National Strategy for Malaria Elimination in Cambodia. Ministry of Health National Centre for Parasitology, Entomology and Malaria Control (CNM)

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1 National Strategy for Malaria Elimination in Cambodia ( ) 2025) Ministry of Health National Centre for Parasitology, Entomology and Malaria Control (CNM)

2 Contents Recommendation of Samdech Prime Minister Hun Sen Vision, Mission, Long Term Strategies, Goals, Strategic objectives and Strategic Activities Budget Estimation i Monitoring and Evaluation Partners Conditions required Post 2025 Scenario

3 Let our people not suffer from the scourge of Malaria any more. Please prepare and implement a plan to wipe out the disease from our country Samdech Hun Sen, Prime Minister, Cambodia (while speaking on the occasion of the inauguration of the new building of the Referral Hospital, Kampong Cham Province on 20 January 2011)

4 V I S I O N Our long-term vision is of a Cambodia totally free from the burden of malaria.

5 NMCP s LONG TERM STRATEGY FOR MALARIA ELIMINATION

Strategy for Growth, Employment, Equity and Efficiency (RS) The Millennium i Development Goals (MDG) The RBM

6 Strategic Fit with National & Global Commitments Poverty Reduction Strategy Papers (PRSP) National Strategic Development Plan (NSDP) Malaria Health Sector Strategic Plan (HSP2) Elimination The Rectangular Strategy for Growth, Employment, Equity and Efficiency (RS) The Millennium i Development Goals (MDG) The RBM Strategic Plan ( ) 2015) The WHA resolution (1977) on primary health care The Global Malaria Action Plan (Aug. 2008)

G O A L Short Term (by 2015) To move towards pre-elimination of malaria across Cambodia with special efforts to contain artemisinin i i resistant t P.falciparum Pf malaria.

7 G O A L Short Term (by 2015) To move towards pre-elimination of malaria across Cambodia with special efforts to contain artemisinin i i resistant t P.falciparum Pf malaria. Medium Term (by 2020) To move towards elimination of malaria across Cambodia with an initial focus on P.falciparum malaria and ensure zero deaths from malaria. Long-Term (by 2025) Long Term (by 2025) To achieve phased elimination of all forms of malaria in Cambodia.

8 S T R A T E G I C O B J E C T I V E S 1. To ensure universal access to early malaria diagnosis and treatment services with an emphasis on detection of all malaria cases (incl. among mobile/ migrant populations) and ensure effective treatment t t including clearance of P. falciparum gametocytes and dormant liver stage of P. vivax. 2. To halt drug pressure for selection of artemisinin resistant malaria parasites by improving access to appropriate treatment and preventing use of monotherapies and substandard drugs in both public and private sectors. 3. To ensure universal access to preventive measures and specifically prevent transmission of artemisinin resistant malaria parasites among target populations (including mobile/migrant populations) p by mosquito control, personal protection and environmental manipulation. 4. To ensure universal community awareness and behavior change among the population at risk and support the containment of artemisinin resistant parasites and eliminate all forms of malaria through comprehensive behavior change communication (BCC), community mobilization, and advocacy. 5. To provide effective management (including information systems and surveillance) and coordination to enable rapid and high quality implementation of the elimination strategy.

9 Sequential Elimination i of Malaria in Cambodia Deaths Plasmodium Falciparum Plasmodium Vivax The first priority will be to achieve 0 mortality from malaria while at the same time eliminating The first priority will be to achieve 0 mortality from malaria while at the same time eliminating falciparum malaria, the more severe form (by 2020) followed by vivax malaria (by 2025)

10 Malaria incidence of confirmed case by Operational District in Cambodia 2010 N Samrong Thmar Puok Preah Net Preah Kralanh Uo Chrov Siem Reap Mongkol Borei Ankor Chum Preah Vihear Steung Treng Rattanakiri Thmor Koul Sang Kae Sotr Nikum Pailin Ville Battam Bang Bakan Mong Russey Sampov Meas Smach Meanchey Srae Ambel Stong Boribo Kampong Thom Baray and Santuk Kroch Chhmar Chamkar Leu Kratie Kampong Chhnang Kampong Cham Chhlong Tbong Khmum Kampong Tralach Prey Chhor Ponhea Krek O Reang Ov Memut Oudong Ang Snuol Kampong Speu. Chhouk Kong Pisey Ang Rokar Kampot Kirivong Sihanouk Ville Kampong Trach Kilometers Kep Ville Sen Monorom Tonle Sap & Mekong River Pf Elimination by OD No transmission

11 Proposed Malaria Elimination by Operational District in Cambodia ( ) N Samrong Thmar Puok Preah Net Preah Uo Chrov Ankor Chum Siem Reap Preah Vihear Steung Treng Rattanakiri Thmor Koul Sampov Luon Sang Kae Sotr Nikum Stong Pailin Ville Battam Bang Mong Russey Bakan Kampong Thom Baray and Santuk Kratie Sen Monorom Sampov Meas Boribo Kampong Chhnang Chhlong Smach Meanchey Kampong Tralach Memut Srae Ambel Sihanouk Ville Kampong Speu. Chhouk Kong Pisey Kirivong Kilometers Tonle Sap & Mekong River Elimination by OD No transmission

12 Proposed Pf Malaria Elimination by Operational District in Cambodia ( ) N Samrong Thmar Puok Preah Net Preah Kralanh Uo Chrov Siem Reap Mongkol Borei Ankor Chum Preah Vihear Steung Treng Rattanakiri Thmor Koul Sang Kae Sotr Nikum Pailin Ville Battam Bang Bakan Mong Russey Sampov Meas Smach Meanchey Srae Ambel Stong Boribo Kampong Thom Baray and Santuk Kroch Chhmar Chamkar Leu Kratie Kampong Chhnang Kampong Cham Chhlong Tbong Khmum Kampong Tralach Prey Chhor Ponhea Krek O Reang Ov Memut Oudong Ang Snuol Kampong Speu. Chhouk Kong Pisey Ang Rokar Kampot Kirivong Sihanouk Ville Kampong Trach Kilometers Kep Ville Sen Monorom Tonle Sap & Mekong River Pf Elimination by OD No transmission

13 Proposed Pv Malaria Elimination by Operational District in Cambodia ( ) 2025) N Samrong Thmar Puok Preah Net Preah Kralanh Uo Chrov Siem Reap Mongkol Borei Ankor Chum Preah Vihear Steung Treng Rattanakiri Thmor Koul Sang Kae Sotr Nikum Stong Kampong Thom Pailin Ville Kratie Battam Bang Bakan Mong Russey Baray and Santuk Sen Monorom Kroch Chhmar Sampov Meas Boribo Chamkar Leu Kampong Chhnang Kampong Cham Tbong Khmum Chhlong Kampong Tralach Prey Chhor Ponhea Krek Memut Oudong Ponhea Leu Smach Meanchey Kampong Speu. Srae Ambel Chhouk Kampot Kirivong Sihanouk Ville Kampong Trach Kilometers Kep Ville Tonle Sap & Mekong River Pv Elimination by OD No transmission

14 Key Strategic Targets for Elimination ofmalaria in Cambodia Impact indicators Baseline Value Year Source Preelimination Pf Total Elimination Elimination by 2015 by 2020 by 2025 Malaria mortality rate: Annual malaria deaths per100,000 mid-year population reported in public health facilities HIS Malaria Incidence: Annual malaria cases per 1000 mid-year population HIS reported in public health facilities. Percentage of households at risk of malaria living in the targeted villages with at least one C b di insecticide- treated net (LLIN/ conventional treated net) and/or sprayed by IRS in the last 12 months 42.6% 2007 Malaria Survey Number and percentage of health facilities with no reported stockouts of nationally recommended antimalarial i l drugs (ACTs) lasting more than 1 week at any time during past 3 months. Cambodia Cambodia 95% 95% 95% 61.5% 2007 Malaria 75% 95% 10 Survey

15 Past and Predicted Malaria Mortality Trends in Cambodia ( ) Trend of Malaria Mortality (Confirmed & Unconfirmed) Trends from 1997 to 2020 (MDG) 8 Number of dea ath per 100,000 0 population/ye ear Recorded deaths/100,000 population p (HIS) Death/100,000 population trend with a slope of yearly reduction (projection with data)

Strategic Actions Routine G6PD testing Free diagnosis & treatment in all sectors Objective 1: To ensure universal access to early malaria

elimination of all forms of malaria in Cambodia Routine expert microscopy Confirmation of all malaria cases by quality malaria microscopy

information system Strict enforcement of Laws and Regulations Comprehensive scale up of VMW initiative Management of importation of parasites,

Mobilization Full cooperation of private sector Objective 2: To halt drug pressure for selection of artemisinin resistant malaria parasites by

16 Strategic Actions Routine G6PD testing Free diagnosis & treatment in all sectors Objective 1: To ensure universal access to early malaria diagnosis and treatment services with an emphasis on detection of all malaria cases and ensure effective treatment Goal To achieve phased elimination of all forms of malaria in Cambodia Routine expert microscopy Confirmation of all malaria cases by quality malaria microscopy Management of malaria foci Case notification Routine Genotyping Active case detection Case investigation and classification Strong malaria information system Strict enforcement of Laws and Regulations Comprehensive scale up of VMW initiative Management of importation of parasites, including intercountry coordination Piloting and scaling up of MDA/FSAT Advocacy Communication & Prevention of malaria in travelers Social Mobilization Full cooperation of private sector Objective 2: To halt drug pressure for selection of artemisinin resistant malaria parasites by improving access to appropriate treatment and preventing use of monotherapies and substandard drugs in both public and private sectors. Implementation of new drug policy

17 Strategic Actions (contd.) Monitoring and researches Geographical reconnaissance Total coverage by ITNs Prevention of malaria in travelers Focal IRS following active case investigation Formative research and BBC monitoring Intersectoral Coordination and Collaboration Monitoring and Evaluation on the strategy Useof multi mediamedia platform for BCC Objective 3: To ensure universal Goal access to preventive measures; To achieve phased specifically mosquito control, elimination of all personal protection and forms of malaria in environmental manipulation. Cambodia BCC Campaigns (e.g World Malaria Day) Advocacy, Communication & Social Mobilization Ensure availability of trained staff Objective 4: To ensure universal community awareness and behavior change among the population at risk and eliminate all forms of malaria through comprehensive behavior change communication (BCC), community mobilization, and advocacy. Increasingly gy strong general health services Strong malaria information system Intersectoral Coordination and Collaboration Objective 5: To provide effective management (including information systems and surveillance) and coordination to enable rapid and high quality implementation o the elimination strategy Special motivation of staff

18 Malaria Intervention Packages O N t 15 Y Over Next 15 Years Malaria Intervention Packages Vector Control and Malaria Prevention Case Management Behaviour Change Communication (BCC) Artemisinin Resistance Containment and Elimination Research & Surveillance Program Management

19 Summary Budget by Cost Category Cost Category Total cost of Elimination Strategy (US $) Total Committed Budget ( )(US $) Total Budget Gap ( ) (US $) 1.Human Resources 65,183,350 18,797,015 46,386,334 2.Training 43,809,300 12,633,350 31,175,950 3.Health Products and Health Equipment 178,542,288 4.Pharmaceutical Products (Medicines) 100,375,966 5.Procurement and Supply Management Costs (PSM) 94,359,327 48,345, ,196,854 5,807,584 94,568,382 5,459,472 88,899,855 6.Infrastructure and Other Equipment 12,945,471 3,086,848 9,858,622 7.Communication Materials 46,160,471 7,312,550 38,847,921 8.Monitoring and Evaluation (M&E) 130,210,742 11,322, ,888,069 9.Living Support to Clients/Target Population 13,443,842 4,026,911 9,416, Planning and Administration 14,266,156 3,401,766 10,864, Overheads 35,565,673 5,871,452 29,694, Other 20,456,302 5,675,188 14,781,114 TOTAL 755,318, ,740, ,578,643

20 Monitoring and Evaluation of the Strategic t Plan Monitoring & Evaluation Framework Routine Monitoring & Supervision Health Information System (HIS), Malaria Information System (MIS) & Community Surveillance Data Visits Cambodia y Malaria Surveys (once in 2 years)

21 M&E Framework for Malaria Elimination Strategy Indicator Base TARGETS -line Malaria mortality rate: Annual probable and confirmed malaria deaths per100,000 mid-year population reported in public health facilities Annual Malaria Incidence Annual confirmed malaria cases per 1000 mid-year population reported in public health facilities # of ODs (out of a total of 43 endemic districts) that reach pre-elimination status (<5% side/rdt positivity rate or <1/1000 incidence rate of confirmed malaria, all species, among the midyear OD population) at public health facilities % 10 23% 12 27% 14 32% 18 42% 24 56% 31 72% 38 88% 41 95% # of ODs (out of a total of 43 endemic districts) that reach elimination status (0 incidence rate of confirmed malaria) at public health facilities % 9 21% 12 27% 14 32% 16 38% % 31 72% 38 88% 41 95% Proportion of Falciparum, Vivax and other types of Malaria among confirmed malaria cases treated in public health facilities PF= 7 PV= 25% 5% PF=6 3% PV=3 7% PF= 57% PV= 35% 8% PF=5 1% PV=4 9% PF=4 5% PV=4 5% 1 PF=3 9% PV=5 11% PF=3 PV=5 8% 12% PF= 21% PV= 66% 13% PF= 12% PV=7 6% 12% PF=3 % PV=8 6% 11% PF= PV= 9 1 PF= PV= 9 1 PF= PV= 9 1 PF= PV=90 % 1 PF= PV= 9 1 PF= PV=

22 M&E Framework for Malaria Elimination Strategy Indicator Base TARGETS -line Percentage of households at risk of malaria living in the targeted villages with at least one insecticidetreated net (LLIN/ conventional treated net) and/or sprayed by IRS in the last 12 months Percentage of population at risk of malaria living in the targeted villages who slept under an insecticidetreated net (LLIHN/ LLIN/ conventional treated net) during the previous night % of people in the target areas with fever in the last two weeks who received antimalaria treatment according to national policy within 24 hrs of the onset of fever. NA 85% 95% 95% 95% 95% 95% 95% NA 7 85% 9 95% 95% 95% 95% NA % 9 95% 95% 95% # and % of Health facilities with microscopy and/or rapid diagnostic testing capability NA 8 85% % 100 % 100 % 100 % # and % of Health facilities with no reported stock-outs of nationally recommended ACTs lasting more than 1 week at any time during past 3 months. NA 7 75% 9 95% 95% 100 % 100 %

Partners for Elimination of Malaria in Cambodia MoH (CNM, DDF, CMS, NCHP, PHD, OD, RH, HC/HP, ) MoI, MoND, MoEYS, MoWA, MoEF, Ministry of Information, Ministry of Labor and Vocational trainings, i

Cambodian Red Cross Provincial and District Authorities and Local Communities World Health Organization NGOs: Population Services International (PSI), Health Unlimited (HU), Partners for

23 Partners for Elimination of Malaria in Cambodia MoH (CNM, DDF, CMS, NCHP, PHD, OD, RH, HC/HP, ) MoI, MoND, MoEYS, MoWA, MoEF, Ministry of Information, Ministry of Labor and Vocational trainings, i Ministry i of Rural development, Ministry i of Agriculture, Ministry of Environment, Ministry of Industry,. Cambodian Red Cross Provincial and District Authorities and Local Communities World Health Organization NGOs: Population Services International (PSI), Health Unlimited (HU), Partners for Development (PFD), Malaria Consortium (MC), University Research Co. (URC), Family Health International (FHI), BBC World Trust. AMDA, Women s Media Center (WMC) and Institute Pasteur-Cambodia (IPC), etc. Other government institutions and development partners would be more included if required.

24 CONDITIONS REQUIREDFOR MALARIA ELIMINATION REQUIREMENT CAMBODIA s CURRENT WHAT NEEDS TO BE DONE IN THE NEXT 15 STATUS YEARS Political and financial stability Cambodia is relatively politically and financially stable Cambodia continues to make further strides in achieving financial stability and socio-economic development Clearly articulated political will Prime Minister s s pro-active interest Advocacy efforts should be directed towards sustaining to embark on such a political interest and will. programme Operational maturity and efficacy of malaria control NMCP is one of the oldest national health programs in Cambodia Elimination efforts should commence with a technical, operational and financial (including cost-effectiveness) feasibility study. Well developed health care infrastructure throughout the operational area Successful implementation of full coverage by epidemiological surveillance Availability of an efficient technical infrastructure for all parts of the operations Health Sector Reform ongoingconsiderable progress made, challenges remain Epidemiological surveillance only recently rolled out Malaria Supervisors in position in PHDs and ODs. However, no entomological teams at provincial level MoH to ensure that the operational districts targeted for malaria elimination during the initial phases are accorded priority for expansion of physical infrastructure and human resource development. # and geographical spread of sentinel sites should be expanded. Further rapid scaling up of Day 3 (and if required Day 7 & Day 21) positive surveillance & active case investigations Resources will need to be mobilized to set up entomological teams at provincial level and malaria drug depots/malaria posts in villages located at > 5kms from P.H. facilities Relatively l modest migration Very high h levels l of migration and All efforts will need to be made to track all incoming i between areas of high and low mobility have characterised population migrants/mobile population groups in endemic areas and malaria endemicity dynamics in Cambodia in recent years provide them with LLINs/LLIHNs, EDAT and BCC. Programme discipline Monitoring, supervision and auditing being strengthened at all levels Micro planning at OD level should be rapidly scaled up to ensure total decentralization and deconcentration of malaria activities. Monitoring, supervision and internal auditing should be further strengthened. Strong advocacy from provincial governors and district governors and other local authorities to be ensured.

malaria Vigilance through general health services Perfect case detection,

Integration of malaria programme staff into other vector control & health

25 Post-2025 Scenario 1. Prevent Reintroduction of Malaria Prevention and management of imported malaria Vigilance through general health services Perfect case detection, investigation Maintenance of central nucleus of malaria expertise Integration of malaria programme staff into other vector control & health programmes Vector control to reduce receptivity in vulnerable areas Outbreak control 2. Seek and obtain WHO certification of malaria elimination

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Expression of Interest (EoI)

Expression of Interest (EoI) Subject: EOI to Collect Data for the Thailand Malaria Knowledge, Attitudes and Practices (KAP) Survey 2014 1. You are requested to submit an Expression of Interest to collect