Attachment_J.6_MEAF.pdf

Attachment J.6

The Malaria Elimination Action Framework (MEAF) for 2016-2020

Kingdom of Cambodia

Ministry of Health

(DRAFT: October 5, 2015)

National Centre for Parasitology, Entomology and Malaria Control Page 2

PREFACE

Cambodia has significantly reduced malaria morbidity and mortality over the last 10 years and is on the path for elimination as laid out in the National Strategic Plan for Elimination of Malaria in the Kingdom of Cambodia, 2011‐2025, which was endorsed by Samdech Akka Moha Sena Padei Hun Sen, Prime Minister of the Kingdom of Cambodia. The Malaria Elimination Action Framework (2016‐ 2020) is an amendment to the original strategy and reflects new strategic updates based on changes in the country’s epidemiological and programmatic context, while taking into account recommendations from the 2012 Malaria Program Review and recent global and regional policy guidelines.

The Malaria Elimination Action Framework was developed to clearly describe the approach, implementation strategies, and roles and responsibilities of stakeholders involved in the national malaria response. It is a dynamic document that lays out in detail the five‐year action plan for elimination, but will be updated as necessary based on results produced and the availability of new evidence or tools. This document was developed primarily by the National Centre for Parasitology Entomology and Malaria Control (CNM), with support from the World Health Organization (WHO) and other technical partners (as described in Annex 1). Consultations with Ministry of Health provincial and district staff, Ministry stakeholders from Central Medical Stores (CMS) and the Department of Food and Drug (DDF), as well as technical and implementing partners took place between May‐July 2015 to generate consensus on elimination approaches.

Beyond consultation with local stakeholders, this document is constructed based on guidance from the Malaria Elimination in the Greater Mekong Subregion 2015–2030 and is aligned with the principles of the new WHO Global Technical Strategy (GTS) for malaria 2016–2030, including:

All countries can accelerate efforts towards elimination through combinations of interventions tailored to local contexts.

Country ownership and leadership, with involvement and participation of communities, are essential to accelerating progress through a multi‐sectoral approach.

Improved surveillance, monitoring and evaluation, as well as stratification by malaria disease burden, are required to optimize the implementation of malaria interventions.

Equity in access to services especially for the most vulnerable and hard‐to‐reach populations, is essential.

Innovation in tools and implementation approaches will enable countries to maximize their progression along the path to elimination.

The successful implementation of Cambodia’s Malaria Elimination Action Framework will contribute to the country’s overall objectives for elimination of the disease as well as regional objectives to interrupt transmission of P. falciparum in areas of multidrug resistance, including ACT resistance, by no later than 2020, and in all areas of the GMS by 2025.

Page 3 Malaria Elimination Action Framework

TABLE OF CONTENTS

Acknowledgements

Acronyms and Abbreviations

Executive Summary

I. Introduction

II. Country Profile

2.1 Socio‐political System

2.2 Demographics

2.3 Environment and Climate

2.4 Socio‐Economic Context

2.5 Health Systems Analysis

III. Malaria Situational Analysis

3.1 History of Malaria Control

3.2 Epidemiological Profile

3.3 Current Situation and Trends

3.4 Program Organization, Management and Performance

IV. Strategic Plan

V. Key Interventions and Implementation Strategies

Specific Objective n°1:

Specific Objective n°2

Specific Objective n°3

Specific Objective n°4

Specific Objective n°5

VI. Implementation of the Strategic Plan

6.1 Stratification

6.2 Phasing

VII. Monitoring and Evaluation

VIII. Coordination Mechanisms

IX. Budget and Financial Plan

9.1 Costing Methodology

9.2 Estimated Budget

9.3 Resource Mobilization

X. ANNEX

Annex 1. Process for MEAF Development

National Centre for Parasitology, Entomology and Malaria Control Page 4

ACKNOWLEDGEMENTS

The Malaria Elimination Action Framework (MEAF), 2016‐2020, was developed between May‐ September 2015 by the National Center for Parasitology, Entomology and Malaria Control (CNM).

This framework was constructed through numerous consultations within CNM along with malaria focal points from the provincial and district health departments, other departments with the Ministry of Health, and technical, implementing, and financial partners. The MEAF development process was overseen by CNM Director, Dr. Huy Rekol; Deputy Director, Dr. Lek Dysoley, and Chief of Technical Bureau, Dr. Siv Sovannaroth. Inputs on strategy formulation, microplanning, monitoring and evaluation, and costing of the framework were also provided by other senior management staff and representatives of various programs and units at CNM including Dr. Chea Nguon (Deputy Director, Global Fund Project); Dr. Chea Huch (Deputy Director); Dr. Sok Chantha and Mao Sokny (Entomology); Dr. Muth Sinuon (Microscopy); Dr. Leang Rithea (Research Unit), Dr. Boukheng Thavrin (IEC/BCC); Dr. Po Ly (VMWs); Dr. Bun kea (Epidemiology); Mam Boravann (PPM); Ouk Rada and Hok Chantheasy (Procurement) , Mam Tel & Kunthea Kalyan Khan (Finance). Other CNM staff also contributed to the writing of the MEAF and completion of the costing.

Technical and financial support for development of the MEAF was provided by the World Health Organization (WHO) and the Clinton Health Access Initiative (CHAI). Partners including Population Services International (PSI), Malaria Consortium (MC), Partners for Development (PfD), University Research Co. (URC), Health Poverty Action (HPA) and United Nations Office for Project Services (UNOPS) also participated in the strategy development process.

Additional feedback on the MEAF was provided by the Bill and Melinda Gates Foundation (BMGF);

Emergency Response to Artemisinin Resistance (ERAR) team; health specialists from the Asian Development Bank (ADB), and technical officers from The United States Agency for International Development (USAID) and the President’s Malaria Initiative (PMI).

Page 5 Malaria Elimination Action Framework

ACRONYMS AND ABBREVIATIONS

ACT Artemisinin‐based combination therapy ADB Asian Development Bank API Annual Parasite Index APLMA Asia Pacific Leaders Malaria Alliance APMEN The Asia Pacific Malaria Elimination Network ASMQ Artesunate‐Mefloquine BMGF Bill and Melinda Gates Foundation CMS Central Medical Store CNM National Centre for Parasitology, Entomology and Malaria Control DDF Department of Drug and Food DHA‐PIP Dihydroartemisinin and Piperaquine GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria GMS Greater Mekong Subregion HC Health Center HIS Health Information System IPC Institut Pasteur du Cambodge IRS indoor Residual Spraying LLIN Long‐lasting Insecticidal Net LLIHN Long‐lasting Insecticidal Hammock Net MEAF Malaria Elimination Action Framework MDR Multidrug Resistance MIS Malaria Information System MMW Mobile Malaria Worker MoH Ministry of Health NFM New Funding Model NMCP National Malaria Control Program OD Operational District PHD Provincial Health Department PMW Plantation Malaria Worker PPM Public‐Private Mix PSI Population Services International RAI Regional Artemisinin Initiative RCAF Royal Cambodian Armed Forces RDT Rapid Diagnostic Test TES Therapeutic Efficacy Studies UNOPS United Nations Office for Project Services URC University Research Council VHSG Village Health Support Group VHV Village Health Volunteer VMW Village Malaria Worker WHO World Health Organization

National Centre for Parasitology, Entomology and Malaria Control Page 6

EXECUTIVE SUMMARY

Cambodia has made considerable progress in diminishing their malaria burden over the last decade and has a vision of a malaria‐free country by 2025. The Malaria Elimination Action Framework (MEAF, 2016‐2020) is the guiding document designed to direct the necessary strategies and interventions for Cambodia to successfully reach their elimination objectives over the next five years. The framework was also developed to align the national malaria response to the WHO technical strategies highlighted in the Malaria Elimination in the Greater Mekong Subregion 2015– 2030 to contribute to the overall interruption of P.falciparum transmission in artemisinin resistant areas in the Greater Mekong Subregion.

In the past decade, the National Centre for Parasitology Entomology and Malaria Control (CNM) has worked to cut the number of reported malaria cases (both confirmed and clinically diagnosed) in the public and community levels to half, from 113,855 cases in 2004 to 56,271 cases in 2014. The overall malaria mortality rate has also decreased from 0.98 per 100,000 in 2010 to 0.12 per 100,000 in 2014. This achievement could be credited to the successes of CNM and the introduction of the National Strategic Plan (2011‐2025), which led to increased coverage of malaria control interventions. Despite this dramatic reduction, malaria transmission is still endemic in 21 out of the 25 provinces with more than half the population (an estimated 8.6 million people) still at risk. The northeast region of the country still accounts for over 70% of the malaria burden, mainly along the forested borders of Viet Nam, Lao People’s Democratic Republic, and Thailand.

Building off the national strategy with this new framework and accelerating the approach to elimination based the country’s epidemiological and programmatic context, Cambodia has the goal to reduce the incidence of malaria to less than 1 infection per 1000 people at risk in each operational district and eliminate Plasmodium falciparum including multidrug resistance by 2020.

Intervention strategies will cover a wide range of activities to increase the capacity of the malaria program, its tools and prepare the country for elimination. The specific framework objectives are tailored to the scale‐up of these key elimination strategies:

Providing effective program management and coordination at all levels by 2017 to efficiently deliver a combination of targeted interventions for malaria elimination

Achieving universal coverage of case management services by 2016 to ensure 100% parasitological diagnosis of all suspected cases and effective treatment of all confirmed cases

Protecting at least 90% of all populations at risk of malaria with an appropriate vector control intervention by 2017

Enhancing the surveillance system to detect, immediately notify, investigate, classify and respond to all cases and foci by 2017 to move toward malaria elimination

Implementing comprehensive IEC/BCC approach that facilitates at least 90% of people seeking treatment for fever within 24 hours at a health facility or with a qualified care provider and at least 85% of at‐risk population utilizing an appropriate protection tool by

The Ministry of Health will ensure that the required program management capacity is available at all levels of the health system and CNM leadership will support program units and health offices to hire and train additional human resources to perform the activities outlined in the framework. The MEAF (2016‐2020) is planned to be implemented jointly by CNM and all implementing partners. An

Page 7 Malaria Elimination Action Framework

Independent National Malaria Elimination Committee will be established to ensure effective implementation of this plan and monitoring of the overall goal of elimination.

The malaria situation in Cambodia is heterogeneous due to variance in malaria burden by geographic area, growing artemisinin resistance and mobility of at‐risk populations. To ensure the most operationally feasible strategies are implemented, this framework has outlined malaria strata based on those characteristics. This will assist CNM in determining what intervention packages will be used in what specific areas. ODs were placed in four strata defined as elimination‐targeted, transitional, burden reduction, or non‐endemic. The expansion and rollout of elimination activities will follow a phased approach, based on the operational stratification and capacity of the malaria program to transition.

Under the MEAF (2016‐2020), elimination activities will begin in 18 ODs in the northwest of the country, where surveillance activities will be intensified and will be brought to national scale over the next five years as transitional and higher transmission areas reduce their burden by deploying a targeted response to efficiently interrupt transmission and make it operationally feasible to follow‐ up with cases and investigate focal areas.

National Centre for Parasitology, Entomology and Malaria Control Page 8

I. INTRODUCTION

The rationale for pursuing malaria elimination in Cambodia is based on the current situation and opportunity, including: 1) Malaria interventions have had a significant impact, particularly on P.

falciparum, in reducing incidence down to such low levels in the country that interruption of transmission appears to be a realistic objective; 2) Further delay in addressing the problem of multidrug resistance could lead to the emergence of untreatable P. falciparum malaria; 3) Government leaders have re‐affirmed their political and financial commitments to achieving malaria elimination in the country.

The Malaria Elimination Action Framework seeks to build on the successes of the National Centre for Parasitology Entomology and Malaria Control (CNM) and accelerate progress towards elimination in Cambodia by 2025. This Framework describes how CNM will aggressively pursue elimination in low‐ endemic areas while strengthening interventions to reduce the burden of disease in moderate and high transmission areas that will eventually transition towards elimination.

This Framework highlights the necessity to foster support from the highest level of government to ensure effective multi‐sectoral engagement, secure necessary resources internally and externally to support full strategy implementation; address human resources requirements for malaria at all levels; ensure effective national leadership and governance, including stakeholder coordination;

expand health services to provide full access for people in remote areas.

At a technical level, Cambodia will target elimination in low endemic areas by progressively implementing a robust surveillance system that facilitates immediate case reporting and investigation followed by foci investigation and response. In high burden areas, efforts will be focused on scaling‐up access to and strengthening the quality of diagnosis and treatment in both the public and private sectors and ensuring universal coverage with appropriate vector control interventions. Special effort will be made to extend services to mobile and migrant populations, including increasing the number of access points through village malaria workers, mobile malaria workers, and plantation malaria workers. Cross‐cutting support, including program management, monitoring and evaluation, and behavior change communication, will be strengthened to support the core interventions.

This Framework will be rolled out in a phased approach between 2016 and 2019 in an effort to achieve elimination of P. falciparum and multi‐drug resistant malaria by 2020.

Page 9 Malaria Elimination Action Framework

II. COUNTRY PROFILE

Cambodia is located in southern Indochina Peninsula with a total land area of 181,035 square km extending approximately 580 km from east to west and 450 km from north to south. Cambodia shares its 2,438 km border with Thailand in the west and north, Laos in the north and Vietnam in the east and southeast.

2.1 SOCIO‐POLITICAL SYSTEM

Cambodia is divided into 25 provinces and four municipalities (Phnom Penh, Sihanoukville, Kep, and Pailin), as shown in Figure 1. Each province is divided into districts (srok), and each district into communes (khum). In addition, there are a group of villages (phum), although they are not considered formal administrative units. Each municipality is divided into sections (khan), each section into quarters (sangkat).

Figure 1. Map of Cambodia showing 25 provinces and 4 municipalities

Cambodia is a multi‐party democracy under a constitutional monarchy, currently ruled by Prime Minister Hun Sen of the Cambodian People’s Party (head of government) and King Norodom Sihamoni (head of state). The country’s legislative branch is composed of the executive and the bicameral Parliament of Cambodia, which includes a 61‐seat Senate, a‐123 seat National Assembly, and an upper house.

2.2 DEMOGRAPHICS

Cambodia has a population of approximately 15 million people, with a growth rate of 1.63%. The birth rate is 25.4%, with over 50% of the population below the age of 22. 20.5% of the of the population lives in urban areas, with an annual rate of change of 2.65%. The capital city, Phnom Penh, is also the largest, with a population of 1.7M. The majority of the country’s population (90%) is Khmer, with a small percentage of Vietnamese (5%), Chinese (1%), and other ethnicities (4%). The official language is Khmer, spoken by 96.3% of the population, and the primary religion is Buddhism, practiced by 96.9% of the population.

National Centre for Parasitology, Entomology and Malaria Control Page 10

According to the 2008 Census, 3.5 million people (26.5% of the total population) were categorized as a migrant (“a person who has moved to their enumeration area from another village or another country, which was the person’s last residence”). Over the 5 years previous to 2008, approximately

1.7 million people migrated between different rural areas, of which 45% of them migrated from another province. Migrants are mainly young adults who moved for family or economic reasons.

Almost half of them are skilled agricultural, forestry and fishery workers.

2.3 ENVIRONMENT AND CLIMATE

Cambodia is predominantly a low‐lying country that occupies the central plains of the lower Mekong basin and is bordered on three sides by dense forested mountainous areas. Topographically the country is divided into two distinct parts: (i) the central low lying plains and the flat coastal areas;

and (ii) the mountainous ranges and high plateau surrounding the low lying land. The landscape in the central plains is dominated by Tonle Sap Lake, the Bassac River and the Mekong River system, which cross the country from the north to the south. Surrounding the central plains, which cover three quarters of the country’s area, are densely forested and sparsely populated highlands.

The percentage of Cambodia covered in forest has fallen from about 72% in 1973 to only about 46% in 2013. Forest is one of the most important economic and environmental resources of the country and a key source of government revenue and employment for the local people. At least 32% of the land is classified as agricultural (22.7% arable, 8.5% permanent pasture, and 0.9% permanent crops).

There are two distinct meteorological seasons in Cambodia: the rainy season (May to October) and the dry season (November to April). The temperature changes regionally and seasonally. The warmest month is April, when temperature can rise above 38ºC, and the coldest of about 22ºC is January. The average annual temperature is 27ºC.

2.4 SOCIO‐ECONOMIC CONTEXT

Cambodia is considered a low‐income country, although the country has experienced strong economic growth over the past decade. Gross National Income Per Capita (PPP) in 2013 was $2,890 and GDP (PPP) grew 7.3% from $44B in 2012 to $50B in 2014. Cambodia remains a predominantly agricultural country. Agriculture and forestry contribute significantly to country’s GDP. Thus, the majority of the labor force is agricultural (55.8%), followed by services (27.3%), and industrial (16.9%). Adult labor force participation is high (78.9% for women and 86% for men) but as of 2012, 17.7% of the population continued to live under the poverty line1.

The country's economic potential and natural resources are drawing foreign investment ‐ especially from China and neighboring Vietnam. Garment‐making is the biggest industry, employing around half a million people and accounting for 80% of exports. Tourism is expanding and Cambodia hopes to tap into offshore oil and gas reserves. The inflation rate has increased from 2.9% in 2013 to 4.2% in 2014.

Defined as: Population below $2 a day is the percentage of the population living on less than $2.00 a day at 2005 international prices

(World Bank Data Indicators)

Page 11 Malaria Elimination Action Framework

2.5 HEALTH SYSTEMS ANALYSIS

Cambodia’s health expenditure accounts for 7.5% of the country’s GDP. The country has approximately 0.17 physicians and 0.7 hospital beds per 1000 people. The life expectancy at birth increased by 12 years from 2002‐2012 to an average of 72. The ten leading causes of morbidity in the country in 2012 were acute respiratory infection; diarrhea; malaria; cough (at least 21 days);

gynaeco‐obstetric issues; tuberculosis; road accidents; measles; dengue hemorrhagic fever; and dysentery. Communicable diseases are thus a leading cause of morbidity, accounting for 83% of the reported disease burden. Non‐communicable diseases (NCDs) are increasing significantly, causing an estimated 53% of deaths per year as of 2012.

The Ministry of Health (MOH) has overall responsibility of the health sector, including: development of policies and legislation, strategic planning, resource mobilization and allocation, monitoring, evaluation, research, providing training to support the provinces. The MOH’s main objective in health sector reform is to improve and extend primary health services through the implementation of the operational districts (OD) system. Provincial health departments (PHDs) are the link between the MOH and ODs, and implement health policies, ensure equitable distribution and effective use of resources, manage provincial/referral hospitals, and support the development of ODs. ODs deliver services according to the health sector objectives and community’s needs, ensure equitable distribution and effective utilization of resources and mobilize additional resources.

The resource allocation for health from the state budget has increased steadily, while external assistance by donors remains a substantial source of funding. The Government of Cambodia’s contribution is mostly in the form of salaries and allowances for staff at all health levels. Within the total health expenditure of approximately $70 per capita (2012), out‐of‐pocket health expenditures remain high at above 60% of total health expenditure. The weak regulatory framework, and a need to increase the provision of services, has led to a rapid development of the private sector. According to the 2013 Cambodia Malaria Survey, 25% of those surveyed reporting fever in the past 2 weeks, 25% initially sought treatment in private facility, 23% visited a pharmacy/drug shop, and 22% sought treatment at health center. Barriers to accessing services in the public health sector include distance and rising costs of transport, restricted opening hours at government facilities and the probability of encountering long waiting times.

In order to supplement for health services under the public health system, MOH and National Disease Programs have scaled up several community systems for health including the establishment of village health support groups and health center management committees; community‐based prevention and treatment support for TB and HIV; use of village malaria workers (VMWs) and mobile malaria workers (MMWs) to expand early diagnosis and treatment; and use of village health volunteers (VHVs) and village health support groups (VHSGs) to implement health education programs. These community activities have improved the quality, accessibility and utilization of health services, contributing to the general improvement in health indicators.

In addition to public health sector, a substantial share of healthcare services is provided through regulated and unregulated private sector. The providers in private sector comprise of wide range of outlet types at retail level, including registered health outlets (pharmacies, depot A and B pharmacies, and clinical pharmacies), non‐registered health outlets (drug stores, mobile providers), and general/non‐health outlets (grocery stores and shops). Unlicensed outlets in the country decreased from 1081 in November 2009 to 28 in July 2011, but this oversight only seems relative to pharmacies and depots. There are still numerous unlicensed outlets in the rural areas which are not regulated by MoH and continue to provide health services without any official supervision.

National Centre for Parasitology, Entomology and Malaria Control Page 12

III. MALARIA SITUATIONAL ANALYSIS

3.1 HISTORY OF MALARIA CONTROL

Interventions to reduce malaria in Cambodia started in in 1951 as part of the Global Eradication Campaign. Following a 6‐year indoor residual spraying campaign using DDT, malaria prevalence rates reduced from 60% to 0.9% by the early 1960s. From 1970‐75, malaria activities were reduced to disruptions related to the civil war. During the Khmer Rouge from 1975‐78, all malaria activities were discontinued. In 1984, the Ministry of Health (MoH) founded and designated a specialized institution, the National Malaria Centre, to provide technical and material support to malaria treatment facilities in provincial and district hospitals and to develop and execute a nation‐wide malaria control strategy. It was not until the early 1990s that logistical support for malaria diagnosis and treatment became integrated with the national essential drugs program and the Malaria Center transitioned from purely hospital‐based curative activities to more pro‐active community based health education, evaluation and control activities. The National Malaria Centre (CNM) was reorganized in December 1995 with added responsibilities for schistosomiasis and dengue control activities. The official name of the institution was changed to “National Centre for Parasitology, Entomology and Malaria Control”, but has retained the acronym CNM.

In 2000, the country introduced ACTs at a national scale. With support from Global Fund to Fight HIV, Tuberculosis, and Malaria (GFATM), CNM successfully extended access to insecticide treated bed nets and diagnosis and treatment. In 2004, CNM piloted the village malaria worker program, which was extended in 2009 to the highest‐risk villages and remote areas. Following initial evidence of artemisinin resistance in 2006, a containment project was launched in 2009 along the Cambodia‐ Thai border to increase coverage of control interventions and limit case management factors associated with the growth of resistance. In the past 10 years, the number of reported malaria cases has been halved, from 113855 cases in 2004 to 56271 cases in 2014, as shown in Figure 2 below.

Figure 2. Malaria Cases and Deaths Reported by Public Facilities and VMWs, 2001‐2014

Page 13 Malaria Elimination Action Framework

In 2011, Samdech Decho Hun Sen, Prime Minister of Cambodia, endorsed the National Strategic Plan for Elimination of Malaria in the Kingdom of Cambodia, 2011‐2025. The National Strategic Plan calls for elimination in the following phased approach:

Short –Term (by 2015): To move towards pre‐elimination of malaria across Cambodia with special efforts to contain artemisinin resistant P. falciparum 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): To achieve phased elimination of all forms of malaria in Cambodia

3.2 EPIDEMIOLOGICAL PROFILE

3.2.1 Parasites

Plasmodium falciparum was the predominant species among confirmed malaria cases until 2011.

With the roll‐out and scale‐up of multi‐species (Pan) rapid diagnostic tests in 2009, the proportion of infections due to P. falciparum shifted and for the first time in 2012, P. vivax accounted for the majority of the cases (see Figure 3). In 2014, P. vivax infections accounted for 47% (26,183) of cases, followed by 23% (12,422) of P. falciparum cases, followed by 30% (16,540) of mixed infections2 of both P. falciparum and P. vivax. Prevalence of Plasmodium infection has declined in each successive national survey, from a weighted national prevalence (as measured by microscopy) declining from 4.4% in 2004, to 2.6% in 2007, to 0.9% in 2010, and finally to 0.1% in 2013.3

Figure 3. Malaria cases in Public Sector, by Species, and Annual Blood Examination Rate4, 2010‐14

2 Mixed infections predominantly include P. falciparum species in Cambodia and should be interpreted and managed as such.

Malaria Consortium and CNM. Cambodia Malaria Survey 2013. 2013.

ABER (%) is calculated as number of people tested by microscopy and RDTs in a year divided by total estimated population

National Centre for Parasitology, Entomology and Malaria Control Page 14

3.2.2 Vectors

Twenty five malaria vector species have been identified in Cambodia between 2007 and 2013.

An.maculatus s.l. is present throughout Cambodia with An.minimus s.l. more prevalent in the west, while An.dirus in the northeast. Other vectors such An.barbirotrist, An.phillipinensis, An.vagus, and An.hyrcanus are also present in Cambodia (see Figure ).

An. dirus is found forested mountains and foothills, cultivated forests, and rubber plantations, whereas An. minimus is found outside the forests or in areas where the forests have been cleared.

An. maculatus is found in hilly or mountainous areas and breeds in or near permanent or semi‐ permanent bodies of clean water like streams or rivers. An. epiroticus is able to breed in water with some salinity and is therefore typically found in Cambodia’s coastal areas. These vectors bite during all hours of the evening, but peak biting hours are usually found to be between 8 pm and 12 am.

Figure 4: Vector Distribution according to Entomological Surveillance at Sentinel Sites (2007‐2013)

3.2.3 Malaria Transmission

In Cambodia, malaria transmission is endemic in 21 out of 25 provinces, but incidence is highest in the north eastern part of the country, where the malaria burden has become more concentrated over the past 3 years (see Figure 5). Transmission occurs primarily in the hot and rainy season between July and November. It is estimated that 58% of the population, or approximately 8.6 million people, live in malaria at‐risk areas. Malaria risk is highest in forest or forest fringe areas of the country, usually found along the borders of Viet Nam, Lao People’s Democratic Republic, and Thailand.

Page 15 Malaria Elimination Action Framework

Figure 5. Confirmed Malaria Cases (Public Health facilities and VMWs) per 1000 Population by OD (2012‐2014)

Human movement is common in Cambodia and contributes to the continuous geographical distribution of malaria through the importation (related to populations coming from outside the country) and intra‐portation (related to populations moving within the country) of parasites. In the 2013 Cambodia Malaria Survey, prevalence as measured by PCR was highest among forest goers (5.4%) and travelers (2.2%), compared to residents (1.2%).5 The profiles of mobile and migrant populations (MMP) in Cambodia include seasonal workers associated with agriculture, construction or mine workers, forest workers, security personnel, and visitors traveling for tourism or to see relatives. Profiles of types of MMPs and their associated activities are described in the table below.

Table 1. Profile and Activities of Mobile and Migrant Populations in Cambodia6

Profile Activities Example

Seasonal workers Agricultural activities occurring during planting season(end of dry season) and harvesting season (end of rainy season, usually in foothills/plains/valleys

Farming, rubber or cassava plantations

Construction/mine workers Activities related to infrastructure construction or mining in forested areas, usually in upland forest/hills/valleys

Dam or road construction, gold or gem mines

Forest workers Activities in heavily forested and remote areas in small mobile groups, usually in upland forest/hills

Gathering forest products, hunting, logging, fishing

Security personnel Activities related to patrolling in forested border areas, including military, police, border patrol units

Visitors Tourism, visits to relatives which could include spending up to one week in or near the forest

Family event, national holiday, ecotourism

3.3 CURRENT SITUATION AND TRENDS

3.3.1 Morbidity and Mortality

In 2014, Cambodia recorded 56,271 malaria cases in public health sector comprised of public health facilities and Village Malaria Workers (VMWs), a 47% decrease from 2010. However, this case load showed approximately 26% increase compared to 2013 and this trend of increase in number of cases, starting in April 2014 has continued in 2015. In first seven months of 2015, the total number of confirmed cases (public health facilities and VMWs) has increased by 36% compared to the same

5 Malaria Consortium and CNM. Cambodia Malaria Survey 2013. 2013.

6 Guyant P, Canavati S, Chea N, et al. Malaria and the mobile and migrant population in Cambodia: a population movement framework to inform strategies for malaria control and elimination. Malaria J. 2015. 14: 252.

National Centre for Parasitology, Entomology and Malaria Control Page 16 period in 2014, as depicted in Figure 6, indicating a potential resurgence of the malaria burden nationally.

Figure 6. Malaria Cases (Public Health Facilities and VMWs) by Month (January 2013 – June 2015)

The case confirmation by microcopy and/or RDTs rates at public health facilities have remained consistently high (≥ 90%) since 2010, as shown in Figure 7. VMWs diagnosed and treated more than half of malaria cases recorded in the public sector in 2014 and 100% of these cases are confirmed by

RDT.

Figure 7. Number of Malaria Cases Recorded by Public Health Facilities and VMWs (2010‐2014)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2015 2014 2013

Page 17 Malaria Elimination Action Framework

This overall case load does not include malaria cases treated by the private sector, which is believed to treat up to two‐thirds of patients with febrile illness.7 As of December 2014, there were nearly 1200 licensed private providers enrolled in the PPM program implemented by CNM, Population Services International (PSI) and University Research Council (URC) in 34 ODs out of total 45 malaria endemic ODs. These private providers recorded 17,361 confirmed malaria cases in 2014. However the case data from unlicensed health and non‐health outlets that also provide malaria services is not captured as these outlets are not part of the PPM program. Thus the number of malaria cases recorded in public health sector is an underestimation of the true burden of the disease.

A total of 8 Operational Districts (ODs) accounted for 73% of cases treated in public health facilities, VMWs, and the private sector in 2014: Steung Treng OD (Steung Treng province), Kratie OD (Kratie province), Tbeng Meanchey OD (Preah Vihear province), Ratanakiri OD (Ratanakiri province), Sen Monorom OD (Mondulkiri province), Samraong OD (Oddar Meanchey province), Sampov Meas OD (Pursat province), kampong Speu OD (Kampong Speu province) (see Figures 8 and 9). The combined population of these provinces is only 1.8 million, 12% of the total population of Cambodia.

Figure 8. Malaria Cases Recorded in Public and Private Sector by OD (2014)

7 Cambodia Malaria Survey (2013)

National Centre for Parasitology, Entomology and Malaria Control Page 18

Figure 9. Distribution of Absolute Number of Infections by Species by OD (2014)

Cambodia’s malaria case load is primarily concentrated in adult males, with males between the ages of 15‐49 years comprising two‐thirds of malaria cases reported in the public sector in 2014, as shown in Figure 10. This trend is likely related to the exposure of these populations to forest‐ associated vectors during peak biting hours as adult males are often working in agricultural or forest‐ related industries at these times.

Figure 10: Malaria Cases Recorded by Age and Gender ‐ Public Health Facilities and VMWs (2014)

Cambodia recorded 18 malaria deaths in 2014, a slight increase from 12 in 2013, but a 60% decrease from 45 in 2012. The overall malaria mortality rate has decreased from 0.98 per 100,000 in 2010 to

0.12 per 100,000 in 2014. This achievement could be attributed to the introduction of the National Strategic Plan (2011‐2025), which built national attention on malaria and led to increased coverage of malaria control interventions.

14498

20834

3600 3270

10000

15000

20000

25000

0‐14 years 15‐24 years 25‐49 years 50+ years

N u m b e r o f co n fi rm e d c as es

Male Female

Number of Confirmed P. falciparum & Mixed Cases Number of Confirmed P. vivax Cases

Page 19 Malaria Elimination Action Framework

3.3.2 Multi‐Drug Resistance

Parasite resistance to artemisinin and other ACT partner drugs has been detected in five South‐East Asian countries, including Cambodia. There is a concern that multi‐drug resistance could spread, given the high level of population mobility. If resistance were to spread to or emerge in India or sub‐ Saharan Africa, the public health consequences could be dire, as no alternative antimalarial medicine is currently available with the same level of efficacy and tolerability as ACTs.

Artemisinin resistance was first identified in clinical studies in Cambodia in 2006, however retrospective analysis of molecular markers indicates that artemisinin resistance likely emerged as early as 2001 before the widespread deployment of ACTs in Cambodia. Initially, due to high treatment failure rates with artesunate‐mefloquine (AS‐MQ), the first‐line treatment for the treatment of uncomplicated P. falciparum malaria was changed from co‐blistered AS‐MQ to fixed‐ dose dihydroartemisinin‐piperaquine (DHA‐PPQ) in Pailin in 2008 and then nationwide in 2010.

After the implementation of this new treatment policy, an increase in treatment failures with DHA‐ PPQ was quickly identified in therapeutic efficacy studies in Pailin followed by seven other provinces between 2008 and 2014 in the western and northern part of the country. In provinces with DHQ‐ PPQ failure, the decision to re‐introduce ASMQ per national policy was reached in 2014 as first‐line treatment, since the proportion of P. falciparum strains with multiple Pfmdr1 copy numbers (which confer mefloquine resistance) is currently minimal in the area. DHA‐PPQ remains the first‐line treatment in the rest of the country. Quinine plus doxycycline over 7 days has been adopted as second‐line therapy.

As of June 2015, failure rates of DHA‐PPQ have crossed 60% in Siem Reap and have reached 30‐40% in provinces including Oddar Meanchey, Stung Treng and Battambang, as shown in Table 2. Further increase in multidrug resistance including artemisinin resistance could lead to the resurgence of malaria not only in Cambodia, as well as neighboring countries. In areas with early treatment failure, alternatives to ACT, specifically quinine and doxycycline, administered via inpatient care may be required.

Table 2. Day 28 Cure Rates following Treatment with ACT from 2010‐20148

ACT 2010 2011 2012 2013 2014

DHA‐PIP

76% Pailin 93% Pursat 100% Rattanakiri

90.5% Pursat 100% Kratie

91.3% Pursat 69.2% Battambang 100% Kampong Speu 100% KampongThom

98.3% Rattanakiri 100% Kratie 100% Kampot 93.3% Preah Vihear

37.5% Siem Reap 66.7% Stung Treng 89.4% Mondulkiri

ASMQ 100% Pailin

Artesunate‐ Pyronaridine

86.7% Pailin

89.8 % Pursat

Previously, drug resistance stratification risk was divided into two tiers: Tier 1 being those nine provinces with demonstrated artemisinin resistance; and Tier 2 referring to the other 12 provinces that, by definition, are at risk but where resistance has not been confirmed. Because resistance affects the malaria situation of the entire country, no tier stratification will be used, but evidence of multidrug resistance will be one of the factors used in the phasing strategy.

As recorded via therapeutic efficacy studies (TES)

National Centre for Parasitology, Entomology and Malaria Control Page 20

3.4 PROGRAM ORGANIZATION, MANAGEMENT AND PERFORMANCE

3.4.1 National Malaria Program Organization

In recent years CNM has evolved from an essentially vertical program to a more administratively decentralized and integrated program within the Cambodian public health system (Figure 11). The providers in public health system are composed of:

1) National, provincial and district referral hospitals (RH)

2) Health centers (HC) and health posts: minimum level primary health care services mainly for rural populations that cover around 10,000–20,000 people each

3) Community health volunteers/workers (under MOH/National Disease Programs or NGOs)

Responsibility for the detailed planning of many activities has been assigned to staff at PHDs and ODs with dedicated malaria teams. Implementation of activities relating to public sector malaria diagnosis and treatment are now more fully integrated into the general health services at the health post, health center and referral hospital level.

In addition, CNM in collaboration with partners also provide malaria diagnosis and treatment services through collaboration with private providers. Under the Public‐Private Mix (PPM) program, the licensed private sectors are enrolled, trained and monitored for malaria case management services and case load reporting.

Figure 11. Structure of National Malaria Program Organization

Page 21 Malaria Elimination Action Framework

3.4.2 CNM Structure

CNM is divided into three main bureaus each handling the technical, financial and administrative aspects of the NMCP (Figure 12). All three bureaus are under the direct management of the Director.

The Deputy Directors provide necessary support in terms of technical oversight, financial planning, partner relations and/or project management.

The Technical Bureau oversees treatment, training and supervision for the four disease‐specific programs. The malaria program is the largest among the disease specific programs managed by the Technical Bureau, accounting for 75 percent of the Technical Bureau’s staff. The work of the Bureau is carried out by twelve technical units: Entomology, Epidemiology, Research, Vector Control, Monitoring and Evaluation, Laboratory, Health Education, IT, Helminthiasis, Filariasis, PPM and Village Malaria Workers. The Administration Bureau is primarily responsible for administration including personnel and logistics management. The bureau oversees the functioning of 6 units, namely Administration, Transportation, Procurement, Library, Security and Cleaning. The Procurement Unit is responsible for the quantification, ordering and purchasing of drugs, commodities, equipment and goods required by the programs operated by CNM. The Finance Bureau manages all financial matters including donor supported grants and projects. The Bureau’s work is carried out by three units, namely Accounting; Planning and Materials; and Financial Services Unit. The Financial Services Unit is solely responsible to manage the GFATM grants.

CNM has a total staff of 152 (as of December 2014) out of which 80 are government staff, 38 are temporary and 15 are contracted under the GFATM grants and 19 under other malaria grants. The organizational structure of CNM and the staff per unit is shared in Figure 12 below.

Figure 12. Organizational Structure of CNM and Staff Number per Unit

3.4.3 Program Performance

Cambodia has strong political will for and commitment to malaria elimination from both government and partners. Financial support from the government includes resources to support

Director

Administrative Bureau Chief: 1

Deputy Chiefs: 2

Technical Bureau Chief: 1

Deputy Chiefs: 3

Finance Bureau Chief: 1

Deputy Chief: 2

Entomology (6)

Epidemiology (2)

Health Education (4)

M & E Unit (5)

Laboratory (9)

VMW Unit (5)

Research (3)

Vector Control (5)

Filariasis (3)

Helminth (3)

PPM Unit (2)

IT

(3)

Deputy Directors = 7

Dengue (3)

Data Mgmnt.

(3)

National Centre for Parasitology, Entomology and Malaria Control Page 22 infrastructure, transport, and permanent human resources. The government supports decentralization of health activities to the peripheral level for more efficient and effective implementation of strategies, but low salaries and capacity within the staff across the health levels is a significant challenge to quality implementation and provision of services. Salary and capacity growth severely affects hiring and retaining of talented staff within the public health system in Cambodia. Partners offer a range of malaria expertise in terms of research, technical assistance and implementation of malaria program throughout the country, but coordination remains a challenge.

CNM has experience in managing concurrent multi‐million grants for malaria. CNM has administered/received grants from GFATM since 2002; Bill and Melinda Gates Foundation (BMGF, 2009‐2010); and has recently started new malaria projects (2015‐2016) funded by Regional Artemisinin Initiative (RAI) and New Funding Model (NFM) under GFATM and Pilot Elimination Project in Preah Vihear province under Asia development Bank (ADB). For GFATM, CNM has acted both as Principle Recipient and Principal Implementing Partner (PIP).

Page 23 Malaria Elimination Action Framework

IV. STRATEGIC PLAN

Vision:

A Malaria‐Free Cambodia

Mission:

The Royal Government of Cambodia’s mission is to work together with all relevant partners and the communities themselves to enable sustained delivery and use of the most effective prevention and treatment measures for those affected most by malaria by mobilizing all the required resources and ensuring compliance with all national standards and guidelines for key malaria interventions toward elimination.

Guiding principles o Political commitment, leadership and ownership o Equity in access to services, especially for the most vulnerable and other underserved populations at risk of malaria o Improvement of performance of health services o Innovative tools and approach o Community participation o Inter‐sectoral approach

Goal

Reduce the incidence of malaria to less than 1 infection per 1000 people at risk in each operational district and eliminate Plasmodium falciparum including multidrug resistance by 2020

Specific Objective n°1:

Providing effective program management and coordination at all levels by 2017 to efficiently deliver a combination of targeted interventions for malaria elimination

Specific Objective n°2:

Achieve universal coverage of case management services by 2016 to ensure 100% parasitological diagnosis of all suspected cases and effective treatment of all confirmed cases

Specific Objective n°3:

Protect at least 90% of all populations at risk of malaria with an appropriate vector control intervention by 2017

Specific Objective n°4:

Enhance the surveillance system to detect, immediately notify, investigate, classify and respond to all cases and foci by 2017 to move toward malaria elimination

Specific Objective n°5:

Implementing comprehensive IEC/BCC approach that facilitates at least 90% of people seeking treatment for fever within 24 hours at a health facility or with a qualified care provider and at least 85% of at‐risk population utilizing an appropriate protection tool by 2017

National Centre for Parasitology, Entomology and Malaria Control Page 24

V. KEY INTERVENTIONS AND IMPLEMENTATION STRATEGIES

SPECIFIC OBJECTIVE N°1:

Provide effective program management and coordination at all levels by 2017 to efficiently deliver a combination of targeted interventions for malaria elimination.

1.1 Strengthen Program management and coordination

The Ministry of Health will ensure that the required program management capacity for planning, implementation, monitoring and evaluation is available at all levels of the health system. The CNM will develop and update a human resource development plan and advocate for high level commitment for implementation of this plan. CNM leadership will support program units and PHD/OD health offices to hire additional human resources to perform activities as detailed under the Malaria Elimination Framework. National policies and guidelines will be reviewed and updated as necessary based on the results of monitoring and evaluation. CNM will carry out Mid‐Term Review of Strategic Plan in 2017 and Malaria Program Review in 2019 with support from WHO and external stakeholders. Outcomes of these reviews will inform revision of Malaria Elimination Action Framework.

All health staff involved in malaria operations will be trained on program management approaches and planning and technical guidance for malaria elimination. Standard operating procedures for all activities managed at provincial and district level will be developed to improve management and accountability of malaria operations. Provincial health departments will meet with district health staff carry out an annual review to chart progress against the national monitoring and evaluation plan and develop provincial operational plans in quarter four for the coming year. CNM and PHDs will meet in quarter one of each calendar year at Annual Malaria Review Meeting to align operational plans across provinces. These plans will be submitted to the Ministry of Health to improve transparency and coordination. As data is collected and information analyzed, national, provincial, and district plans will be adapted on an ad hoc basis to respond to the dynamic malaria situation accordingly. To support those working on malaria at provincial and district‐level, CNM will carry out bi‐annual supervisory visits with field staff to assist in planning, implementation, monitoring and evaluation of malaria control activities.

A Malaria Elimination Taskforce will be created at national level amongst senior management at CNM, MOH, and lead technical and implementing…