternal mortality. The Project's specific objectives are: (1) to build capacity of national malaria institutions to develop acceptable, affordable and effective strategies for malaria control for ethnic minorities; (2) to scale up malaria control efforts for these populations through NMCPs; and (3) to promote regional collaboration for malaria control.

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Expected outputs of the Project are as follows: (1) NMCP staff improve capacity to develop malaria control strategies for vulnerable ethnic minority groups. (2) Malaria control interventions are piloted and evaluated in the areas where ethnic minorities reside in each OMS country. (3) Plans are developed for scaling up malaria control interventions for the targeted ethnic minority groups. (4) Advocacy for improved malaria control in areas where ethnic minorities reside is focused toward malaria stakeholders. (5) Operational research (both qualitative and quantitative) is strengthened, particularly in the area of monitoring and evaluation (M&E). (6) Possible benefits and constraints of regional collaboration for malaria control are evaluated, as a model for other communicable disease health sector collaboration. (7) Regional guidelines/strategies for improving malaria control in the areas where ethnic minorities reside are developed and disseminated, and regional collaboration for malaria control is promoted. In the current Project, the respective NMCPs aim to improve the malaria situation among ethnic minorities by adopting globally accepted malaria control interventions (such as ITN usage and prompt diagnosis and treatment) to the local situation. ADB will fund the project for a total ofUS$ 750 000. WHO will contribute an additional US$ 130000, while the national governments of the OMS countries will contribute staff time, office accommodation/utilities and other in-kind items (such as ITNs, insecticide, RDTs and antimalarial drugs as needed by the respective country teams) worth a total of US$ 100 000. 1 The total budget for the current Project is US$ 980 000.

2. A SUMMARY OF MALARIA CONTROL FOR ETHNIC MINORITIES IN THE OMS AND LESSONS LEARNT

The Project Inception and First Advisory Committee Meeting was organized in collaboration with the Centre for Malariology, Parasitology and Entomology (CMPE) in Vientiane, 2 Lao People's Democratic Republic, from 25 to 26 November 2006 The purposes of the meeting were to introduce the project and to discuss the implementation schedule, expected project outcomes, plans for capacity-building and field studies in each country.2 Following the meeting, each respective OMS country developed their specific project plan. As the current project builds on the previous ADB/WHO Mekong RBM IEC Project, at the beginning of this meeting the previous project was reviewed, constraints for malaria control for ethnic minorities in the OMS were identified, and activities and target groups for the new Project were identified. A summary is given below.

2.1

Review of the ADB/WHO Mekong Roll Back Malaria IEC Project

The ADB/WHO Mekong RBM IEC project introduced a participatory approach for malaria control for ethnic minority groups in the OMS, specifically in developing IEC materials that would be more acceptable to the target groups and thus would enhance the sustainability of the chosen interventions over time. The first activity of the project was to conduct a situation analysis in each country. The ethnic minorities targeted in each country were: the Kreung in I For details see Technical Assistance Agreement between Asian Development Bank and World Health Organization Regional Office for the Western Pacific, RET A No. 6243, signed on 4 October 2005. 2 See the report Strengthening Malaria Control for EthniC Minorities in the GMS - Project Inception and First Advisory Committee Meeting, Vientiane, Lao People's Democratic Republic, 25-26 November 2005, Manila, WHO, 2006.

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Cambodia, the Wa in Yunnan, the Brau/Lave and Taliang in the Lao People's Democratic Republic, the Shan and Lahu in Myanmar, the Karen in Thailand and the Raglai in Viet Nam. Using a participatory approach, user-friendly IEC materials and communication strategies were developed with input from villagers, village authorities, local health personnel and local mass media staff. The local participants were involved in both identifYing the most appropriate means of communicating health education and developing culturally appropriate educational materials. The materials wete developed based on what was identified as the most important malaria issues relative to the respective ethnic minorities. Examples of the IEC materials produced in this project include: (I) Printed interactive materials such as cards with malaria-related pictures, flipcharts and picture stories that are to be used by village health volunteers, village heads, local health staff and trained villagers for basic malaria education. (2) Printed materials, such as leaflets for migrant workers, brochures and calendars, which are to be distributed by village volunteers after an introduction and by local health staff when people come to health centre for treatment. These materials are meant to reinforce othet methods of health education. (3) Audio and video visual materials that were developed for radio and television health education programming. These materials could also be distributed through the public system in local communities or disseminated through members of various social groups, such as women's unions or school teachers, during village, school and religious events. (4) Simplified technical malaria information for use by village volunteers and local health staff, including guidelines for conducting effective health education sessions. 3 National team members were trained on conducting participatory-based IEC approaches and on designing culturally appropriate materials that were more acceptable to the ethnic minority groups at risk. They gained experiences and skills during the project that enabled them to work with more than just mainstream population groupS. 4 The project had a positive impact in the NMCPs, as most countries expanded the participatory-based IEC approaches to other ethnic minority groups and geographical areas. For example, the Lao NMCP reproduced some of the materials developed with the Brau and Taliang ethnic minorities to use with other ethnic groups in Salavanh and Xekong provinces in the southern areas of the country. After a project dissemination workshop was conducted in Yunnan Province, China, the video developed with the Wa ethnic group was dubbed into Dai and Hani ethnic languages to use in the areas supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The video in Chinese (Mandarin) language was broadcast in 33 county television stations in Yunnan Province. The "buddy system" educational tool and some printed materials were also reproduced and used by various malaria partners. In Cambodia, funds from GF ATM have been used to produce additional IEC materials (printed and video) for other ethnic minorities, using the participatory approach adopted during the ADBIWHO project. At the regional level, a draft IEC plan for the Greater Mekong Subregion was formulated based on the lessons learnt during the development of country IEC plans and materials.

3 For a list of produced IEC materials, see Annex 5 of Final Report of WHO/ADB GMS RBM lEG Project - RETA: 5958. Manila, WHO, February 2005. 4 WHO Report on Technical Consultation on lEG Field Materials Production and Design, Bangkok. Thailand. 2-4 February 2004. Manila, WHO, July 2005.

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2.2

GMS countrv review of malaria control for ethnic minority groups

During the First Advisory Committee Meeting in November 2005, the member countries reviewed their malaria prevention and control programmes for ethnic minorities. This information will be used to plan for the project control interventions. Table I summarizes current malaria prevention and control programmes according to bednet, diagnosis and treatment interventions. 5 Table 1: Malaria prevention and control programmes in GMS countries Malaria control for EMG - Vario us malaria partners in some provinces focus on ethnic minorities. - CNM has no specific approach to work with ethnic groups. - CNM developed IEC tools for the Kreung in Phase 1. Bednets - Bednet coverage is adequate, but not sufficient among target group. - Low re-treatment rate and delays in the scheduled retreatment. - EMGs consider net distribution important but do not prioritize re-treatment. - Health education is inadequate. - Communities know about bednets but do not use them very often. - Some do not have money to buy nets. - Others are not using nets correctly or neglect to bring them to the forest. Diagnosis - NMCP procures RDTs. - People in the community consider malaria not as a problem, but rather as part of their normal life - VMWs are trained to provide diagnosis test with RDT (Paracheck) in high-risk villages. Treatment - Private sector is used for consultation because of easy access. - Private retailers are perceived as more reliable, as they are always open when needed - VMWs provide malaria treatment. - Social marketing ACT Who does, where? - There is an adequate supply of drugs in China. - Drugs are available at the market. - People don't use the full course.

Cambodia

China Yunnan

- Some focus on ethnic minorities as part of theGFATMsupported project.

- Microsopy is not available in the village; no health worker can provide diagnosis. - Patients must go to the township hospital, which is far. - Some health centres staff don't do confirrned diagnosis.

, For details, see Table 1 & 2 Annex 3 of the report. Strengthening Malaria Control for Ethnic Minorities in the GMS - Project Inception and First Advisory Committee Meeting. Vientiane. Lao People's Democratic Republic. 25-26 November 2005. Manila, WHO. 2006.

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Malaria control for EMG Lao People's Democratic Republic - No specific strategy for ethnic minority. - There are IEC materials for the programme but not targeted for ethnic minorities

Bednets - ITN is used in the project. - Expand coverage in target village. - Re-treatment rates are low. People prefer to buy new nets (through the project) rather than re-treating old ones. - Nets are 0 ften reserved for guests.

Diagnosis - RDTs were introduced last year. - Village volunteers have been trained to use them. - Some people try to treat themselves. - Ifpatients don't get better, they go to the hospital. - Health service staff are not so competent in giving service. - Inappropriate distribution (equal quota at field level) - Storage and quality assurance of RDT - not adequate to provide all health staff - cannot expand to community (volunteer) level for early diagnosis due to limited resource - RDT is available at malaria posts and clinics.

Treatment - ACT was introduce this year in pilot area. - Treatment is usually to completed. - If fever subsides, they usually stop. - People do not fully understand that they are supposed to complete treatment. - Spiritual belief in ethnic group - Self medication - Late treatment - Start to use ACT in some areas but not in enough quantity - Presence offake anti-malarial drugs - Regular monitoring on therapeutic efficacy of antimalarial drugs - Free treatment is provided to all malaria patients. Access to treatment is high. - Patients go to malaria clinics when sick. - IEC tools are lacking for this Issue.

Myanmar

- Language barrier - Physical barrier (communication, topography) - Poor accessibility to health infrastructure - Need specific approaches for hardto-reach groups

- People are not used to using bednets. - Rates of net ownership, ITN coverage and re-treatment are low. - Programme aspectin some area improper distribution (distribute at low malarious area) - less affordable to health-good including bednet - Less than 50% of popUlation use bednets. - ITN use is low. - Re-treatment rate is low because the population is mobile.

Thailand

- ITNs are provided only for Thai residents. - Diagnosis and treatment are provided for anyone, including non-Thais. - Some educational materials have been translated into Karen.

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VietNam

- Forest gatherers are treated with ACT or CV8 and Artekin. - standby treatment - management of patient in those crossing the border - CHCs provide antimalarial drugs. - Outreach health teams visit villages to provide services. ACT, artemlsmm-based combmatlOn therapy; CHC, commune health centre; CNW, NatIOnal Malana Center, Cambodia; EMG, ethnic minority group; IEC, infonnation, education and communication; lTN, insecticide-treated nets; LUN, long lasting insecticide-treated nets; RDT, rapid diagnostic test; VMW, village malaria worker Proposed activities and identification of target populations

Malaria control for EMG - Some projects put focus on malaria control for ethnic minorities. - No specific malaria educational material has been produced for ethnic minorities. - Mobile population and illegal migrant workers are hard to tackle.

Bednets - Treated bednet or indoor spraying - People do not bring their bednets when they go to the forest. - LLIN will be provided. - Hammock nets are promoted to those who go to the forest.

Diagnosis - Microscopy and RDT are used in pilot area. - parasite pf or optimal - People go to commune health workers for diagnosis. - People in remote areas come late for treatment due to distance.

Treatment

2.3

Gaps remain in the provision of malaria control in all GMS countries for ethnic minorities and other vulnerable populations, particularly those who reside along international borders. The ethnic minorities have different cultural practices and beliefs than the national mainstream popUlations, with marked levels of poverty and low levels of education. The vast majority of malaria control interventions including IEC materials have been geared to the national populations in the GMS; thus, some of the most vulnerable populations have not benefited from the gains made in malaria control by the national population. During the previous project, all member countries identified that providing health education and social mobilization to promote malaria control interventions in the ethnic minority populations were major challenges for the NMCPs. During the First Advisory Committee Meeting, the interventions, target populations and cofunders were outlined for the current project (see Table 2).

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Table 2: Project interventions, target populations and co-funders Project interventions Cambodia - community-based retreatment of bednets - health education focused on increasing usage ofITN s - health education focused on increasing prompt diagnosis and treatment Target populations Kreung etbnic group in Rattanakiri Province Co-funders - ADB-CDC - GFATMtbru Health Unlimited Existing programme - Bednet procurement (CNM), - Bednet distribution (HU through GF) - Diagnosis & treatment at health facilities (HNI - contracting NGO) - Diagnosis & treatment at the village level (CNM through VMW) - drugs (CNM) - drugs (GFATM) - nets (50% GFATM) - RDTs and MIC (GFATM)

- increase coverage of ITN Wa etbnic group inXimeng - promote use of ITN by HE county, Yunnan and improve EDAT Province - monitor compliance to completion of treatment, i.e. directly observed treatment, short-course (DOTS) Lao - improving VC by ITN Brau-Lave and People's - improving EDPT by RDT and Taliang ethnic Democratic ACT groups in Republic Attapeu - improving health-seeking province behaviour and completion of treatment - promoting for thern to come to health facility Myanmar - volunteers for implementing Shan and Lahu malaria prevention and control ethnic groups in - provide and increase access to Eastern Shan State EDPT according to National Drug Policy - Prevention mainly emphasized on ITN - Epidemic preparedness

ChinaYunnan

-GFATM

-GFATM - ADB-CDC

- plan to cover with ITN next year - RDT and antimalarials

-WHO - UNICEF

- social marketing in Tarchileik (Population Services International)

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Project interventions Thailand - focusing on IEC to promote ITN - seeking early diagnosis by ROT - taking ACT properly

Target populations Karen ethnic group in Maehongsom province

Co-funders -GFATM - Ministry of Health

Existing programme - ITNs for Thai residents (VBDC and GFAM) - Training of village volunteers - support for ROTs - treatment for all patients - expanding coverage to nonThai who are mobile - IEC materials for non-Thai residents - bednets, insecticides and ROTs (GFATM) - antimalarial drugs and microscopy (NIMPE) - training health workers (NIMPE, GFATM)

VietNam

- promoting ITN usage - promoting EDPT using ROT and ACT - carry out intensive lEe intervention

Raglai ethnic group in Khanh Hoa province

-GFATM -MCNV

ACT, artemlsmm-based combmatlon therapy; ADB, ASIan Development Bank; CDC, Centers for Disease Control and Prevention; EDAT, early diagnosis and treannent; GFA TM, Global Fund to Fight AIDS, Tuberculosis and Malaria; ITN, insecticide-treated nets; MCNV, Medical Committee Netherlands-Viet Nam; NIMPE, National Institute of Malariology, Parasitology and Entomology; ROT, rapid diagnostic test; VBDC, Vector-Borne Disease Control

..

-9-

3. PROJECT DESIGN AND COUNTRY PLANS

3.1

The Second Advisory Committee Meeting

A Second Advisory Committee Meeting was held in Chiang Mai, Thailand, from 8 to 10 March 2006. It was attended by all NMCP directors, country focal and technical points and WHO country focal points. The objective was to finalize and approve the six pilot studies, project budget and M&E tools and plans. The second year ofthe Project was designed to use 'lessons learnt' from the first year and expand interventions to additional villages; the Project would then share project outcomes with other malaria partners. The key concern of this Project is to add value to existing NMCP interventions by targeting specific at-risk popUlations that are difficult to reach due to geographical and cultural factors. The meeting was delayed due to a number of factors. First, administrative changes caused delays in early project set-up and implementation. Although the current project is built upon the previous ADB/WHO IEC project, both the national malaria institutes (NMls) and WHO country offices needed to nominate focal points and technical persons for the new Proj ect. Due to the changes in personnel, time was needed to inform the new personnel about the previous project. Second, and most importantly, there was a desire to combine the Second Advisory Committee Meeting with the capacity-building workshop on monitoring and evaluation; therefore it had to be scheduled in March in order to accommodate previously arranged commitments of the course facilitators. During this meeting, the member countries refined their project plans to include expected results, indicators, activities and time frames. All of the countries focused on similar outcomes, such as: (I) increased knowledge of the target population regarding malaria prevention and control; (2) improved correct usage of IINs; (3) enhanced local capacity to provide effective malaria control interventions so that scale-up can occur; and (4) expanded advocacy for continued attention to the vulnerable, targeted ethnic minority groups. Indicators for meeting project goals were identified, with examples such as: (1) at least 90% of the population in the target villages know prevention strategies and know where to obtain treatment for malaria (Cambodia); (2) 80% of target population re-treat their bednets with insecticide (China); and (3) all children under five years of age and pregnant women sleep under insecticide-treated bednets (Lao People's Democratic Republic). Some countries have indicated outcomes of the Project, for example: (1) strategy on malaria control for ethnic minority groups developed (Viet Nam), and (2) report on the results and lessons learnt on pilot interventions for malaria prevention and control distributed and published on the Internet (Myanmar). There were discussions regarding scope and expected outcomes for objective 2 (i.e. scale up malaria control efforts for ethnic minority populations through NMCPs), and objective 3 (promote regional collaboration for malaria control). The ideas proposed for objective 2 included: integrate lessons learnt from the pilot country projects into NMCP strategies; use project results to plan for an additional scaling-up budget; and link to other partners (e.g. nongovernmental organizations [NGOs]) and projects/programmes that work with ethnic groups. The proposed ideas for objective 3 included: establish communication and exchange project information among national and regional project counterparts; establish special collaboration between neighbouring countries that share common ethnic popUlations; and share project developments with all member countries and malaria partners through the ACTMaiaria website. The Project Coordinator introduced the overall project implementation schedule and budget breakdown. The member countries then summarized their respective country plans. All countries agreed that the country budgets as planned were sufficient. They also agreed that all

- 10member countries would collaborate with the NMCPs and their available resources for necessary district training, procurement of supplies and implementation of ITNs, RDTs and ACT. Only China and Myanmar would need to use project funds to procure such commodities for the pilot project target popUlation. The following decisions were reached during the Second Advisory Committee Meeting: (I) the country project plans of the Cambodia, Lao People's Democratic Republic, Thailand and Viet Nam were approved; (2) China's plan was tentatively approved with [mal approval after revision and resubmission of plan and budget; (3) approval of Myanmar's plan was withheld until full proposal was available, including budget, additional clarification on sample specifics and timeline; and (4) overall project budget and implementation plan was approved. The China-Yunnan and Myanmar country plans would be revised and resubmitted to all committee members after the meeting. Based on their approved country project plans, each member country then would submit an implementation plan of the first year for funding to the WHO Regional Office for the Western Pacific. The Project aims to strengthen local capacity to provide effective malaria control to the ethnic minorities at risk through the distribution of ITNs, RDTs, and ACT by local health care staff and village volunteers. Participatory-based IEC approaches will be used, supplemented by education and communication materials developed during the previous IEC proj ecl. At the country level, the project teams will collaborate with local NODs for project implementation and continued advocacy for malaria control geared specifically to the ethnic minorities. In addition to IEC, community mobilization will be used to assist in implementing the chosen control interventions. The project team will plan a series of activities with local health staff to sensitize and mobilize the communities for malaria prevention and control. Project dissemination workshops will be organized at the end of the project to advocate for continued attention to the malaria concerns of the ethnic minorities. M&E will be conducted during the life of the project in order to measure the progress and outcomes of the interventions. Monitoring the project at regular intervals will assist in identifYing gaps that needed to be better addressed. Each country will have developed M&E plans and indicators, including the tools to be used for measurement, to address their respective goals and objectives. Outcomes and 'lessons learnt' will be shared with the NMCPs in order to jointly develop regional IEC strategies and plans. 3.2 Country pilot projects

Based on information from the previous IEC project and results of the First Advisory Committee Meeting, the member countries have developed and proposed project intervention and budget plans. All member countries have adopted community-based approaches for malaria control among ethnic minorities. All countries will continue to work with the ethnic minority groups with whom they worked in the previous IEC project, while some countries will expand interventions to further ethnic minorities living close by. Cambodia will work with the Kreung ethnic groups; Yunnan will continue working with the Wa and expand to the Dai ethnic group; Lao People's Democratic Republic will work with the BrauiLave and Taliang; Myanmar will work with the Shan and Lahu; Thailand with Karen; and Viet Nam will continue their work with the Raglai. Main activities for 2006 will focus on implementing IEC and social mobilization interventions, monitoring the intervention (including baseline surveys in all countries), coordinating with other sectors, providing specific malaria prevention and control interventions, and strengthening local staff capacity through training and regular supervision and monitoring support. All countries have planned to provide equipment (e.g. loudspeaker systems, bicycles, motorcycles) and small incentives to village volunteers and local health staff so that they can effectively conduct the planned activities. Most NMCPs will contribute the needed ITNs, RDTs and ACT for the Project.

- II -

10

The country project plans approved by the Second Advisory Committee Meeting are outlined sectIOns 3.2.1 to 3.2.6 (detailed activity and budget plans in Annexes 1-6). Cambodia project plan

3.2.1

The Cambodian team selected 10 Kreung ethnic villages in Rattanakiri province, targeting 3670 people, for their pilot control intervention. The total budget approved for Cambodia was US$ 46 500, with the NMCP providing IINs, RDTs and ACT to the pilot villages. The project aims to strengthen local capacity to provide effective malaria prevention and control through lIN distribution and offering health infonnation on proper ITN use and the need for prompt diagnosis and treatment. 6 Uniquely, this project clearly aims to change the behaviour of the target population: to "correctly use IINs", which has been a problem among some ethnic communities that do not have a good understanding of the benefit of using bednets. The project also tries to increase access to quality services by improving skills of local health staff and village volunteers. The pilot intervention has five expected results with indicators. Expected results Result I: Knowledge on malaria (refers to biomedical definition of malaria) control increased among EMGs in selected areas Result 2: Behaviour changed among EMGs for malaria control in selected areas (lIN use, diagnosis and treatment seeking) Indicators 1.1 At least 70% of the whole population, and 90% of pregnant women and mothers of children under five, in the target villages know the preventive and curative care of malaria 2.1 At least 70% of the whole population, and 90% of pregnant women and children <5, in the target villages correctly used IINs the previous night. 2.2 At least 70% of the whole population, and 90% of pregnant women and children <5, in the target villages seek EDAT within 48 hours of development of a fever 3.1 At least 70% of the whole population, and 90% of pregnant women and children <5, in the target villages have access to IINs 3.2 At least 70% of the whole population, and 90% of pregnant women and children <5, in the target villages have access to EDAT 4.1 Increased capacity of three health staff (CNM, PHD and HC) 4.2 Increased capacity of 20 volunteers from 10 villages on control needs of EMGs

Results 3: Accessibility, acceptability afford ability, and quality of malaria control services improved at community level in target EMGs

Result 4: Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs ofEMGs Result 5: Lessons learnt and results of pilot interventions disseminated at country level and shared at regional level, and policy recommendations for scaling up malaria control plans for poor EMGs available

CNM, NatlOnal MalarIa Center, CambodIa, EDA T, early dIagnOSIs and treatment, EMG, ethmc minority group; ITN, insecticide-treated net

6

See Annex 1: Cambodia project implementation and budget plan

- 12 -

3.2.2

China-Yunnan province project plan

The project team will work with the Wa ethnic group in Ximeng county. It will cover around 4000 people within two administrative villages, which consist of 20 natural villages. The total of budget approved for China is US$ 56 200. The national control programme will contribute insecticide for bednet treatment and anti-malaria drugs to the project areas, while 7 bednets and RDTs will be procured with Project funds. The project will increase capacity of village volunteers, primary school teachers and identified peer educators, to educate and mobilize community for malaria prevention and control; establish bednet subsidy scheme; deliver bednets to target communities and impregnate bednets; train village volunteers and peer educators to monitor and evaluate project intervention. The unique aspect of the China project is that the team will establish a bednet subsidy scheme, which aims to create ownership and involve the target population in malaria prevention. The project aims to demonstrate the usefulness of establishing village health volunteers in each natural village (one administrative village may consists of 10-15 natural villages). Training and regular monitoring by community and local health staff should provide effective services for the villagers. Malaria education directed at primary school children is an initiative that has shown acceptance during the previous project. The China project has five expected results and indicators. Expected results Result 1: Knowledge on malaria control increased among EMGs in selected areas Indicators 1.1 80% of primary school students can list at least two malaria signs and name mosquito as vector. 1.260% of villagers aged 16-60 can answer at least three technical questions on malaria. 2.1 Percentage of people using bednets increased 50% compared to the baseline. 2.2 80% ofbednets get treated with insecticide. 2.3 Percentage of people seeking diagnosis and effective treatment within 24 hours after fever onset increased 50% compared to the baseline. Result 3: Accessibility, acceptability, affordability and quality of malaria control services improved at community level in targetEMGs 3.1 Establish village health volunteer, one VHV for one natural village. 3.2 Community malaria case management is available in all target natural villages. 3.2 80% of villagers are satisfied with malaria control service. 3.4 80% offever patients utilize public health services. 3.5 80% of malaria treatment courses given are following national guidelines.

Result 2: Behaviour changed among EMGs for malaria control in selected areas (lTN use, diagnosis and treatment seeking)

7

See Annex 2: China-Yunnan project implementation and budget plan

- 13 -

Result 4: Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs of EMGs

4.1 80% of health care providers from township and village level communicate with their customers in a friendly way, and practise diagnosis and treatment following national guidelines; 4.2 80% of customers are satisfied with providers' attitudes, behaviours and service cost. 4.3 All malaria control staff from county and township level received training on community-based methodology. 5.1 Lessons learnt and results of pilot interventions disseminated at country workshop, and shared with other countries 5.2 Number ofinfonnation shared with other countries 5.3 Number of papers published 5.4 Practical Manual for BCC Project is made available.

Result 5: Lessons learnt and results of pilot interventions disseminated at country level and shared at regional level, and policy recommendations for scaling up malaria control plans for poor EMGs available

CNM, NatIOnal MalaTla Center, CambodIa; EDAT, early dIagnOSIs and treatment; EMG, ethnIC minority group; ITN, insecticide-treated net

3.2.3

Lao People's Democratic Republic project plan

The Lao team will work with the Brau-Lave ethnic group in Phouvong district and the Taliang ethnic group in Sanxay district of Attapeu province. There will be total of eight villages, four villages in each district, covering 454 households, with a population of 2400 people. The budget approved for the Lao People's Democratic Republic is US$ 46 500. The NMCP will contribute ITNs, RDTs and ACT to those villages. 8 The project aims to increase local capacity to effectively control malaria; to deliver ITNs, RDT and ACT to target communities; to encourage people to use ITNs and seek EDAT; to strengthen local partnerships; and to train village health volunteers and local health staff to educate and mobilize communities to adopt appropriate behaviours. Beside the clearly stated indicator for desired behaviour, i.e. "20% increase of people seeking care within 24 hours of fever onset", this project also set a clear measurable indicator for children under five and pregnant women: "all children under five years and pregnant women sleep under bednets".

8

See Annex 3: Lao People's Democratic Republic project implementation and budget plan

- 14-

The Lao People's Democratic Republic project has four expected results with the following indicators. Expected results Result I: Ethnic minority population in pilot areas receive, accept and understand IEC messages Result 2: Ethnic minority population in pilot area recognize febrile illness and access malaria diagnosis and treatment and ITN (VHV, health centre, district hospital) Indicators 1.1 At least 80% of adults and schoolchildren in the pilot areas understand malaria symptoms and preventive methods. 2.1 50% increase of people using ITNs regularly 2.2 20% increase of people seeking care (within 24 hours of fever onset) 2.3 100% ofP. falciparum malaria patients receive treatment from VHV complete full dosage 2.4 10% increase of people utilizing public health services or village volunteers 2.5 All children under five and pregnant women sl~ under bednets 3.1 IEC/BCC training for health care providers conducted (district, health centre staff and VHV~ 4.1 Number of proposed sites for scale-up 4.2 Number of stakeholders attending final presentation meeting

Result 3: Strengthen the capacity of health care providers to address specific needs of malaria control for EMGs Result 4: Lessons learnt and results of pilot interventions disseminated at country level and to the relevant stakeholders, and policy recommendations for scaling up malaria control plans for poor EMGs made available EMG, ethntc minority group; lEe, InfOrmatlOn, educatlOn and commUntCatlOn; ITN, insectICide-treated net; VHV, village health volunteer 3.2.4 Thailand project plan

The Thai team will continue working with the Karen ethnic group in Mae Hong Sorn province. The project will cover 525 households (2400 people) in five villages of two districts. The Bureau of Vector Borne Disease (BVBD) was willing to accept a smaller budget compared to other member countries. This will help to increase funding for member countries that receive little external support. The approved budgl"t is US$ 40 250. The NMCP will contribute ITNs to the project villages. 9 The Thai project intervention aims to strengthen capacity of national institutions to develop acceptable, affordable and effective control strategies for ethnic minority groups; increase access to malaria diagnosis and effective treatment; educate and mobilize community to use ITNs; and strengthen decentralization for malaria control and prevention with local organizations. The previous IEC proj ect was the first time that the Thai team used a participatory approach for IEC development. The team found the approach very useful for developing culturally appropriate IEC strategy and materials.

9

See Annex 4: Thailand project implementation and budget plan

- IS -

The pilot project intervention of the Thai team has five expected results. Expected results Result 1: Ethnic minority populations in pilot areas increase awareness of appropriate malaria control practices and utilize horne and community-based approaches for malaria control Result 2: Ethnic minority popUlations in pilot areas apply vector control measures and properly use ITNs Result 3: Increased access to early diagnosis and prompt effective treatment in communities. Result 4: Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs ofEMGs Result 5: Lessons learnt and results of pilot interventions disseminated at provincial level and shared at country and regional level, and policy recommendations for scaling up malaria control plans for poor EMOs available Indicators 1.1 80% of target population have good knowledge on malaria prevention and control.

2.1 80% of population have and use ITN.

3.1 80% of malaria cases receive drug treatment within 24 hours after onset of fever. 4.1 Local health services have implementation plan on malaria control in EMGs in target area. 5.1 The partnerships have an implementation plan on malaria control in EMGs in target area.

EMG, ethnIc mmonty group; ITN, msectlclde-treated net

3.2.5

Viet Narn project plan

The Institute of Malariology, Parasitology and Entomology (IMPE) Qui Nhon project team will continue to work with the Raglai ethnic group in Khanh Vinh district, Khanh Hoa province. The pilot project will cover eight villages in Khanh Nam and Khanh Trung communes. The estimated population in target villages is 5000. The budget approved for the team is US$ 46 500. 10 The project aims to increase commune health staff and village health workers' capacity to improve access to effective malaria prevention and control. The national control programme will provide ITNs, RDTs and ACT to the pilot villages. The RDT will be provided by the OF ATM supported project. The popUlation in the project area has high coverage ofbednets, which gives a unique opportunity to educate and mobilize target population to use bednet correctly. Communication skills training and social mobilization will be the main interventions of the project.

10

See Annex 5: Viet Nam project implementation and budget plan

- 16 -

The project intervention has five expected results. Expected results Result 1: Know ledge on malaria control increased among EMGs in selected areas Indicators 1.1 Increase of at least 30% of villagers who recall at least two messages related to malaria prevention 2.1 100% bednet coverage 2.2 90% properly using ITN 2.390% fever cases go to CHC or VHWs 3.1 70% fever cases receive slide testiRDT 3.2 100% confirmed malaria cases receive appropriate treatment 4.1 100% VHW sand CHC staff can correctly provide services related to malaria prevention and treatment

Result 2: Behavior changed among EMGs for malaria control in selected areas (ITN use, diagnosis and treatment seeking) Result 3: Access of EMGs to good quality community-based malaria control measures improved in selected areas Result 4: Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs ofEMGs Result 5: Lessons learnt and results of pilot 5.1 Strategy on malaria control for EMGs interventions disseminated at country and developed shared at regional level, and policy 5.2 Plan for application of results of this recommendations for scaling-up malaria project for other EMGs is developed control plans for poor EMGs available CHC, commune health centre; EMG, ethnic mmonty group; ITN, msecttclde-treated net; RDT, rapid diagnostic test; VHW, village health worker 3.2.6 Myanmar project plan (pending approval)

Vector-Borne Disease Control (VBDC), Ministry of Health will continue collaboration with VBDC in Tachilek, Eastern Shan State, to work with the Shan and Lahu ethnic minority groups in Mong Tone, Mong Hsat and Tarchileik townships, which are located along the borders with Thailand and Lao People's Democratic Republic. There are 15 000 people covered by the pilot intervention. Eventually approximately 214 544 people will benefit from improved malaria control services. The allocated budget is US$ 72 000, as Myanmar will need to procure necessary malaria control commodities for the target population (nets, insecticide, drugs) from Project funds. II Besides increasing local staff capacity and ITN coverage, the team plans to measure perceived satisfaction with the services provided by local health staff, including community volunteers. Approval of the Myanmar project has been withheld until a full proposal is available, including a budget and timeline. The revised proposal will be circulated among all Advisory Committee members for comments and approval.

II

See Annex 6: Draft Myanmar project implementation and budget plan

- 17 -

The Myanmar project is likely to have three main expected results. Expected results Result 1: Strengthened capacity of VBDC and the basic health staff on planning, implementation, M&E of malaria prevention and control services for "national races" (EMG) Indicators 1.1 Availability of operational manual for malaria prevention and control at township level 1.2 % of basic health staff surveyed I supervised who treat malaria according to national guidelines 1.3 % of health facilities without stockout of drugs for more than a week within the last three months prior to the monitoring visit and/or survey 2.1 % of trained CORPs who deliver malaria control services in accordance with the operational guidelines 2.2 % of households who own bednets who had their nets treated 2.3 % of target population who slept under ITNs/LLINs every night during the last seven nights prior to the survey 3.1 Report on the results and lessons learnt on pilot interventions for malaria prevention and control disseminated widely, including publication on the Internet 3.2 Draft policy recommendations by Malaria Technical Advisory Group on malaria prevention and control among "national races" in Myanmar available

Result 2: Quality community-based malaria prevention and control services for "national races" in Tarchilek District established

Result 3: Lessons learnt and results of pilot interventions disseminated at country and regional level, and policy recommendations for scaling up malaria control for national races available

EMG, ethniC mmortty group; ITN, msectlclde-treated net; LLIN, long lastmg msectlclde-treated net; M&E, monitoring and evaluation

4. CAPACITY-BUILDING AND MONITORING AND EVALUATION

4.1

Capacity-building

The Project's first objective is to strengthen national and local capacity to deliver effective malaria control for ethnic minorities. The project will increase national capacity through regional training workshops, consultation workshops, routine country monitoring visits and in-country and long-distance technical support (Table 3). Regular supervision for member countries is planned to assist the teams throughout the project implementation. The Project Coordinator and project consultants will provide technical assistance as needed, as will the WHO project focal points in the respective countries. 12 Training is one of main activities to strengthen local capacity for providing effective malaria prevention and control measures in the at-risk communities. Local training is included in all country pilot intervention projects, and will focus on developing culturally appropriate health education methods, improving communication skills, using social mobilization to improve acceptance and use of selected malaria control interventions, impregnating bednets, using ROTs and providing antimalarial drugs (ACT) correctly. In addition, some country teams, for 12

Please see Annex 7: Project Technical Assistance and Supervision Support Plan

- 18 -

example the Lao People's Democratic Republic and Myanmar, will revise the roles and responsibilities of village volunteers and local health personnel to better suit remote areas. Education and communication training manuals and guidelines will be revised and adapted to suit the needs ofvil1age volunteers and local health staff. Besides offering technical support, providing essential equipment and information on the proper use of that equipment are also important issues for sustaining control interventions. The Cambodia team plans to provide loudspeaker systems to village volunteers and offer training on the use of the systems. The Lao team plans to provide bicycles to village volunteers to monitor the progress of their project interventions and encourage individuals to use those interventions. Supervisory teams at provincial and district levels will assist village health volunteers and members of the local communities in conducting health education campaigns and activities after training is completed. Table 3: Capacity-building activities for country and local teams Cou~teams

•

• •

• • • •

... ACT, artemlsmm-based combmatlOn therapy; RDT, rapId dIagnostIc test; VHV, vIllage health volunteer

Regional training on qualitative and quantitative data collection and analysis Country assistance for finalizing qualitative and quantitative research protocols Strengthening team members in conducting field research Assistance with education, communication and social mobilization training Gathering data for project cost analysis Technical support on malaria epidemiological and entomological aspects Long-distance technical sllJlPort

• • •

• • •

Local teams Training on education, communication and social mobilization skills Training on bednet impregnation, the use ofRDTs and ACT Strengthening roles and responsibilities ofVHVs and local health staff Reviewing and finalizing malaria I education guidelines Strengthening implementation capacity by providing essential equipment, training teams on how to utilize it and offering small incentives Setting up regular supervision and monitoring visits

4.2

Regional training workshop on Quantitative and Qualitative Assessment ofCountrv Pilot Intervention Studies

Immediately following the Second Advisory Committee Meeting, a training workshop on "Quantitative and Qualitative Assessment of the Country Pilot Intervention Studies" was conducted at the same site from 13 to 18 March 2006. Facilitators and faculty for this workshop included: Dr Jo Lines (Malaria Expert for the Project, London School of Hygiene and Tropical Medicine [LSHTM]), Dr Holly Ann Williams (United States Centers for Disease Control and Prevention [US CDC], malaria and qualitative methods expertise), Ms Jane Bruce (LSHTM, survey methodology expertise) and Mr Pricha Petlueng (Technical Coordinator for the Project).ll The course consisted of research methodology content and principles ofM&E including economic analysis, plus gave classroom and field practice for qualitative and quantitative methods. All teams produced an initial M&E plan (including specific indicators, budgets and tools) by the end of the workshop, although refinements to the plans would be necessary in their respective home countries. The workshop was not long enough to adequately cover the

13

See Annex B: Technical Report on Regional Training Workshop

- 19 -

material in a manner that allowed participants to feel comfortable with the subject matter, but it gave all participants a framework to use as a guide in their proj ects. The respective countries' sets of indicators were finalized during the training workshop. The workshop time was devoted to develop and refine M&E plans, budget and tools. ImtIal M&E budget and plans and survey protocol and qualitative research guides were 10 the begmnmg of the development stage. All member tearns sent edited plans and tools for review by the technical experts. Most tearns also identified the need to obtain technical support through e-mail and supervisory country visits during field implementation and data analysis. Although a proper economic analysis would be quite beneficial for future activities, it was agreed during the meeting and workshop that this was not feasible due to factors mentioned above. Sending information through the course facilitators, Dr Eve Worrell (LSHTM) provided expertise to help guide the development of a simple cost calculation matrix for a costing analysis. If obtainable, the information would be used to plan for expansion of the intervention into other areas. While it was hoped that proj ect costing would include direct and indirect costs at both the provider/ministry of health and community level, it is doubtful that such information will be forthcoming. It was clear at the end of the workshop that the country-level tearns had minimal understanding of what was needed for costing, as the time during the workshop was exceedingly brief and did not allow for full discussion of this topic (see 4.4 below). 4.3 Monitoring and evaluation

Monitoring and evaluation will be performed throughout the Project. Data from M&E will assist the respective NMCPs in the GMS countries to better plan for scaling up of malaria control strategies for ethnic minorities. Although the country teams have been involved in data collection and various research in malaria control, there is little capacity in designing M&E plans. Identifying realistic indicators was problematic for most teams during the M&E workshop held after the Second Advisory Committee Meeting. All teams requested technical support. The technical experts involved in the project recommended that a workshop be held mid-way through the project to provide further support to the teams. 4.4 Project cost analysis

Cost analysis of the malaria control interventions for ethnic minority groups is an aim of the project, particularly the marginal cost needed to make malaria control work among these populations. It is a way of describing and analysing a choice between two or more possible alternatives. Simply examining one alternative is not an economic evaluation. Given limited resources at all levels from household to country, a cost analysis is important as it offers information on which budgets can be based. This cost analysis facilitates the choice between what to consume or produce with limited resources. It will help to calculate basic costing and plan for expansion of interventions in other areas. Discussion among participants about what data would be most relevant for an economic analysis concluded that project costing would be limited to a cost analysis, which would entail measuring and documenting the individual components of the costs involved in implementing strategies. This would facilitate estimating costs involved.in scaling up. It is not possible to do a cost-effectiveness study. Project costing will include direct and indirect costs that occur at both provider (Ministry of Health) and community level. During the training workshop on qualitative and quantitative

- 20-

data collection, a simple cost calculation table (Table 4) was presented to all country teams (see also Annex 12). Table 4: Cost calculations Cost Direct Provider (ministrv of health) Treatment costs (drugs, staff, buildings, running costs), prevention costs (insecticide, salaries, vehicles), programme costs Treatment cost + prevention costs + % of programme costs Lost tax revenue and reduced productivity Community Expenditure on health care (drugs and consultation fees) and preventive measures (nets, coils) Treatment cost + Prevention costs Travel costs, food costs, lost productivity (due to time spent sick or at clinic), reduced educational attainment Travel costs + food costs + lost productivity

Proj ect direct costing (both IEC and no IEC interventions) Indirect

Proj ect indirect costing (both IEC and no IEC interventions) Estimated costs

Lost tax revenue + value of lost productivity

Drug/insecticide costs and quantities - central medical supplies/procurement Staff cost - human • resources department, interviews with staff • Building and running costs - works department Vehicle costs and • mileages - drivers, log books lEe, mformatlOn, educatIOn and commumcatlon

•

•

•

Focus groups on impact and cost of malaria in community Household surveys on frequency, behaviour and cost of malaria treatment and prevention

At the end of the workshop, a planning matrix for project costing was provided to country teams. The matrix consists of recurrent costs and fix costs for year 1 and 2 from both the provider (Ministry of Health) and community levels.

5. PROJECT IMPLEMENTATION SCHEDULE, BUDGET AND STRUCTURE

5.1

Project implementation schedule and budget

The overall project implementation schedule and a breakdown of the project budget are attached as Annexes 9 and 10. Funding for country pilot intervention projects will be channelled to the implementation counterparts in the six countries. Fifty per cent of the requested 2006 budget will be made available upon signing the contracts between NMls and the WHO Regional Office for the

- 21 -

Western Pacific. Based on implementation achievements, the remaining amounts of funding will be provided incrementally. The same arrangement will apply to the 2007 country budgets. 5.2 Project structure

ADB is the executing agency for this technical assistance project. The WHO Regional Office for the Western Pacific is the implementing agency, jointly with the NMCPsinational malaria institutes that are responsible for project implementation using their existing programmes and staff. The Project Steering Committee, consisting of the NMCP managers of each member country, oversees and guides project implementation. The Project's regional team is situated in the WHO office in Vientiane, Lao People's Democratic Republic, to coordinate project implementation and provide technical input to the member countries. The team consists of the project coordinator, Mr Pricha Petlueng, and a project assistant (to be selected in the near future). The Project receives temporary technical support on malaria control issues from the project malaria expert, Dr Jo Lines. As needed, consultants and technical experts provide further technical assistance, notably on epidemiology, entomology and social science. In the six GMS countries, the project consists of a networl<: ofNMCP directors, national focal points and technical persons as well as WHO country staff (Tables 5 and 6).14 Table 5: NMCP directors, national focal and technical persons, and WHO country officers GMS countries Cambodia NMCP directors Dr Duong Socheat Director, National Center for Parasitology Entomology and Malaria Control Program, Ministry of Health Phnom Penh Prof Tang Linhua Director, National Institute of Parasitic Diseases Chinese Center for Disease Control and Prevention Shanghai

National focal and technical persons Ms Dr Buakheng Thavrin ChiefIEC Unit, CNM Dr Suon Pov Communication Officer, CNM

WHO country officers Dr Abdur Rashid Medical Officer, WR, Cambodia Dr Junko Yasuoka Scientist (Malaria) WR, Cambodia Dr Francette Dusan Medical Officer, WR, China

China

Mr Xu Jianwei Yunnan Institute of Parasitic Diseases (YIPD), Yunnan Ms Xia Min YIPD, Yunnan

14

For details, see Annex 11

- 22-

OMS countries Lao People's Democratic Republic

NMCP directors Dr Samlane Phompida Director, Centre for Malariology, Parasitology and Entomology Ministry of Public Health Vientiane Dr Saw Lwin Director of Bureau of Vector Borne Diseases, Department of Health Yangon

National focal and technical.~ersons

WHO country officers Dr Deyer Oopinath Malaria Officer, WR, Lao People's Democratic Republic

Ms Dr Soudsady Udonsuk Deputy Chief IEC Unit, CMPE Dr Bounphone Sydavong Chief Entomology Unit, CMPE Dr Win Naing Assistant Director Central VBDC, Yangon Dr Myat Kyaw Team Leader VBDC project in Tachilek, Eastern Shan State Ms Kesanee Kladphuang VBDC, Ministry of Health Ms Piyaporn Wangroongsarb VBDC, Ministry of Health

Myanmar

Dr Leonard Ortega Malaria and Communicable Disease Officer, WR, Myanmar

Thailand

VietNam

Dr Chaiporn Rojanawatsirivej Director, Bureau of Vector Borne Diseases Department of Communicable Disease Control, Ministry of Health Nonthaburi Dr Trieu Nguyen Trung Director, Institute of Malariology, Parasitology and Entomology (IMPE) Qui Nhon City Binh Dinh Province

Dr Charles Delacollette Mekong Roll Back Malaria Coordinator Dr Chawalit Tantinimitkul Medical Officer, WR, Thailand Dr Tran Cong Dai National Malaria Officer, WR, VietNam

Dr Trung Van Co IMPE Quy Nhon Dr Ho Van Hoang IMPE Quy Nhon Dr Tran Van Tien District health centre of Khanh Vinh Khanh Hoa-.l'rovince

- 23 -

Table 6: Project personnel, consultants and WHO/ADB advisors Project ~ersonnel/consultants

Mr Pricha Petlueng Team Leader/Social Scientist WR, Lao People's Democratic Republic Dr Jo Lines Entomolo gist London School of Hygiene and Tropical Medicine, UK

WHO Regional Office for the Western Pacific Dr Kevin Palmer Regional Advisor, Malaria, Other Vectorborne and Parasitic Diseases Manila, Philippines Dr Eva Christophel Medical Officer, Malaria, Other Vectorbome and Parasitic Diseases Manila, Philippines

WHO South-East Asia R~ional Office Dr Krongthong Thimasam Regional Advisor, Malaria New Delhi, India Dr Charles Delacollette Mekong Roll Back Malaria Coordinator Bangkok, Thailand

ADB Dr Barbara Lochmann Social Development Specialist Mekong Department, Manila, Philippines Dr Vincent de Wit Senior Health Specialist Mekong Department, Manila, Philippines

Dr Holly Williams Medical Anthropologist United States Centers for Disease Control and Prevention, Atlanta, USA Dr Jane Bruce Statistician London School of Hygiene and Tropical Medicine, UK

Assistant Proj ect Team Leader WR, Lao People's Democratic R~ublic

6. CHALLENGES FOR PROJECT IMPLEMENTATION

The ADB/WHO "Strengthening Malaria Control for Ethnic Minorities in the GMS" project includes all six GMS countries. This Project is unique in that it offers a regional approach using six countries to focus on similar malaria control issues found in vulnerable and ethnic minority groups. Although this project builds upon the previous Mekong RBM IEC project, there are changes concerning administrative details. This Project is completely integrated into NMCPs, using NMCP staff and drawing on necessary supplies from the national programmes. There were some delays in setting up the project: In each respective country, ADB initiated the project by contacting the ministries of finance or the ministries of foreign affaires, who then requested approval from the ministries of health and the national malaria institutes. Further delays occurred through requests to identify country focal persons, who would be the people working most closely with the Project Coordinator and the technical experts; in addition, technical persons who would assist the project focal point needed to be identified.

- 24-

Once official approvals were given for this collaborative project, country-level project proposals and plans had to be approved by all member countries, followed by approval of project contracts with each country by the WHO Regional Office for the Western Pacific, with subsequent release of funds. Unlike the previous IEC project, which only required input from the IEC units, the current Project is much more complex. As this Project will implement strategies that deal with prevention and case management, including IEC, all relevant parties had to be consulted and give approval for the plans, and particularly agree to the provision of supplies from national budgets. Again, this was a time-consuming process, which delayed the start of baseline data collection.

7. CONCLUSIONS

Countries in the Greater Mekong Subregion shared common malaria control concerns during the First Advisory Committee Meeting for the ADBIWHO project entitled: "Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Subregion." All six OMS countries have adopted a community-based approach to implement global malaria control strategies among ethnic minority groups, by promoting the use ofITNs, encouraging people to seek early diagnosis and effective treatment and strengthening national capacity to provide good control measures. In countries where national control programmes have provided bednets to target populations (Cambodia, Lao People's Democratic Republic, Thailand and Viet Nam), bednet coverage rates in the pilot project areas appear to be high (95% in Viet Nam, 90% in Thailand and 93% in Lao People's Democratic Republic); however, re-impregnation of bednets and regular bednet use remain challenges in preventing malaria in these areas. Some countries have introduced RDTs and ACT for early diagnosis and treatment, with local health staff village volunteers trained to provide the services. In the countries that have not yet introduced RDTs and/or ACT, local health staff will be trained to do microscopy and provide anti-malaria drugs, according to the respective national control policies. The main problems in these areas are the remoteness of the villages and the length of time it takes individuals at risk to reach health centres. Malaria control as it is currently provided in these countries is not reaching these remote areas, particularly among ethnic minorities. Due to high levels of poverty of these groups and cultural differences from the national mainstream populations, the vulnerable populations at risk may not have a good understanding of the benefits of using ITNs or taking appropriate antimalarial drugs. All countries in the Project have identified control interventions that put emphasis on strengthening local capacity to educate and mobilize communities for malaria prevention and control by increasing coverage and usage ofITNs, increasing health staff abilities to provide effective diagnosis and treatment, improving collaboration between communities and local health staff. Most member countries share goals and objectives as well as expected results. These results include: (1) increased knowledge and understanding of target populations on malaria prevention and control, (2) increased bednet re-impregnation rates and usage ofITNs, (3) strengthened health staff capacity to deliver effective services, and (4) increased advocacy and scale-up for malaria control interventions for ethnic minority groups. All expected results will be measured against M&E indicators that were described in the respective country-level M&E plans. Example of indicators to measure behaviour change include increases in the percentages of people sleeping under ITNs on a regular basis and seeking treatment within 24 hours of fever onset or the numbers of community members and local health staff trained for malaria prevention and control. Capacity-building at the local level to deliver effective malaria control to vulnerable at-risk populations will be a major focus of this Project. Training, provision of external technical

- 25assistance, routine supervisory visits and long-distance technical support will be used for capacity building. Although delayed initially, most country teams have their plans approved and, at the time of the writing of this report, have started activities related to the collection of baseline data.

ADB Phase II Project Planning Matrix: Cambodia ADBPROJECT GOAL Reduce burden of malaria among poor ethnic minority groups in malaria-prone locations in GMS To pilot effective approaches to the delivery and usage of malaria control interventions as a model for scaling up in ethnic minority communities in the GMS Knowledge on malaria (refers to biomedical defmition of malaria) control increased among EMGs in selected areas Behaviour changed among EMGs for malaria control in selected areas (lTN use, diagnosis and treatment seeking) At least 90% population in the target villages know the prevention and place to curative care of malaria 2.1 At least 90% population in the target villages correctly used llNs the previous night. 2.2 At least 90% population seek EDAT within 48 hours of development of a fever ADB project INDICATORS % reduction of malaria cases in malaria prone locations in GMS Means of Verification survey Contributions from NMCP Baseline data on burden of malaria in this specific location Assumptions 1. Surveillance covers the targeted area 2. The EMG population is stable in this area. 1. The EMG population is stable in this area. 2. Resources (funds and personnel) are adequate to complete the planned activities. Appropriate lEC materials are available

PURPOSE

Mid term and final project reports

Snrvey

Expected Result I

Expected Result 2

Qualitative/quantitative survey

Adequate ITNs, RDT and drugs will available from GF and MoH.

I

ADBPROJECT Expected Result 3 Accessibility, acceptability affordability, and quality of malaria control services improved at conununity level in target EMGs

ADB project INDICATORS 3.1 100% population in the target villages have access to ITNs 3.2 100% population in the target villages have access to EDAT

Means of Verification (l)IBN distribution! reimpregnation record sheets

Contributions fromNMCP ITNs, RDT and drugs from the NMCP

Assumptions ITN, insecticides, RDT and anti-malarial drugs from the GF and MoH

(2)VMWdata Training records

Expected Result 4

Capacity of health care providers improved on conununity needs and ways to effectively address specific malaria control needs of EMGs

4.1 Increased capacity of 3 health staff (CNM, PHD &HC) 4.2 Increased capacity of 20 volunteers from 10 villages control needs of EMGs

Training records

Expected Result 5

Lessons learned and Results of pilot interventions disseminated at country and shared at regionallevei, and policy recommendations for scaling-up malaria control plans for poor EMGs available

Workshop report

-~

ACTIVITIES Main activities for Result I: Knowledge on malaria control increased among EMGs in selected areas Activities (a) Modify existing materials and reproduce lEC prototypes for the EMG (b) Disseminate IEC materials among the target population through conducting HE sessions on regular basis b.1 VMWNHV provides individual HE at household leve I. b.2 Monthly village meetings to reinforce malaria education. (c) Monitor the use orlEC materials (d) Conduct baseline and post implementation surveys. (e) Procure equipments for the project staff (computer)and the Volunteers (bicycle) (f) Select 10 villages and 20 volunteers Main activities for Result 2 Behavior changed among EMGs for malaria control in selected areas (ITN use, diagnosis and treatment seeking) by increasing

Responsible

QI

Timeline YI Q2 Q3 Q4

Q5

Timeline Y2 Q6 Q7 Q8

Rudlet

CNM

X X

X X X X X X

6850

PHDIHCN olunteers

CNMlPHD/HC

X

X

X

X

X

X

under result 2a under result 2c

CNMlPHD CNM

X

X 2500

X 1034 X I

ACTIVITIES Activities (a) Monitor the use of bed net a.1 VHV NMW does the household census to determine retention rates of nets on weekly basis. a. 2 HC /PHD staff interviews random selection of HH about bed net use. (b) Record the number of consultations with VMWs and HC for febrile illness within 48 hours of onset of fever. (c) Conduct baseline and post implementation surveys (quantitative/qualitative assessment on illness narrative). Main Acti vities for Result 3 Access of EMGs to good quality communitybased malaria control measures improved in selected areas Activities (a) Distribute !TN among the families of 10 selected villages (b) Re-impregnate the bed net on yearly basis

Responsible CNMlPHDIHC

Timeline YI QI Q2 Q3 Q4 X x X

Timeline Y2 Q5 Q6 Q7 Q8 x X x

Budget 5304

X

X

X

X

X

X

CNMlPHDIHC

CNMlPHD

X

X

3773

PHDIHCNMWsNHVs

X

X

X

X

X

X

X

4508 (operational cost)

HCNMWsNHVs (c) Provide EDAT at the community level by the VMWS and VHV s refer malaria suspects to HC VMWsNHVs (d) Monitor the VMWs and VHV activities on ITN distribution! re-impregnation and EDA T (e) Conduct monthly VMWNHV meetings

X

X

X

X

X

X

X

X

X

X

X

X

X

X

ITNIRDTand drugs GFlMoH 2438

CNMlPHDIHC ~-

X ~ _.-

X -

X L--

X ~-

X -

X

ACTIVITIES

Responsible

01

Timeline Yl I Q2 Q3 Q4

QS

Timeline Y2 Q6 Q7 Q8

Budget 3840

PHDIHCI VMWNlN Activities for Result 4 Increased the capacity of health care providers for community needs and ways to effectively address specific malaria control needs of EMGs Activities (a) Select and train 3 persons (one from each of the CNM, PHD and HC) to implement the preventive measures and EDAT for malaria. (b) Train VlNs/VMWs on EDAT and bed net re-impregnation (c) On the job support to VMWs and YHVs on EDAT and bed net re-impregnation CNMlPHDIHC

X

X

X

X

X

X

CNMlPHD

X

X

X

X

X

X

8340

CNMlPHDIHC

X

X

X

X

X

X

2438

X

X

X

X

X

X

2792

Activities for Result 5 Lessons learned and Results of pilot interventions disseminated at country and shared at regional level, and policy recommendations for scaling-up malaria control plans for poor EMGs available Activities (a) Prepare the ADB project phase-II report. CNM (b) Organize dissemination workshop to present phase-I! results and recommendations for scaling up at the country level

X X

1000

CNM

5000

ACTIVITIES

Responsible

Timeline Yl

Timeline Y2

Budget

Ql

Q2

Q3

Q4

Q5

Q6

Q7

Q8

(c) Share the phase-II results and recommendations with the other GMS countries. CNM

X

1000

Total

46039

STRENGTHENING MALARIA CONTROL FOR ETHNIC MINORITIES IN THE GREATER MEKONG SUBREGION Pilot Intervention Study of Community-based Malaria Control for Etlmic Groups and Scaling Up, in Yunnan, China

Program Planning Matrix (PPM) ADBPROJECT Reduce burden of malaria among poor etlmic minority groups in malaria-prone locations in GMS To develop effective strategies to effectively address malaria control needs ofEMGs for scaling up in the GMS Knowledge on malaria control increased among EMGs in selected areas ADB project INDICATORS % reduction of malaria cases in malaria prone locations in GMS Means of Verification Information reporting systems & special survey Final report of intervention trial Contributions fromNMCP Salary of staff; Office and supplies Salary of staff; Office; Assumptions Stable supporting environment

GOAL

The strategies developed and tested

PURPOSE

Project Fund available in time

1-------

• •

Expected Result 1

80 % of primary school students can list at least 2 malaria signs and consider mosquito as vector 60 % of villagers aged 16-60 can answer at list 3 teclmical questions on malaria. Percentage of people using bednets increased 50% compared to the baseline; 80% ofthe bednets get treated with insecticide; -

•

Testing

Salary of staff; Office;

Project Fund available in time

•

Interviewing Salary of staff; Office; Insecticides. Project Fund available in time; NMCP's or other project's insecticides

Expected Result 2

Behavior changed among EMGs for malaria control in selected areas (ITN use, diagnosis and treatment seeking) --

• •

special surveys

'--

--

--

-

I N

• Percentage of people seeking diagnosis and effective treatment within 24 hours after on-set fever increased 50% compared to the baseline. Expected Result 3 Accessibility, acceptability , affordability, and quality of malaria control services improved at community level in target EMGs

available

•

I VHW or VHV per 200 people (basically a VHV a nature village) ; Community malaria case management is available in all natural intervention villages. 80% of villagers are satisfactory to malaria control service; 80% of fever patients utilizing public health services; 80% of malaria treatment courses given are following national guidelines. 80% of health care providers from township and village level friendly communicate with their customers, and practice diagnosis and treatment following national guidelines;

Field visit & special surveys

• • •

Salary of staff; Office; Antimalarial drugs

Project Fund available in time; NMCP's or other project's drugs available

• Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs of EMGs

•

Expected Result 4

Survey and training reports.

Salary of national; Office.

Project Fund available in time; Locally full support.

• •

80% of customers are satisfactory to the provider's attitudes, behaviors and service cost. All malaria control staff from county

2

and township level received training on community-based methodology. Expected Result 5 Lessons learned and Results of pilot interventions disseminated at country and shared at regional level, and policy recommendations for scaling-up malaria control plaus for poor EMGs available Lessons learned and results of pilot interventions disseminated at country workshop, and shared with other countries; Number of information shared with other countries; Number of papers published; The Book "Practical Manual for Bee Project" Workshop reports, Materials shared, Papers published, and manuscript of the book. Salary of staff; Office. Project Fund available in time; Locally full support.

3

ACTIVITIES Main activities for Result I: Knowledge on malaria control increased among selected EMGs Identify and reproduce lEC materials; Select & train peer-communicators (village volunteers & teachers). lEC campaign in schools; 1.4 lEC campaign in communities; Main activities for Result 2 Behaviour changed among selected EMGs for malaria control (ITN use, diagnosis and treatment seeking) Procure and supply 2250 bednets to villagers; Teach and mobilize villagers using bednets properly through BCC activities; Mobilize villagers to seek early diagnosis and effective treatment as soon as on-set fever; Peer-communicator monitoring the treatment objectives completing full treatment courses. Main Activities for Result 3 Accessibility, acceptability , affordability, and quality of malaria control services improved at community level in target EMGs Train VHW & VHV selected by communities on malaria control techniques such as dipping bednets, malaria case management and communication skills; Support VHW & VHV to do malaria control activities.

Responsible YIPD, County CDC, Township government.

Timeline YI YI

Timeline Y2

Budget US$ 18700

YIPD, County CDC, Township government.

YI

Y2

US$ 5625

YIPD, County CDC, Township government.

YI

Y2

US$ 13 627.5

-

4

Activities for Result 4 Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs of EMGs Train health providers from townships and villages on communication knowledge and skill, national guidelines on malaria diagnosis and treatment; Support health providers to give service friendly; Train malaria control staff from county and township level on community-based methodology. Activities for Result 5 Lessons learned and Results of pilot interventions disseminated at country and shared at regional level, and policy recommendations for scaling-up malaria control plans for poor EMOs available Organize country dissemination workshop to review project implementation, share experience and lessons learned and behavior change strategy; Share experiences, lessons and information with other countries of OMS; Write and publish papers in national or international journals; Write out a book "Practical Manual for BCC Project" in Chinese to disseminate technical strategies of behavior change; Baseline data collection Monitoring and evalnation Others Total --

YIPD, County CDC, Township government.

YI

Y2

US$ 1750

MOH,NIPD& YIPD.

YI

Y2

US$ 5500

I

US$ 1525 US$ 4650 US$ 4812.5 '-----

- _... _ -

US$ 56190

5

Lao PDR Project Planning Matrix I

ADBPROJECT GOAL To reduce the burden of malaria among poor ethnic minority groups living in malaria-prone locations in Lao PDR thereby reducing child and maternal mortality. To develop effective strategies to effectively address malaria control needs ofEMG's for scaling up in the GMS

ADB project INDICATORS % reduction of malaria cases in malaria prone locations in GMS

Means of verification Survey

Contributions from NMCP 1. Global Fund strategies and activities under Round 1 and Round 4. 2. NMCP/CMPE policy guidelines on EDAT and IBN. Existing infrastructure, staff, network and reporting flows.

Assumptions

PURPOSE

EXPECTED RESULTS Expected Result 1 Ethnic minority population in pilot areas receive, accept and understand lEC messages 1. At least 80% of adults and school children the EMGs in this pilot areas understand malaria symptoms and preventive methods.

Project records and reports of trained persons

-

ADB budget is made available by April 2006 for lEC materials to be made and printed. Active participation of the non-health sector at project sites

Pre-post test scores

I w

Expected Result 2

Ethnic minority population in pilot area recognize febrile illness and access malaria diagnosis and treatment and ITN (VHV, Health center, District Hospital)

I. 50% increase of people using ITNs regularly 2. 20% increase of people seeking care (within 24 hours of fever onset) 3. 100% ofP. falciparum malaria patient receive treatment from VHV complete full dosage 4. 10% increase of people utilizing public health services or village volunteers

Malaria Information System Survey Malaria Information System- VHV reports

Training of HC and district staff on diagnosis and treatment byGFATM; RDT, ACT, IBN, insecticide and lab supplies from GFATM in sufficient quantities

Global fund procurements - RDT, ACT, IBN, insecticide are secured in sufficient quantities and in-country on time for the coming year. Current stocks of IBN are delivered to target populations before the rainy season for this malaria season commencing April.

Survey

Expected Result 3

Strengthen the capacity of health care providers to address specific needs of malaria control for EMGs

1. lEC/BCC training for health care providers

Project records and reports after training

Existing staff. Training for EDAT and !TN by GF ATM.

Participants (health staff) will be able to translate expected outcomes in the target populations to address the specific gaps. (existing health staff) Stakeholder commitment and required budget for scale up plans

I

Expected Result 4

~-

Lessons learned and Results of pilot interventions disseminated at country level and to the relevant stakeholders and policy recommendations for scaling-up malaria control plans for poor EMGs made available.

1. Number of stakeholders attending final presentation meeting 2. Number of proposed sites for scale up

Expressed interest from stakeholders in scale up plans

NMCP coordinates meeting

--

-

ACTIVITIES Main activities for Result 1: Ethnic minority population in pilot areas receive, accept and understand lEC messages (a) Planning and consensus workshop at provincial/district with all stakeholders on strengthening malaria control of EMGs in pilot villages (b) ReprintIEC tools and materials (annex 1) (c) conduct baseline survey for knowledge, behaviour and practices related to malaria prevention and control and mass blood survey (in 4 pilot villages/health center and district hospital) (d) IEC/BCC training for 40 village persons (2 VHV, I Village leader, 1 LWU, Heacher) (e) Implement regular IEC activities using VHW (2/village) and secondary educators at village sector ('khum'l'nuai') (1 secondary educator/sector. Average 5 sector/village) (Q Refresher training IEC/BCC strategy review

Responsible

Timeline Yl (Yl start Oct 2005)

Timeline Y2 (Y2 start Oct 2006)

Bndget

CMPE

Q3

1500

CMPE

Q3

4000

CMPE

Q3

3000

CMPE

Q3

2500

Prov/Dist

Q4-5

Q6- 8

3500

CMPE/Prov CMPE/Prov/Dist

Q4 Q4

Q6 Q8

1500 3000

(g) final evaluation of knowledge, behaviour and practices related to malaria prevention and control and mass blood survey (in 4 pilot villages) (h) Development and implementation of rOlltine quarterly IEC/health education reporting format

CMPE/Prov CMPE/Prov/Dist

Q3 Q4- 5 Q6-8

1000 1000

(i) Supervision and monitoring ofproject activities at project sites (CMPE: once/quarter/district) (Prov/Dist) Main activities for Result 2: Ethnic minority population in pilot area recognize febrile illness and access malaria diagnosis and treatment and !TN (VHV, Health center, District Hospital) 2.1 (a) training on malaria diagnosis (Clinical aspects, RDT and Blood slide preparation) and treatment (uncomplicated) and pre-referral (severe) for VHV (b) distribute rapid diagnostic tests and ACT supplies, slides and reagents to district malaria stations and VHVs in pilot villages (d) Slide QA from VHV sent to provincial and CMPE quarterly (100% of all positives and 10% of negatives) 2.2 (a) training for VHV on ITN use, treatment of nets and reporting for 16VHV (b) distribute bednets, insecticide and dipping sets to target villages (e) Target population treat (new nets) and retreat (old nets) 2.3 (a) Procurement and distribution of supplies and CMPE /Prov running cost to Prov / Dist IV illage in pilot areas

3000

CMPE/Prov

Q3

2500

2000 CMPE/Prov Q3 700 Prov Q3 I

2000 CMPElProv/Dist Q3 2000 Prov/Dist Prov Q3 Q3 1200

CMPE/Prov

Q4

2000

2.4

CMPE/Prov

Q3

800

(a) Revise existing MIS to include village level all-cause mortality and printing (b) Development and printing of job-aids for VHV in target villages Main Activities for Result 3 Strengtben the capacity of health care providers to address specific needs of malaria control for EMGs (a) lEC/BCC training for health care providers (b) conduct BCC and community mobilization (c) Review lEC/BCC strategy Activities for Result 4 Lessons learned and Results of pilot interventions disseminated at country level and to the relevant stakeholders and policy recommendations for scaling-up malaria control plans for poor EMGs made available (a) train lEC/BCC, ACT/RDT and bednet dipping to VHV and partners in expanded villages (4) (b) scale up plan to treat new and old nets in existing and expanded villages (c) Final report writing (d) Final presentation meeting with all stakeholders including EMG TOTAL Prov/dist CMPE CMPE CMPE/prov

Q2

700

I

I

Q3 Q3 Q6

1500 1200 700

Q6

1200

Prov/dist

Q4

1800

Prov/dist CMPEINIPE

Q4-Q8 Q8

500 2700 47500 -

,

~

---

Total budget available US$ 41000 + 5500 = US$ 46 500

Strengthening Malaria Control for Ethnic Minorities in Mae Hong Son, Thailand. Project Planning Matrix:Items Goal ADB project Reduce burden of malaria among poor ethnic minority groups in malaria-prone locations in Mae Hong Son, Thailand indicator 20% of reduction Malaria morbidity rate compare with the previous year. Means of Verification Survey Report Contribution from NMCP Supported Drug supply Bed Net Insecticide Equipment Salary of employees in Co-Me. Salary of Health staff Assumption

Purpose

To pilot effective approaches to the delivery and usage of malaria control interventions as a model for scaling up in ethnic minority communities in the 5 village, Mae Hong Son Ethnic minority populations in pilot areas increase awareness of appropriate malaria control practices and utilize home and community based for malaria control Community Etlmic minority populations in pilot areas apply vector control measures and proper use ITNs 80% of populations have good KAP. Survey Salary of Health staff If no problem in transportation in rainy season

Expected Result expected result 1

expected result 2

80% of population who have and nse ITN

Survey

Provide Bed Net and Insecticide

If no problem in transportation in rainy season

~ ..,. ~

Items expected result 3

ADB project To increases the access to early diagnosis and prompt effective antimalarial treatment in communities. Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs of EMGs Lessons learned and Results of pilot interventions disseminated at provincial and shared at country, regional level, and policy recommendations for scaling-up malaria control plans for poor EMGs available

indicator 80% of Malaria cases receive drug treatment within 24 hr after onset of fever. The local health services have an implementation plan on malaria control in EMGs in target area. The partnerships have an implementation plan on malaria control in EMGs in target area.

Means of Verification Report Survey

Contribution from NMCP Supported Drug supply Equipment

Assumption If no problem in transportation in rainy season

expected result 4

Summary of Training and Meeting

Technical Support

expected result 5

Summary of Meeting

Technical Support

If malaria is the partnerships' priority and interest

-

-

--

2

Plan of Action, ADB Project, Thailand Timeline Activities Main activities for Result 1 Ethnic minority populations in pilot areas increase awareness of appropriate malaria control practices and utilize home and community based for malaria control (a) Base line data survey (b) Improve Previous IEC Material (c}reproduce and distribute IEC Materials (d)Training volunteer/ Key informance/ Leader on malaria prevention and control as well as how to involve behaviour change (1) Malaria Campaign Main activities for Result 2 Community Ethnic minority populations in pilot areas apply vector control measures and proper use ITNs (a) Conduct Mapping of target villages for !TN and development of plan of action for lTN distribution (b) Provide/distribution bed net and reimpregnation. (c lSurvey of using lTN Responsible apr may jun jul

2006 aug sep oct nov dec ian feb

2007 mar apr jun jul aug sep

Budget

VBDU BVBD,PCO BVBD BVBD,PCO, VBDC

x x x x

750 750 11250

2500 PCO, VBDC, VBDU x

3250

VBDU

x

130 BVBD, VBDU VBDU, VBDC x x x x -

600 600

3

Main Activities for Result 3 To increases the access to early diagnosis and prompt effective antimalarial treatment in communities. (a) Situation analysis and priority setting (b )Reproduce guideline for disease management at Community Malaria Clinic. (c) Refresh training non-health worker employees on malaria diagnosis by using microscope and treatment. Activities for Result 4 Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs of EMGs (a)Training Local staff to be able to monitor and evaluate malaria control for ethnic minorities. (b) Conduct technical workshop to review project implementation, lessons learned and behaviour change strategy for local staff in provincial Level.

VBDC,VBDU PCO

x x

250 90

BVBD, PCO, VBDC

x

1500

BVBD,PCO, VB DC BVBD,PCO, VBDC

x

x

3500 3500

4

Activities for Result 5 Lessons learned and Results of pilot interventions disseminated at provincial and shared at country, regional level, and policy recommendations for scaling-up malaria control plans for poor EMGs available (a) Conduct the strengthening advocacy meeting to promote Malaria control with stakeholder including communities (b) Result study publication. (c) further dissemination the lessons learned to other EMG Monitoring and Evaluation Total Budget (U$) Remark:VBDU VBDC PCO BVBD =

BVBD,PCO, VBDC BVBD

x

3500 230 x x

BVBD,PCO, VBDC, VBDU

8000 40400

Vector Bone Disease Unit = Vector Bone Disease Center = Prevention and Control Office = Bureau of Vector Borne Disease

5

Viet Nam Project Planning Matrix VIETNAM GOAL ADBProject Reduce burden of malaria among poor ethnic minority groups in malariaprone locations in Vietnam To develop effective strategies to effectively address malaria control needs of EMGs for scaling ~ in VTN Knowledge on malaria control increased among EMGs in selected areas Behavior changed among EMGs for malaria control in selected areas (ITN use, diagnosis and treatment seeking)

ADB project Indicators

Means of Verification Survey

Contributions fromNMCP

Assumptions

PURPOSE

Expected Result 1

Expected Result 2

Increase at least 30 % villagers recall at least 2 message related to malaria prevention 100% bednet coverage 90% properly using 1TN 90% fever case go to CHCNHWs 70% fever case receive slide testlRDTs 100% confirmed malaria case receive appropriate treatment 100% VHWs/CHC staff can correctly provide services related to malaria prevention and treatment Strategy on malaria control for EMGs developed Plan for application the result of this project for other EMGs is developed

Survey, Training i

Survey, Training, Distribution

Bednets and RDTs byGF Insecticides and ACTbyNMCP

Expected Result 3

Access ofEMGs to good quality community-based malaria control measures improved in selected areas

Survey, communication

Expected Result 4

Expected Result 5

Capacity of health care providers improved on community needs and ways to effectively address specific malaria control needs ofEMGs Lessons learned and Results of pilot interventions disseminated at country and shared at regional level, and policy recommendations for scaling-up malaria control plans for poor EMGs available

Survey, Management

Evaluate, Workshop, Share information

-

-~

I v.

ACTIVITIES

Responsible

Timeline Yl (2006)

Timeline Y2 (2007)

Budget (USD)

Main activities for Result 1: Knowledge on malaria control increased among EMGs in selected areas. (a) Launching meeting at district health center to introduce the project with different sectors of province, district and commune. (b) Training on communication skills for health staff of district, commune and VHW s.

IMPE Quy Nhon and PMS Khanh Hoa. IMPE Quy Nhon District and commune health center IMPE Quinhon

April

1500

May, Dec

2000

(c) Reproduction/print and distribution LEC material developed by first phase and procurement equipment (d) To educate villagers on malaria prevention knowledge through commune load- speak system in Raglei language speaking and face to face communication with particular group (forest goers ... ) Main activities for Result 2 Behavior changed among selected EMGs for malaria control (ITN use, diagnosis and treatment seeking) (a) Conduct baseline survey on malaria prevention (bednet coverage and use, treatment seeking ... ) (before and after intervention) (b) Regular household visit by VHWs to communicate and educate villagers on malaria knowledge. (c) Monthly meeting at commune health center to report and review activity of CH staff and VHW s chaired by district or PTOvince/IMPE Quinhon

May Commune health center and VHWs

10 000

June

Sep

2000

IMPE Quy Nhon, PMS Khanh Hoa, district and commune health center Commune health center and VHWs District, commune health center and VHWs

April

April

5000

May

April

2000

June

June

2000

Main Activities for Result 3 Access of EMGs to good quality community-based malaria control , measures improved (a) Training on impregnation bednet, diagnosis (microscopic, RDTs) and treatment for commune health staffs and VHWs (b) Identify the needs (RDTs, ACT, bednets and insecticides, medical bag ... ), supply and distribute to the target commune (c) Regular supervision and guide commune health staffs and VHWs by malaria specialists (d) To identify forest goers and spend overnight in the forest and supply stand-by treatment for them Activities for Result 4 Knowledge and experience ofNMCP and other health staff improved on addressing the malaria control needs of EMGs (a) Onjob training on EDAT for commune health staffs VHWs and microscopy points by experienced staffs of Quinhon IMPE and PMS every quarter. (b) Workshop on experience in malaria control services for EMGs from different provinces Activities for Result 5 Lessons learned and Results of pilot interventions disseminated at country and shared at regional level, and policy recommendations for scaling-up malaria control plans for poor EMGs available (a) Conduct technical workshops to review project implementation, lessons learned and behavior change strategy and develop plan for integration malaria control into NMCP (b) Introduce the result of project on IMPE Qui Nhon website and project web

IMPE Quy Nhon and PMS KhanhHoa IMPE Quy Nhon and PMS Khanh Hoa, district IMPE Quy Nhon and PMS Khanh Hoa, district Commune authorities and health staff and VHWs

May

May

2000

May

May

4000

November

August

2000

May

October

1000

IMPE Quy Nhon and PMS KhanhHoa CHC IMPE Quy Nhon

September, December

2000

I

November

4000

IMPE Quy Nhon, WHO VTN

October

4000

IMPE Quy Nhon

September

to October

1000

-----

~-

---

---~

(c) Share project and control infonnation with other GMS member countries and write report (d) Miscellaneous

IMPE Quy Nhon

September

-

to October I

2000

TOTA L

8 units (IMPE Quy Nhon, PMS Khanh hoa, Khanh Vinh district, Khanh Nam and Khanh Trung commune health center, VHWs, WHO-VTN)

2 years (2006-2007)

46500

Project Proposal

ANNEX 6

Strengthening Malaria Prevention and Control Among the National Races in Tarchileik District, Eastern Shan State, Union of Myanmar

A component ofthe Project on Strengthening Malaria Control for Ethnic Minorities in the Greater Mekong Sub-Region supported by Asian Development Bank World Health Organization and by the member countries in the Greater Mekong Sub-Region

Submitted by Vector Borne Diseases Control Department of Health Ministry ofHeaIth Union of Myanmar May 2006

o

Executive summary The proposal aims develop and implement community-based approaches to deliver malaria control interventions for national races in selected remote villages in Tarchileik District, Eastern Shan State, Myanmar. By end of2007, the expected results from the project are: (1) Capacity ofVBDC Staff and the Basic Health Staff to plan, implement, monitor and evaluate malaria prevention and control services for national races in Tachileik District, Eastern Shan State is strengthened; (2) National races in target villages are empowered to plan, implement, monitor and evaluate community-based malaria prevention and control; and (3) Lessons learned on community-based malaria prevention and control among national races in Tachileik District, Eastern Shan State are adopted to the NMCP and shared to key stakeholders on malaria in Myanmar and in other countries in Greater Mekong Sub-region. The project will be implemented from July 2006 to September 2007 in three townships Tarchileik, Mong Tone and Mong Hsat - in Tarchileik District, which are located in the along the borders with Thailand and Lao PDR. Approximately 214 544 population will benefit from improved malaria control services by the VBDC and by the BHS. In addition, about 15 000 population will benefit from community-based malaria control interventions. The estimated budget needed from ADB-WHO Project is US$ 72 000. WHO Country Office will provide counterpart support totaling approximately US$ 42 000. These include drugs and commodities being provided by WHO for malaria control program that would be used in the three townships, costs of developing some materials and travel expenses of its international and national staff will provide technical support. The Government counterpart includes salary of VBDC staff and the Basic Health Staff and operating expenses of their offices. Community counterpart includes voluntary work of community members and their leaders that are critical to the success of this project and other resources that the community already owned (e.g., bednets). VBDC shall be the responsible implementing agency in collaboration with the concerned local administrative and health authorities.

Background and rationale Malaria is one of the major diseases that hinders socio-economic development of rural communities in Greater Mekong Sub-region (GMS) that comprised of Cambodia, China, Lao PDR, Myanmar, Thailand and Vietnam. While all the populations living and/or working either temporarily or permanently in endemic areas are at risks of malaria, the national races are particularly highly vulnerable. It is not uncommon to see them living in very remote villages where physical access to formal health services is difficult. Moreover, socio-economic and cultural factors are additional constraints in their access to health services. The Asian Development Bank (ADB) supported a communication for behaviour change initiative for malaria control for ethnic minorities in the GMS through WHO. The project, which was implemented from November 2002 to December 2004 in the six GMS countries, achieved the following: (I) IEC materials and guidelines were developed for six different ethnic minOrity groups; (2) NMCPs' capacity in community-based activities was enhanced through formal and informal training and project implementation; and (3) a draft regional IEC strategy for ethnic minority groups was developed, and (4) experiences and lessons learned were shared among GMS countries to increase the responsiveness of national programmes to the needs of these target communities. In 2005, ADB agreed to provide further financial support through WHO WPRO to the GMS countries for the project on Strengthening Malaria Control for Ethnic Minorities in the GMS. The goal is to reduce malaria burden among poor ethnic minority groups living in malaria-prone areas. The specific objectives are to (I) build capacity of national malaria institutions to develop acceptable, affordable and effective strategies for malaria control for ethnic minorities; (2) scale -up malaria control efforts for these populations through NMCPs; and (3) promote regional collaboration for malaria control.

The project's goal is to reduce the burden of malaria in ethnic minorities and migrants living in malaria-prone locations in the GMS, thereby helping to reduce child and ,maternal mortality. The objectives are to (i) demonstrate how to develop acceptable, affordable and effective strategies for malaria control for ethnic minorities; (ii) build capacity of national malaria institutions in doing so and scale up efforts for malaria control for these populations through NMCPs; and (iii) strengthen the institutional network and mechanism for promoting regional collaboration for malaria control. The project period is 18 months. The project wi!! benefit ethnic minorities and migrants by directly reducing the burden of malaria in six selected communities; by adaptation of locally appropriate models of malaria control; by expansion of malaria control efforts for ethnic minorities through NMCPs; and by enhanced regional learning and collaboration for malaria control. Proj ect area Location and population The project will be implemented in selected hard to reach villages in Tarchileik District, Eastern Shan State. The district is located in the eastern part of Myanmar bordering and Lao PDR and Thailand (Fig 1). It comprised of five townships: Tarchileik, Mong Hsat, Mong Tone, Mong Phyak, Mong Yaung. The estimated population is 320000, with almost 113 residing in Tarchileik township (Table 1).

2

·

.

3

,•

Table I. Estimated population per township and the malaria situation in Tarchileilk District in relation to the situation the Eastern Shan State and in the country, 2004 Morbidity Mortality Township in Tarchileik Total per 1000 per100,000 CFR(%) District Population population population Tarchileik 104,593 18 15 4.86 MongHsat 76,120 22 16 3.75 MongTone 33,831 59 33 3.59 MongPhyak 38,698 13 16 4.96 MongYaung 66,644 20 ? ? District 319,886 Eastern Shan State 679,004 20 8 3.87 Myanmar 54,280,000 11 3.7 There are several national races - Shan, Akha, Lahu, Wa, Paluang, Bamar, Kachin, etc - who reside in the three townships. Table 2 shows the estimated number of population of the different races in rural areas in Tarchileik township. Table 2. National Races in Rural Areas of Tarchileik Township Estimated No. of Villages Households Population Akha 120 21849 4083 Lahu 83 14278 2886 Shan 100 38389 8830 Others* 23 6822 1291 81338 Total 17090 326 *Includes Bamar, Kachin, Paluang In the other two townships (Mong Hsat and Mong Tone) the breakdown of population by races is not available. However, it is estimated that in rural areas in Mong Hsat, the Wa are the most numerous followed by the Lahu and then the Akha. In Mong Tone, the majority is Lahu followed by the Akha. The Shan mostly live in plain and urban areas and the Akhar and Lahu live in hilly and mountainous areas. In addition to indigenous population, there are migrant workers and / or settlers from other parts of the country. The rural populations are mainly engaged in subsistence farming (about 86%) and gathering of forest produce. In addition, there are migrants mainly from central part of Myanmar who work in orchard plantation, road construction, and other economic activities. The project beneficiaries will include all the population (around 214 544) in the three townships who will benefit from improved malaria services by the VBDC and by the BHS. In addition, about 15 000 population will benefit from community-based malaria control interventions. Health services and practices Over the past several years, the coverage of health care services has expanded, and the road networks and agricultural development have markedly improved. However, a significant number of villages is very far from health facilities. Even if there is a road, there may be no vehicle, and if vehicles are available the fee is beyond the reach of most villagers. Thus, when people are ill a lot of them resort to self medication or seek treatment from untrained health care providers

"

4

residing either in their village or in nearby villages or from itinerant untrained health care providers. A recent survey of 50 households was done in 2006 in Kya Ga and Pan Non villages in Tarchileik townships. Results indicate high bednet ownership (48/50 households have on average 2.4 nets) and 94% of household sleep with bed net. Recognition of uncomplicated malaria seems good; at 98% of 50 respondents knows the signs and symptoms of uncomplicated malaria. However, they do not know about the signs and symptoms of severe malaria. Only 10% of household knows that blood examination is needed for malaria diagnosis. Regarding treatment seeking behaviour, 80% of households practices self medication first when they suffer fever and any other discomforts. In 2004 a survey in Pansili village of 80 households showed all have mosquito nets (partly due to distribution done by the program) but 56% have only one bednet. Only 12.5% of 80 respondents claimed that they seek care first from Basic Health Staff; the majority self-medicate with left over drugs from previous malaria episode or drugs they buy from vendors.

The availability of malaria drugs in the village is variable. In Pansili village, 45% of 80 respondents claimed that malaria drugs are available in the village stores. In Kya Ga and Pan Non villages, of the 50 households surveyed, 98% said that they can not easily get antimalarial drugs in their village. Artemisinin derivative and mefloquine are considered the best drug by 30% and 28% of 50 respondents, respectively. Although most of them cannot give reason, some said that it is the best drug because they are relieved of illness after taking it. Malaria situation Malaria is a major health problem in Tarchileik District. The topography, ecology and socioeconomic environment favor malaria transmission. The district comprises of valleys, hills and mountains, with significant forest cover. The temperature ranges from 2-3JOC while relative humidity ranges from 46% to 82%. Rainy season is from June to October. Anopheles minimus and Anopheles dirus are the main vectors. Tables 1 & 3 shows some details on malaria in Tarchileik District. Since a significant proportion of the population do not access the public health facilities, the data reported do not capture the true magnitude of the malaria problem.

5

Table 3. Reported morbidity 1994 - 2003 Year 1994 Clinical cases 3880 (outpatients) Clinical case 1787 (inpatients) Malaria deaths 63 Active Case 918 Detection Passive Case 4854 Detection No of blood slide 5772 examined No of blood slide 3440 positive SPR (%) 59.6 Pf% 98.8 PyOlo 1.1 Mix% 0.1 Morbidity rate/l 000 pop. Mortality rate/IOO 000 pop. C.P.R

and mortality of malaria in Tachileik district, Eastern Shan State, 1995 6519 984 83 1064 4215 5279 3114 59 95.6 4.2 0.2 1996 6108 1233 51 781 5327 6108 2052 33.6 88.9 10.1 1.0 1997 4451 1248 64 1102 4550 5652 2342 41.4 95.7 3.9 0.4 1998 3145 1708 87 1184 3555 4739 2299 48.5 97.8 1.4 0.8 1999 2962 1218 88 400 1459 4348 1873 43.1 98.2 1.3 0.5 29 88 7.2 2000 1642 454 37 862 2273 3135 913 29.1 99.1 0.9 -

2001 1990 532 64 705 2652 3357 976 29.1 99.9 0.1

2002 2013 302 22 1453 2127 3580 1022 28.5 99.1 0.8 0.1 25 25 7.3

2003 1492 432 25 723 1546 2269 824 36.3 98.3 1.5 0.2 18 25 5.8

28 71 12.0

26 46 8.15

Malaria morbidity per 1000 population dropped from 29 in 1999 to 18 in 2003. Malaria mortality per 100 000 population was reduced from 88 in 1999 and 25 in 2003. Report in 2005 indicated further drop of malaria morbidity and mortality rates to 15/1 000 population and 13/1 00 000 in 2005. The severity of the disease and late arrival to the hospital are the main detennmants of high mortality. In the past 10 years the reported proportion of P. falciparum ranged from 88 to 99.9%. Although the malaria burdens are still high, the trend is declining. Improved access to health care services, including malaria control, environmental changes brought by agriculture development and reduced number of migrant workers from other parts of the country could be the significant factors for the reduction of malaria morbidity and mortality. Malaria control services Malaria control services are being delivered by the Basic Health Staff and by the VBDC team. Under the leadership of the State Regional Officer (Malariologist), the district VBDC team is headed by a Medical Officer. In Tarchileik township, 6000 ordinary insecticide treated bed nets and 8000 LLINs (Pennanet) were dIstributed from 2001 to 2004. Much more needs to be done to increase coverage in Mong Tone and Mong Hsat townships. Case detection and treatment are being done at health facility level. Microscopy is available at district and station hospitals and in some RHCs but the quality needs to be further improved. ACTs and RDTs are being used since the past few years. Prom May 2005 onwards RDTs are available in all sub-rural health centers in Tarchileik township. Although VBDC staff are highly dedicated to their job, their major constraint is inadequacy of resources and lack of transportation.

6

The three townships - Tarchileik, Mong Tone and Mong Hsat - are among the 100 priority townships supported under GFATM grant. Although the grant will end this August 2006 supplies of ACTs and RDTs may last up to at least mid-2007. Phase 1 of the ADB-WHO supported project on LEC was done in the Tarchileik Township. Currently WHO is supporting a project on "primary drug providers" (PDP). The project, which started last February 2006, envisages that trained PDPs (numbering 21) would provide early diagnosis and appropriate treatment for uncomplicated malaria and recognize and immediately refer severe febrile diseases. In addition, they will also do health education on malaria prevention and control. This proposal builds on and will expand the existing project and will take into account the accomplishments and the lessons learned in Phase 1 of ADB-WHO project. The added value of the current proposal will be: (1) strengthened capacity of VBDC staff and Basic Health Staff to deliver quality services and to empower the national races to become active participants rather than just passive recipients of malaria control services; (2) empowered the target beneficiaries through their "Community-owned resource persons (CORPs) to address malaria at community level; (3) expanded geographic coverage and quality of malaria control services, and (4) improved information system for decision making by the target beneficiaries and by the health staff. These will improve access to and quality of malaria control services by the national races and contribute to reduction of malaria morbidity and mortality.

Goal Contribute to the reduction of malaria burdens in Myanmar and in the Mekong Sub-region. Purpose To develop effective strategies for malaria prevention and control among national races in Tarchileik District, Eastern Shan State, Myanmar that could be scaled up.

Expected Results By end of2007: 1. Capacity of VBDC Staff and the Basic Health Staff to plan, implement, monitor and evaluate malaria prevention and control services for national races in Tachileik District, Eastern Shan State is strengthened; 2. The national races in target villages, through their community-owned resource persons, are empowered to plan, implement, monitor and evaluate community-based malaria prevention and control; and 3. Lessons learned on community-based malaria prevention and control among national races in Tachileik District, Eastern Shan State are adopted to the NMCP and shared to key stakeholders on malaria in Myanmar and in other countries in GMS.

Methods aud key activities The basic concept of the project in Myanmar is illustrated in Figure 1 below. The capacity of the VBDC Staff and the Basic Health Staff to deliver quality malaria control services will be further strengthened through training, continuing medical education, supportive supervision and provision oflogistics including means to travel to remote villages. They will facilitate the empowerment of national races in remote villages. Through their guidance and through participatory approaches, the national races will be empowered to become active participants and not just passive recipients of malaria control services. This will require putting in place enabling

7

factors for the health care providers and for the trained community owned resource persons (CORPs) to do their tasks efficiently and effectively. The CORPs could be the existing voluntary health workers, primary school teachers, the "primary drug providers" and others whom the villagers may select to be trained in order to provide voluntary services for malaria prevention and control in their respective villages. In Tarchileik township, WHO is currently supporting a project that trained 21 "primary drug providers" (PDP) to provide early diagnosis and appropriate treatment for uncomplicated malaria and recognize and immediately refer severe febrile cases. In addition, they will also do health education on malaria prevention and control. This proposal builds on and will expand the existing project and will take into account the accomplishments and the lessons learned in Phase I of the WHO-ADB project.

Fifty community-owned resource persons (CORPs) from 50 villages (30 in Tarchileik, including the existing 21 trained "primary drug providers", 10 in Mong Tone, and 10 in Mong Hsat) will be selected by the villagers. They will be trained and re-trained to equip them with the requisite knowledge and skills to deliver a package of malaria control interventions and to mobilize their respective villagers to actively participate in malaria prevention and control. From the 50 villages, 15 villages will be selected to set-up a more intensive community-based malaria control program, including malaria surveillance system. The approaches and tools developed and the lessons learned will be used to scale up malaria control interventions in other areas where national races are at risk of malaria. The key activities are listed in the Project Planning Matrix (Table 4).

8

Figure 1. Framework for strengthening malaria control among national races in Tarchileik District, Eastern Shan State, Myanmar Impact Contribute to the reduction of malaria burdens in Myanmar and in the Greater Mekong Sub-region

Outcome Improved access to and utilization of quality assured malaria control services by the national races in target areas Output Empowered communities of national races actively participating in malaria prevention and control Output Empowered Basic Health Staff and VBDC Staff delivering quality malaria control services

Inputs • Concerted community actions, including monitoring and evaluation • Participatory decision making at household and community level (initially facilitated by BHS and VBDC staff) • Internalization by community leaders and members that the malaria problem could be solved with their commitments, active involvement and collaboration with local health staff. • Community needs assessment (facilitated by the health staff) • Correct knowledge and skills on malaria control, and practices that reduces the risk of malaria (facilitated thru community workshops, IEC) • Logistics support from within the community (bednets, volunteers) • Sustainable technical and logistics support external to the community

Inputs • Committed health staff • Improved knowledge and skills on: social mobilization, IEC, planning, imp-implementation, M & E of community-based MCP, training of volunteers, etc. • Team building, critical thinking and decision making • Logistics support (LLINs, RDTs, ACTs, job aids, operational guide / manual, transportation, per diem during field work, etc) • Supportive supervision, continuing medical education, recognition and awards, etc. • Improved data base for decision making; information sharing • Continuing technical support

9

Implementation structure and partners VBDC shall be the responsible implementing agency in collaboration with the State Health Office of Eastern Shan State, District Health Office in Tarchileik District and the respective local authorities in the three townships (Tarchileik, Mong Hsat and Mong Tone). VBDC shall designate a focal person at central level and will empower the VBDC Regional Officer in Eastern Shan State and the VBDC Team Leader in Tarchileik District to implement the project. WHO Country Office shall provide and / or coordinate technical support for planning, implementation, monitoring and evaluation, including development of tools for the project. Estimated budget and sources of funds The estimated budget needed from ADB-WHO Project is US$ 72 000. WHO Country Office will provide counterpart amounting to approximately US$ 42 000. These include drugs and commodities to be provided to VBDC for use in the three township, costs of developing some materials and travel expenses of its international and local staff who will be involved in this project. In addition, it will provide technical support through its national and international staff. Government counterpart includes salary ofVBDC staff and the Basic Health Staff and operating expenses of their offices. Allocation of some drugs and supplies to the project sites. Community counterpart includes voluntary work of community members that will help ensure success of this proj ect. Time Frame July 2006 to September 2007 (some materials are being developed with support from WHO starting June 2006). Risk and assumptions Successful implementation of the project depends c;m the following factors: (1) Commitment and dedication of the VBDC Team in Tarchileik District and the VBDC Regional Officer in Eastern Shan State. The current Team Leader and the Regional Officers are highly committed to implement this kind of project. It is expected that they will remain in their current positions during the life of this project. (2) Active cooperation and support of the District Medical Officer, Township Medical Officers and the Basic Health Staff are essential to the success of this project. It will be the task of the Central VBDC team, the Regional Officer and Team Leader to advocate and secure support from them. (3) Endorsement and support of the project from the local authorities especially the area commander is critical to move the project forward. (4) Peace and security in the project area is also a critical factor to implement community-based interventions. (5) VBDC need to allocate some of its drugs and supplies being provided by other partners such as WHO and UNICEF to the project sites. (6) Counterpart funding and technical support from WHO Country Office are essential. (7) The project requires frequent visits to the villages by VBDC and by the Basic Health to empower the villagers and the CORPs. Thus, provision of reliable transportation and travel expenses are very essential. These should be supported in the project budget.

10

Table 4: Project Planning Matrix: Strengthening Malaria Prevention and Control Among National Races in Tachileik District, Eastern Shan State, Myanmar Description Contribute to the reduction of malaria burdens in Myanmar and in the Mekong Sub-region INDICATORS % reduction of malaria cases in malaria prone locations in GMS Means of Verification Contribution fromNMCP' Assumptions! Risks" Given the small scale and short duration of the project, its contribution to the overall impact on malaria in the country and the GMS will be difficult to demonstrate and measure.

GOAL

I

PURPOSE

Expected Result I

To develop effective community-base strategies for malaria prevention and control among national races in Tarchileik, Eastern Shan State, Myanmar that could be scaled up. Strengthened capacity of VBDC and the Basic Health Staff on planning, implementation, M & E of malaria prevention and control services for national races

• % of target population who slept under ITNs I LUNs

every night during the last 7 nights prior to the survey • % of malaria cases treated within 24 hours of onset of

• •

Survey report

fever by trained health care providers (Basic Health Staff and by the CORPs) according to national guidelines l.l Availability of operational manual for malaria prevention and control at township level

Patients' records and survey reports

1.1 Project document

1.2 % of BHS surveyed I supervised who treat malaria according to national guidelines

1.2 Survey and monitoring reports 1.3 Survey and monitoring reports 2.1 Supervision and monitoring reports 2.2 Survey reports 2.3 Survey reports

Salary of VB DC Staff and BHS Staff to be involved in the project

1.3 % health facilities without stock out of drugs for more than a week within the last three months prior to the monitoring visit and I or survey Quality community-based Expected Result 2 malaria prevention and control services for national races in

Tarchileik District established

2.1 % of trained CORPs who deliver malaria control services in accordance with the operational guidelines 2.2 % of households who owned bednets had their nets treated 2.3 % of target population who sleep ITNs I LUNs every night during the last 7 nights prior to the survey

Salary of VBDC and BHS Staff to be involved in the project

11

Expected Result 3

*

Lessons learned and results of pi lot interventions disseminated at country and regional level, and policy recommendations for scalingup malaria control for national races available please see page II ** please see page 11

3.1 Report on the results and Icssons learned on pilot interventions for malaria prevention and control disseminated widely, including publication in the website 3.2 Draft policy recommendations by Malaria Technical Advisory Group on malaria prevention and control among national races in Myanmar - 12

3.1 Review of project report

SaiaryofVBDC and BHS Staff to be involved in the project

I

3.2 Review of proiect report

12

ACTIVITIES Main activities for Expected Result 1 1.1 Conduct series of advocacy meetings in three townships 1.2 Development of a Practical Guide on Community Empowerment for Malaria Prevention and Control (Leamer's Guide and Trainer's Guide), including the training curriculum and materials, for training VBDC and BHS staff 1.3 Development / refinement and reproduction of tools / job aids for: -effective conduct ofIEC -facilitating community needs assessment -supportive supervision and monitoring 1.4 Training workshop on community mobilization for malaria control Targets: Key VBDC staff and Basic Healtb Staff 1.5 Training workshops on community needs assessment, planning, implementation, monitoring and evaluation of community-based malaria prevention and control Targets: Key VBDC staff and Basic Health Staff 1.6 Establish computerized database at township level for decision making 1.7 Supportive supervision, monitoring and evaluation (periodic supervision of trained CORPs to re-enforce their knowledge and skills, motivate them, facilitate solving problems, etc; participate in community-based M &E 1.8 Provision of motorcycles (6 units), repair of VB DC vehicle (1), fuel and maintenance Estimated budget for Expected Result 1

Responsible VBDCandTMO VBDC and WHO

Timeline YI 2006 July June- Sept

Timeline Y2 2007 Jan - Sept

Budget (US $) ADBProj WHO 1500

14000

2000 VBDCand WHO July-Dec

2000 VBDC Sep 1500 VBDC Sep Jan- Sept VBDC and WHO Aug-Dec Jan - Sept 3000 3000

500

500

VBDC andBHS

Oct - Dec

17000

28000

17 000

13

ACTIVITIES Main activities for Expected Result 2 2.1 Community mobilization in 50 villages -initially by VBDC staff and Basic Health Staff; to be sustained by CORPs with the support by VBDC staff and Basic Health Staff 2.2 Development and reproduction of training curriculum and training materials for use in training the CORPs 2.3 Workshops for participatory development of job aids for CORPs and reproduction of the finish product 2.4 Training of CORPs (Community-owned resource persons) -Selection will be done by the villagers; to be facilitated by VBDC staff and Basic Health Staff. The CORPs could be the "primary care providers or the so called "quack doctors", drug vendors, existing Community Health Workers and Auxiliary Midwives, primary school teachers, religious leaders, etc -Training will be done by the VBDC staff and Basic Health Staff 2.5 Conununity needs assessment (15 villages) -to be done by key leaders in the target villages and to be facilitated by VBDC stafT and Basic Health Staff 2.6 Participatory planning of community-based interventions for malaria prevention and control (for 15 villages) Key interventions: (I) IEC - by the CORPs and to be re-enforced by VBDC staff and by Basic Health Staff (2) Early diagnosis using RDTs (3) Treatment according to national guidelines (ACT for Pf cases and chloroquine for RDT negative but highly suspicious of malaria) (4) Early recognition of severe cases (5) Pre-referral treatment using rectal artesunate for severe cases (6) Referral of severe cases, "treatment failures" and non-malaria cases

Responsible VBDCandBHS

Timeline YI 2006 Jul- Dec

TimeIine Y2 2007

Budget ADB Proj WHO 2000

VBDC and WHO

-

Aug

2500

VBDC, BHS, WHO

Aug - Sep

2000

I

I

VBDC,BHS, WHO

Sept -Oct

7000

I

I

I

VBDC andBHS

Sept - Nov

1500

1500

VBDC,BHS, CORPs

Nov

May& Sept

3000

2000

-~-

---

14

2.7 Provision oflogistics for implementation of community-based interventions for malaria prevention and control -ACT, RDTs, -insecticide tablets -LUNs -Training kit for BHS -Training kit for CORPs 2.8 Community meetings (for feedback, to resolve issues, establish mechanisms for sustaining the CORPs, etc), at least every 3 months -to be done by the community and to be facilitated by VBDC staff and Basic Health Staff 2.9 Establishment of community-based monitoring and evaluation system (in 15 villages) -community data board -reporting of deaths from any causes -periodic meeting at community level (frequency and agenda to be set by village health committee and by the CORPs; VBDC staff and Basic Health Staff will be "participant observers" 2.10 Expansion of community-based malaria prevention and control in other villages Estimated budget for Expected Result 2

VBDC and WHO

July-Dec

Jan- Dec

12500

10000

VBDC, TMO, CORPs

Oct - Dec

Jan - Sep

1500

VBDC, TMO CORPs

Jan - Sep

1500

1000

VBDC, TMO

May - Sept

3000 34000

2000 19000

15

ACTIVITIES Main activities for Result 3 3.1 3.2 Surveys (baseline and just before end of project) Participatory project evaluation (by community representatives, VBDC staff, BHS, and by WHO staff) and documentation Publication of comprehensive report on the project and wide dissemination within and outside the country through various channels (including websites of WHO and ACT Malaria) Presentation and discussion of the report in various fora in the country: -Malaria Technical Advisory Group meeting for possible development of policy -Malaria Technical and Strategy Group meeting to enlist their support in adopting the lessons learned to NMCP -Health Committee meetings (National, State/Division and Township levels) -Research congress -Conventions / meetings of health professional organizations (Myanmar Medical Association, Myanmar Nurses Association, Health Assistants Association) -Undergraduate and post-graduate students medical students -Meetings with partners (UNICEF, JICA, Local NGOs, INGOs, bilateral agencies)

Responsible

Timeline YI 2006

Timeline Y2 2007

Budget ADB Proj WHO

VBDC,BHS, WHO VBDC, WHO

July

July Oct

4000 2500

1000 2000

3.3

VBDC, WHO

Nov-Dec

500

1000

3.4

VBDC, WHO

Aug - Dec

1000

1000

3.5

Identify and support potential advocates for community-based malaria prevcntion and control among the national races The potential advocates could be: -VBDC staff and BHS staff who are directly involved in the project and the Community Owned Resource Persons. They should have very good communication skills and are willing to act as resource persons in disseminating the lessons learned from the project -Malaria Regional Officers and Team Leaders - they will be supported to visit the project sites by end of year 1 and will be supported (from other sources of funds) to carry out similar activities in their respective areas -The "converts" - other TMOs, State/Divisional Directors, etc, could serve as advocates. Thev will be invited to visit the project sites. Estimated budget for Expected Result 3 Estimated total budget

I

VBDC, TMOs

Aug - Dec

2000

1000 ,

-

10 000 72 000

6000 42000

16

Technical Assistance and Supervision Plan, 2006-2007

.W,

LVU()

LooO lOOt

2007 ."V'

Activities Jo Lines

Nov Dec x x 25-26

lan

Feb Mar ADr May lun

lui

Au. SeD

Oct Nov Dec

lan

Feb Mar An, Mav lUD

lui

Aug Sep

Oct

Nov Dec

Inception workshop 2nd ADC meeting and M&E traininst Technical supervision and momlorinl?: visit Mid-tenn project review and advisory conunittee meeUne: Overall project evaluation

8-17

x

x x

x

x

x

x x x

Final oroiect meetin!..and project dissemnation

Jane Bruce 2nd ADC meetin~ and M&E training M&E assistance - CAM + VlN + LAO Data analysis - 6 cOWltries Mid-tenn project review and advisory conunittee meetin!! Final project meetin£ and vroiect dissenmation

8-17 6-20

x

x x

x x

Holly Williams

2nd ADC meeting and M&E traininl!. M&E assistance· CAM + VTN + LAO Data analysis - 6 cOWltries Mid-tenn project review and advisory committee meetine

8-17 6-20

x

x x

x x x x

Overall project evaluation Finalize common reltionallEC

strate2Y

Final Droiect meetinlZ and nroiect dissemnation

Pricha Pt'dueng assist lEe, Soc-mob training and advocacy works bop to member countries, CAM. CHN, LAO, MMR., THA and VTN Mid-tenn project review and advisory conunittee meetin~ Supervision visit to member cOlUltries Country dissenunination workshoDS Finalize conunop reaionallEC strate~y final project meetin~ and PTolect dissemnation

x

x

x

x

x x

x

x

x

x

x x x x x

x

I -.(

ANNEX 8

1. PURPOSE OF MISSION

The writer visited Thailand from 4 to 21 March 2006 with the following terms of reference:

In collaboration with the national authorities: (1) to participate in and provide technical inputs for the second Advisory Committee meeting for the project, Malaria Control for Ethnic Minorities in the Greater Mekong Subregion (GMS), in Chiang Mai from 8 to 10 March 2006; and (2) to prepare and conduct training (including field training) for staff of the National Malaria-Control Programmes (NMCPs) of the six GMS countries on qualitative research methods in Chiang Mai from 13 to 17 March 2006.

2. BACKGROUND

A behaviour-change initiative for malaria control for ethnic minorities was implemented in the six countries representing the Greater Mekong Subregion from November 2002 to December 2004. This was done through funding from the Asian Development Bank (ADB) and with support from WHO. Outputs of the project included: (a) development of information, education and communication (lEC) materials and guidelines for six different ethnic minority groups; (b) enhancement ofNMCPs' capacities for community-based activities through formal

and informal training and project implementation; (c) development ofa draft regional IEC strategy for ethnic minority groups; and (d) dissemination of "lessons learnt" among GMS countries. A major output from this work was the recognition ofNMCPs that IEe materials for the national population needed to be produced in a participatory fashion and tailored to the particular ethnic minorities most at risk for malaria. Following the project described above, ADB and WHO jointly agreed in 2005 to provide technical and fmancial support to the GMS countries. This would be done through the project entitled "Strengthening Malaria Control for Ethnic Minorities in the GMS". The goal of the project is to reduce the malaria burden among poor ethnic minority groups living in malaria-prone areas in these countries. The specific objectives of this project include: (1) to build capacity of national malaria institutions to develop acceptable, affordable and effective malaria control for ethnic minorities; (2) to scale up malaria-control efforts for these populations through NMCPs; and

(3) to promote regional collaboration for malaria control. Similar challenges in malaria control exist for all the GMS countries. They include late treatment seeking and labour migration into malarious areas with insufficient prophylactic measures. They include low levels of insecticide-treated net (ITN) usage and re-treatment. They also mclude purchase of antimalarials from the private sector, often resulting in incomplete dosages of the drugs. Pilot projects designed to address these areas will be implemented and evaluated by the NMCPs, which will contribute commodities as needed. The countries will work with the ethnic groups previously identified in the first phase of the project and expand to other groups whenever feasible. The major focus of this project will be to improve NMCPs' capacities to address the malaria-control needs of ethnic communities in remote areas. A second Advisory Committee Meeting was held in Chiang Mai, Thailand from 8 to 10 March 2006. Its aims were to finalize and approve the six pilot studies, fmalize the budget for project implementation and finalize monitoring and evaluation (M&E) tools and plans. Following this, a training workshop on "Quantitative and Qualitative Assessment of the Country Pilot Intervention Studies" was conducted at the same site from I3 to 18 March 2006. Facilitators and faculty for this workshop included: Mr Pricha Petlueng, Technical Coordinator for the Project; Dr Holly Ann Williams (CDC, malaria and qualitative methods expertise); Dr 10 Lines (LSHTM, malaria expertise) and Ms Jane Bruce (LSHTM, survey-methodology expertise). Dr Williams and Ms Bruce had not been involved in the first Advisory Meeting. However, Dr Williams had served as a "special Adviser" for the first phase of the project (2002-2004).

3. ACTNITIES AND FINDINGS

3.1

Activities

During the Advisory Meeting, discussion centred on issues such as how the pilot projects would mesh with activities already planned or under way as part ofthe respective countries' workplans. This particularly concerned activities deriving from the Global Fund for AIDS, TB and Malaria (GF ATM). In essence, this project should be viewed as "added value" for those activities. It was stressed that ADB really wanted this project to assist NMCPs in adapting interventions targeted at the national population to meet the specific needs of the affected ethnic populations. Documenting "lessons learnt" will be a valuable output for future programmatic planning to ensure that these vulnerable groups continue to receive attention from the NMCPs. Additional discussion focused on the need to gather data to assist in programme management. Identifying the reasons why behaviours do not always match intervention goals (e.g. nets are distributed, but community members do not use them when going to the forest) was stressed as critically important for the project. This would serve as the background for lessons learnt. The use of participatory methods was also discussed as an important methodology that should be included in each country-level plan. Each country summarized its individual plan. All countries agreed that the budget as planned was sufficient. The following decisions were reached: (l) Lao People's Democratic Republic - approved, with the recommendation that $5500 should be added to the budget for scaling-up;

(2) Viet Nam - approved; (3) Thailand - approved, with the addition of $5500; (4) Cambodia - approved; (5) China - approved, although the proposal was incomplete as the budget needed to be re-adjusted downwards: and (6) Myanmar - approval withheld until full proposal was available, including budget, additional clarification on sample specifics and time line. Throughout the meeting, several concerns were voiced. First, given the limited funding and the timing of the project, it will be virtually impossible to demonstrate larger outcome indicators such as impact on malaria-related morbidity and mortality. The project should be seen as successful if the outcome of the pilot study increases NMCPs' sensitivity to and interest in underserved, vulnerable ethnic populations. It will be not be possible to conduct a proper analysis of cost-effectiveness of the various interventions. Capacity is sorely limited in this area and there are insufficient resources to carry out this activity. At best, the teams may be able to provide actual costing figures that will be useful from a programmatic perspective. The country-level teams will need technical assistance throughout the process. This will involve limiting projects to a few interventions that are manageable, and assisting with proposal development (particularly stressing the need to use data already collected in the first phase of the project and not waste resources collecting information that was recently collected). Technical assistance will also be needed for refining the most appropriate M&E indicators, analysing data, and particularly for writing up the results of the data in a manner that policy-makers can comprehend. Joint country visits were recommended as a way to build capacity. The writer was not involved in the first Advisory Committee Meeting (neither was Ms Bruce). Hence it was initially difficult to comment on the progress of the country-level teams, not having a good understanding of the background for this phase. Also, the second project has shifted from the IEC and advocacy focus of the first project to a much broader intervention focus. It is suggested that in future endeavours, participating partners should be included from the first Advisory Committee onwards. Following the meeting, a training workshop was held to build capacity in both qualitative and quantitative methods for M&E activities. Content covered in this workshop (not in the order presented during the course) and the faculty who taught it are described below: (a) Applying Lessons Learnt from ADB IEC Project (H. Williams) (b) M&E: Introduction (H. Williams) (c) Development of an M&E Plan (H. Williams) (d) Introduction to Survey Design and Sampling (J. Bruce) (e) Introduction to Questionnaire Design and Interviewing (J. Bruce) (f) Overview of Data Processing and Analysis for Survey Data (J. Bruce) (g) Qualitative Data Analysis: Overview (H. Williams)

(h) Analysis of Qualitative Data (H. Williams) (i) Contextual Factors (H. Williams) (j) Translating Findings to Policy (H. Williams)

A PowerPoint presentation on Economic Evaluation was prepared by Dr Eve Worrall (LSHTM), but the technical detail was too advanced to be appropriate for the course. Dr J 0 Lines summarized the infonnation briefly for the participants. Due to lack oftime on the last day of the workshop, a PowerPoint presentation on Presentation Guidelines was given to the participants as a hand-out, rather than an oral presentation. Participants engaged in several interactive exercises during the week. Drs Williams and Lines developed a class exercise using case examples of ITN coverage and treatment seeking. The participants worked in groups to list behaviours that might influence these activities. A hand-out listing their responses was developed that helped the participants to group the potential reasons for failures of interventions into various contextual areas. These included socio-behavioural, programme-management, economic, logistic and environmental areas. Ms Bruce offered a classroom exercise on selecting village samples. Participants also had classroom practice in conducting focus group discussions. Hand-outs developed for the course included: (I) Suggested Conceptual Framework for M&E; (2) Developing a Qualitative Interview Guide; (3) Role-Playing for Focus Group Discussions; (4) Guiding Principles for Participatory M&E; (5) Maternal and Child Health (MCH) Household Survey Protocol (example from Mozambique); (6) Draft Indicator List; (7) Survey Interviewer Manual (example from Cambodia); (8) Random Number Table; (9) Sample Size for Cluster Surveys; (10) Instructions for Sampling Exercise in the Village; and (11) Sampling Exercise - Census for Village A. Attention was also given to developing code books for variables that would be used in the baseline and M&E surveys. However, most country-level teams struggled with the concept of a code book and how one would be used. Field training was provided during one day at a nearby Karen village. Participants mitially practised selecting a sample from village households, then split into groups to go to the homes to practise conducting a household survey. After concentrating on quantitative methods, they switched to qualitative and practised conducting focus group discussions. After the various field exercises, time was spent debriefing with the participants as a whole group. This was aimed at

helping them identify what went well, where they might need additional practice and how to apply the methods in their home settings. Workshop time was also devoted to refining country-level M&E plans and budgets. While the country-level teams produced an initial plan, it was anticipated that adjustments would occur to some degree once the teams returned home. Initial household-survey protocols and qualitative field guides were in the first stages of development by the end of the week. Modifications were expected to be made based on feedback from the facilitators. The expectation was that the teams would send their edited plans and instruments to faculty for continued review as required.

4. CONCLUSIONS AND RECOMMENDATIONS

4.1

Conclusions

Throughout the workshop, all country-level teams worked hard to refine their plans and to learn new concepts. Despite the pressure to try to comprehend new material that might have traditionally been taught over a much longer period oftime, the participants were enthusiastic and engaged in the process during the entire workshop. The faculty had indicated that the projects would probably incorporate participatory approaches. However, little consideration was given to this in terms of linking decisions made in the Advisory Committee meeting with the workshop that followed. It would have been helpful to have had the workshop participants observe the meeting. This would have allowed them to observe directly the discussions that helped to frame the country-level expectations for the project. Furthermore, given the short period oftime for the workshop, it was impossible to incorporate participatory techniques into the field practice. Many of the participants had little or no experience of designing M&E plans, and some team members were even new to malaria. One major constraint for the workshop was that the expectations for the material to be covered in less than six days were unrealistic, given the teams' lack of capacity for this particular type of work. The broad topics presented (survey and qualitative methodology, principles ofM&E) are generally taught over a longer period of time. They should have involved multiple practice sessions in different settings. The economic analysis could not be presented effectively as the content was technically difficult. Moreover, few participants had any background in these areas, and the faculty present did not have an economic background. Again, for that topic alone, many days would have been needed to present even a cursory introduction that would make sense to the participants. Overall, there was simply insufficient time to present the material in a well coordinated, logical fashion that would include adequate practice opportunities using an array of methods. The faculty perceived a high level of fatigue by the time of the workshop conclusion. A disconnection between the first project (process and results) and this project was evident. The lack of a smooth transition between projects could be accounted for by several factors: (a) some countries had chosen different sites and now needed to collect similar baseline data that should have been collected in Phase I; and (b) some countries had selected different team members for this project, which resulted in a lack of historical memory and experience.

Because of these factors, participants struggled with recognizing what had already been accomplished in Phase 1. This included specific lessons learnt, and how they could use those findings to inform the design of the second project. Identifying realistic indicators was problematic for most teams. They consistently wanted to apply quantitative indicators to qualitative work, which was not appropriate in many cases. In spite of many of the participants having some level of qualitative experience, they found it exceedingly difficult to: (a) identify why they were asking specific questions (what it was that they were actually trying to measure or describe); (b) develop qualitative code books to guide their work; (c) broaden their thinking to develop proxy measures for qualitative indicators; (d) create probes for gathering information in different ways; (e) link individual qualitative questions to their overall goals; and (f) envision how the qualitative data could be used to inform the development of the quantitative survey instruments or to validate information obtained from the household surveys. The teams will need some support (perhaps ADB or WHO's Western Pacific Regional Office staff could help) with templates for costing. There was insufficient time to develop such a guide and to practise use of the guide. They will need to identify a budget person within the NMCP who can show them how to gather such data and how to monitor expenditures over time. There was no discussion on human subject approvals, other than informally having the topic discussed by Dr Williams. It appeared that the teams had not given any consideration to differentiating gathering baseline data (i.e. operational research) from programmatic evaluation. This is a discussion that perhaps needed to occur during the Advisory Committee meeting, but, given that that did not occur, is one that should be considered as the project moves forward. Lastly, the teams will need continued technical assistance. The faculty suggests that, whenever possible, site visits need to be conducted by the facilitators who combine assistance in both quantitative and qualitative methods. Without linking them, the country-level teams run the risk of perceiving these methodologies as quite separate processes. They would thus fail to see how data from one method can be used to inform or verify another method (triangulation of data). Most teams identified that they would need e-mail support for qualitative and survey methods as they designed their instruments. They requested field support during analysis of the data. It is also suggested that a workshop should be held midway through the project to assess where the teams are in the process of project implementation and review concepts of M&E. Conducting such a workshop midway through the project will help them address problematic challenges and make adjustments as needed. It will also help them to track their status so as to ensure that they can meet their projected goals. 4.2 Recommendations

(1) At least one country-level team representative should be included in all future meetings of the Advisory Committee.

(2) Participatory approaches should be emphasized throughout the planning and implementation of the country projects. This can be done by utilizing the Project Manager (Khun Pricha) for technical assistance in developing and applying participatory approaches. (3) Economic analyses should be scaled back to include only costing data. The Advisory Committee should collaborate with country-level economists, Ministry of Finance personnel or others with economic-analysis expertise to develop an easy-to-use guide for costing. (4) The Committee should work closely with the technical consultants provided by WHO (Drs Williams and Lines, Ms Bruce) to finalize plans and analyse data. (5) Funds should be set aside for a mid-project regional workshop (each country could contribute a share of the costs). The workshop would be used to assess the status of the respective country projects, to refine methods as needed, and to review concepts of monitoring and evaluation. (6) The Committee should detennine whether any of the baseline data-collection or M&E activities need to be reviewed by a human subjects review board. There could be a link to the Ministry of Health or to a local university review board if needed. Proposals should be submitted for review as quickly as possible.

5. ACKNOWLEDGEMENTS

The writer wishes to acknowledge the efforts of the following collaborators: Dr Jo Lines, Dr Eve Worali, Ms Jane Bruce, Dr Peter Bloland, Ms Jayne Webster and NMCP personnel for their support.

Project Implementation Plan and Timefiame, Nov 2005 - Dec 2007 Activities

2005 2006 Nov Dec Jan Feb

Mar

Apr May

Jon

Jul

Au<

SeD

2006 2007 Oct Nov Dec Jan Feb

Mar AN May

Jon

Jul

A1tJl

Sep

Oct

2007 Noy Dec

Proiect inccDtion 1st ADC meetin~ and Pro' eet Incep!ion workshop P~ct inception ~ort 2nd ADC meetiq Finalizing M&E plan and tool

x 25·26

x x 8-10

x

x 13-17

Training workshop for qualitative M&E baseline data collection M&E baseline data collection M&E evaluation for intervention Analvsis of field data collection Technical supervision and assistance Mid-tenn project review and advisory committee meeting Overall project evaluation Fianl ADC meeting and dissemination workshop Finalize common regional lEe strategy Proposal for Scaling Up Malaria Control for EMGs Proposal for Rel!;ional Coordination for Malaria Control ControllntenentioD

x x

x x

x x

x x

x x x x

x

x x

x

x

x x x x x x x x x x

Reivew of malaria control nro2rutU11e for ethnic minority Establish field sites for intervention community mobilization Identifv and reoroduce lEC packues for ethnic minority lU'OUDS Conduct baseline survey on malaria Drevalence Trainine workshop comnllmitv-based malaria c~!11Pai2l1 Refresh training workshQQ_cornrn-based Mal campai~_ Commwlity-based malaria carnpaig;D - conununity mobilization scale-up intervention, country level Field monitorine: and supervision Conduct midtenn intervention M&E + malaria prevalence National workshop to' review Droiect intervention Conduct post-intervention evaluatiO'n includin2 malaria prevalence Conduct overall evaluation ofr pilot intervention National dissimination wO'rkshop

x x x x x

x x x x x x x x

x x x

x x x

x

x x

x

x x

x x x

x

x

I '"

________

~~

•• ~ ..........

a...u .... " ........ u.

HI~"

III

1."1;' '-l'U.l~ J

IUJI[:\.l UUUgt:L rl;tll

Field Intervention Rt"g:ionalllntercounlTies Website development M&E training, March 2006 Inception 2nd Advisory committee meeting Project mid-tenn review Final project and advocacy meeting Office communications GMS member countries

Tmining, Capacity Building

Surveys, Studies, M&E

Reports and Communications

Equipment

National Technical Support

Contingency fund - country intervention

Regional meetings and advocacy

Technical support

Total country grants for project Year 1 country implementation grants requested Grand Total

3000 13,250 6,470 15,000 15,000 18,030 1,900

Cambodia China-Yunnan Lao PDR Myanmar Thailand Vietnam Scaling up intervention

20,000 20,000 20,000 36,200 15,000 20,000

5,000 5,000 5,000 5,000 4,750 5,000 5,000 5,000 5,000 5,000 4,000 5,000

9,500 9,500 9,500 9,500 9,500 9,500

500 500 500 500 500 500 500 500 SOD

1,500 1,500 1,500 1,500 1,500 1,500

4,500 4,500 4,500 4,500 4,500 4,500

9,700 10,000

Cambodia China· Yunnan LaoPDR Myanmar Thailand Vietnam Technical support Pricha Petlueng, Project Coordinator Duty travel for Project Coordinator Jo Lines. Malaria Expert Assistant Project Coorinator National assi~tance Programme support cost Total 131,100

500 500 500

46,500 56,200 46,500 72,700 40,250 46,500

20,159 38,602 35,100 30,000 27,245

181,500 11,000 67,600 13,300 9,000 B6,3oo

72,000

57,000

9,000

10,900

27,000

19,700

54,500

368,700

750,000

Note: Summary of total country implemenation funds: Cambodia 46,500 China-YUlman 56,200 Lao PDR 46,500 Myanmar 72,700 Thailand 40,250 Vietnam 46,500

I o

GMSCOUNTRY Cambodia

China

Lao PDR

NMCP Directors Dr Duong Socheat Director, National Center for Parasitology Entomology and Malaria Control Program, Ministry of Health No. 372 Monivong Boulevard Phnom Penh Tel. ++ 8552336241; Fax: ++ 855 23996202 Mobile ph: ++ 85516811 950. Email: socheatd(lilcnm.gov.kh Prof. Tang Linhua Director, National Institute of Parasitic Diseases - Chinese Center for Disease Control and Prevention 207 Rui Jin Er Lu Shanghai 200025 Tel. No.: ++ 86 2164373359; Fax: ++ 86 2164332670; E-mail: jpdtlh@public3.sta.net.cn Dr Samlane Phompida Director, Centre for Malariology, Parasitology and Entomology Ministry of Public Health Vientiane Tel. No. ++ 856 21 214040/252673; Fax: ++ 856 21218131 Mobile Phone: ++ 856 20 522251 E-mail: p.samlane@gmail.com

National Focal Persons Ms Dr Buakheng Thavrin CNM thavrinb@cnm.gov.kh

National Technical Persons Dr Suon Pov

WHO Country Staff Dr lunko Yasuoka yasuokaj@cam.wpro.who.int Dr Chang Moh Seng Changm@cam.wpro.who.int

Dr Abdur Rashid rashid@cam.wpro.who.int

,

Mr Xu lianwei YIPD, Yunnan xjw426@163.com

Ms Dr Francette Dusan DusanF@chn.wpro.who.int I

Ms Dr Soudsady Udonsuk CMPE osoudsady@yahoo.com

Dr Bounphone Sydavong CMPE

Dr Deyer Gopinath gopinathd@lao.wpro.who.int

I

Myanmar

Thailand

VietNam

-"

Dr Saw Lwin Director of Bureau of Vector Borne Diseases Department of Health 27 Pyidaungsu Yolktha Road. Dagon, PO Box 11191 Yangon Tel: ++ 95 I 640031 Fax: ++ 95 1 212604 Email: myanvbdc(almptmail.net.mm Dr Chaiporn Rojanawatsirivej Director, Bureau of Vector Borne Diseases Department of Communicable Disease Control, MOH Tiwanon Road Nonthaburi 11000 Tel: ++662448580 Fax: ++66 2 5918422 Email: chaiporn(a)heaith.moph.go.th Dr Trieu Nguyen Trung Director, Institute of Malariology, Parasitology and Entomology 611 B Nguyen Thai Hoc Street, Qui Nhon City Binh Dinh Province Tel. No. 84.056.847725; Fax: 84.056.647921 E-mail: trieutrung(a)dng.vnn.vn

Dr. Win Naing Assistant director Central VBDC

Dr. Myat Kyaw Team leader VBDC project Tachilek Eastern Shan State

Dr Leonard Ortega ortegal.whomm@undp.org

Ms Kesanee Kladphuang VBDC,MOH keskla@health.moph.go.th

Ms Piyaporn Wangroongsarb VBDC,MOH

Dr Chawalit Tantinimitkul chawalit@whothai.org Mekong RBM Coordinator

Dr Trung Van Co IMPE Quy Nhon ipeqn@dng.vnn.vn

Dr Ho Van Hoang IMPE Quy Nhon ipeqn@dng.vnn.vn Dr.Tran Van Tien District health centre of Khanh Vinh KIlanh Hoa province

Dr Tran Cong Dai dait@vtn.wpro.who.i

Project Personnel/Consultants Mr Pricha Petlueng Team Leader/Social Scientist WHO Vientiane, Lao PDR petluengp@lao.wpro.who.int

Dr Jo Lines Malaria Expert London School of Hygiene and Tropical Medicine, UK jo.lines@lshtm.ac.uk Dr Holly Williams Medical Anthropologist CDC Atlanta, USA hbw2@cdc.gov Ms Jane Bruce Statistics, Survey Methodology London School of Hygiene and Tropical Medicine, UK Jane.Bruce(Q?lshtm.ac.uk

WHOWPR Dr Kevin Palmer Regional Advisor Malaria Vectorbome and Parasitic Diseases, Manila Regional Office, Philippines palmerk@wpro.who.int Dr Eva Christophel Medical Officer, MVP Manila, Philippines christophele@wpro.who.int

WHO SEAR Dr Krongthong Thimasam Regional Advisor Malaria New Delhi Regional Office, India thimasarnk@WHOSEA.ORG N.N. Mekong RBM Coordinator Bangkok, Thailand

ADB Dr Barbara Lochmann Social Development Specialist Mekong Department, Manila blochmann@adb.org

Dr Vincent de Wit Senior Health Specialist Mekong Department, Manila vdewit@adb.org

-

PrOject Costing Tables PLANNED Recurrent Personnel Supplies Operating costs of: - - vehicles equipment Buildings Other operating expenditures Capital Vehicles Equipment Buildings Total ~---

CONTRIBUTOR I - E.G. MINISTRY YEAR I Foreign local currency exchange YEAR 2 local Foreign currency exchange

CONTRIBUTOR 2 - E.G. LOCAL UNIT YEAR I Foreign local exchange currency YEAR 2 Foreign local exchange currency

CONTRIBUTOR 3

Etc ETC

-

-

I N

ACTUAL

CONTRIBUTOR 1 - E.G. MINISTRY YEAR 1 Foreign local exchange currency YEAR 2 Foreign local exchange currency

CONTRIBUTOR 2 - E.G. LOCAL UNIT YEARl Foreign local exchange currency YEAR 2 Foreign local exchange currency

CONTRIBUTOR 3 Etc ETC

Recurrent Personnel Supplies Operating costs of:

- - vehicles equipment Buildings Other operating expenditures Capital Vehicles Equipment Buildings Total - -

--

Planning Management Supervision Actual Planned Recurrent Personnel Supplies Operating costs of: - vehicles equipment Buildings Other operating expenditures Capital Vehicles Equipment Buildings Total -~

Training Planned Actual

Transport Planned Actual Planned

Etc Actual

Etc

_

.. -

- -

-

-'--

-

---~

L- _ _

-