national malaria programme review – viet nam · 2018-08-09 · reorient the programme for malaria...

April 2018

National Malaria Programme Review – Viet Nam

National Malaria Programme Review – Viet NamApril 2018

© World Health Organization 2018ISBN 978 92 9061 842 3Some rights reserved.

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules).Suggested citation. National malaria programme review – Viet Nam. Manila, Philippines. World Health Organization Regional Office for the Western Pacific. 2018. Licence: CC BY-NC-SA 3.0 IGO.Cataloguing-in-Publication (CIP) data. 1. National health programs. 2. Malaria. 3. Vietnam. I. World Health Organization Regional Office for the Western Pacific. (NLM Classification: WC755JV6)Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: [email protected] materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. For inquiries and request for WHO Western Pacific Regional Publications, please contact the Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: [email protected]

Photo credits: © WHO/Y. Shimizu

Review Team

Rabindra AbeyasingheVu Duc ChinhTran Cong Dai

Najibullah HabibSean Hewitt

Nguyen Manh HungLe Xuan HungMasaya KatoTessa Knox

Kim LindbladeMomoe Takeuchi

Ta Thi TinhShuisen Zhou

Contents

Acknowledgements viForeword viiAbbreviations viiiExecutive summary ix1. Introduction 1 1.1. Objectivesofthereview 1 1.2. Reviewmethodology 12. OverviewofthemalariasituationinVietNam 3 2.1. Healthsystem 3 2.2. Epidemiology 3 2.3. NationalMalariaControlProgramme 4 2.4. Progressinmalariacontroltowardselimination 5 2.5. Progressondrugresistance 63. Reviewfindingsandrecommendationsbyprogrammearea 7 3.1Programmemanagement 8 3.1.1 Successes 8 3.1.2 Observations,challengesandrecommendations 8 3.2Vectorcontrolandpersonalprotection 13 3.2.1 Successes 14 3.2.2 Observations,challengesandrecommendations 15 3.3Casemanagement 17 3.3.1 Successes 17 3.3.2 Observations,challengesandrecommendations 18 3.4Surveillanceandfocus/outbreakpreparednessandresponse 23 3.4.1 Successes 23 3.4.2 Observations,challengesandrecommendations 23 3.5Communication 26 3.5.1 Successes 26 3.5.2 Observations,challengesandrecommendations 27 3.6Overarchingrecommendations 274. Overallconclusion 29Annex1. Termsofreferenceforthemalariaprogrammereview 30Annex2. Malariaprogrammereviewteammembers 33Annex3. Peoplemet 34Annex4. Servicedeliverysystems 39Annex5. RegionalFrameworkforActiononTransitioningtoIntegratedFinancing ofPriorityPublicHealthServices 41Annex6. ASystem-WideApproachtoAnalysingEfficiencyacrossHealthProgrammes 41Annex7. Guidelinesforestablishinganindependentnationalmalariaelimination advisorycommittee 42Annex8.OutcomesfrominsecticideresistancemonitoringforAnopheles spp. inVietNam 44

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Acknowledgements

WHO would like to thank Associate professor. Dr Tran Thanh Duong, Associateprofessor.DrNguyenVanChuong,Associateprofessor.DrLeThanhDong,DrNguyenQuang Thieu and Ms Lai Hong Loan who generously gave their time to provideinformationandviewsonVietNam’sNationalMalariaControlProgramme.Inaddition,wewould like to thank staffat theNational InstituteofMalariology, ParasitologyandEntomologyandregionalinstitutes,aswellasgovernmentstaffatprovincial,districtandcommune levels, forproviding informationand investing time in theorganizationandconductoffieldvisits.Withoutthesefieldvisits, itwouldhavebeenimpossibletogaina soundunderstandingof theactivitieson theground.Thisactivitywas supported byfinancialcontributions fromtheGlobalFundtoFightAIDS,TuberculosisandMalaria.

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FOREWORD

From 9 to 18 September 2017, the National Institute ofMalariology, Parasitology andEntomology(NIMPE)ofVietNamandtheWorldHealthOrganization(WHO)conductedajointreviewoftheNationalMalariaControlProgramme.Thereviewisapublichealthmanagementtoolforcountriesthatwishtostrengthentheirmalariacontrolprogrammeperformance and systems. Independent experts used state-of-the-art standards andmethods formalariacontrolandelimination toperformarigorousandcomprehensiveevaluationofthecountry’sprogramme.

Thisfinal report summarizes thefindings fromthe2017malariaprogrammereviewaswellastherecommendationsofnationalandinternationalexperts.VietNamhasmadeimpressivegainsinmalariacontrolandisontracktomeetitsvisiontoeliminatemalariaby2030.Thishasbeenmadepossiblethroughthestrongcommitmentandsubstantialinvestments of the Government of Viet Nam and its development partners. However,challengestoeliminatemalariainthecountryremain:thediseaseisconcentratedinat-riskpopulationslivinginhard-to-reachareas,accesstodiagnosisandtreatmentneedstobeexpanded,andartemisinin-resistantmalaria is spreading.Thus,continuedaction isessential,asistheurgentattentionofpolicy-makers,developmentpartnersandthepublic.

Giventhefindingsofthisreport,policy-makersanddevelopmentpartnersareurgedtoreorienttheprogrammeformalariacontroltowardseliminationtohelpVietNamadapttofuturecircumstanceswhenmalariaeliminationiseventuallyachieved.NIMPEandWHOhavecollaboratedcloselywitheachotherformanyyearsinfightingmalaria.WenowlookforwardtoworkingalongsideallstakeholderstoeliminatemalariafromVietNamforgood.

Dr Tran Thanh Duong AssociateProfessor

DrKidongPark

Director,NationalInstituteofMalariology,ParasitologyandEntomology,VietNam

WorldHealthOrganizationRepresentativetoVietNam

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Abbreviations

ACPR adequateclinicalandparasitologicalresponseACT artemisinin-basedcombinationtherapyADB AsianDevelopmentBankAe. AedesAn. AnophelesAPI annualparasiteincidenceBCC behaviourchangecommunicationCDC centrefordiseasecontrolConsortiumHA ConsortiumforHealthActionCHC commune health centreC54 Circular54DAV DrugAdministrationofVietNamDHA-PIP dihydroartemisinin-piperaquineDHC district health centreDOT directlyobservedtreatmenteCDS electronic Communicable Diseases SystemGMP GoodManufacturingPracticeG6PD glucose6-phosphatedehydrogenaseHMIS HealthManagementInformationSystemIEC information,educationandcommunicationIMPE InstituteofMalariology,ParasitologyandEntomologyIRS indoorresidualsprayingITN insecticide-treatednetLLHN long-lastinginsecticide-treatedhammocknetLLIN long-lastinginsecticide-treatedbednetMIS MalariaInformationSystemM&E monitoringandevaluationNFM NewFundingMechanismNGO nongovernmentalorganizationNIDQC NationalInstituteofDrugQualityControlNIMPE NationalInstituteofMalariology,ParasitologyandEntomologyNMCP NationalMalariaControlProgrammeP. Plasmodium PHD provincialhealthdepartmentPSI PopulationServicesInternationalRAI RegionalArtemisinin-resistanceInitiativeRDT rapiddiagnostictestSMS shortmessagingserviceSOP standardoperatingprocedureTES therapeuticefficacystudiesTFM TransitionalFundingMechanismVHW villagehealthworkerWHO WorldHealthOrganization

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Executive summary

This report is the result of an independent external review of the performance andachievementsofVietNam’sNationalMalariaControlProgramme.TheProgrammehasmadesignificantprogresstowardseliminatingmalariainrecentyears.Malariacasesanddeathshavebeenreducedremarkably,inlargepartbecauseofthesubstantialcommitmentand investments of the Government of Viet Nam and its international developmentpartnersinmalariacontrol.

ThisreportprovidesrecommendationstosupportthereorientationoftheProgramme’sapproach frommalaria control to malaria elimination. Policiesand standardoperatingprocedures will need to be redefined accordingly if the Programme is to sustain itsimpressiveperformance,andcontainthespreadofmultidrug-resistantfalciparummalaria.Specificrecommendationsareprovidedfor:developinganupdatednationalactionplanfor malaria elimination; introducing verification of subnational malaria elimination;sustainingnationalfinancingformalariaelimination;andintegratingmalariasurveillanceactivitiesintoothercommunicablediseasesurveillanceactivities.

VietNamisnowfacedwithacriticalwindowofopportunitytoachievetheeliminationofmalaria as mandated in the National Strategy for Malaria Control and Elimination in the Period 2011–2020 and Orientation to 2030. Efficaciousantimalarialcombinationsstillexistbutarefailingfast;potenttoolsforvectorcontrolareavailablebutcouldbeunderminedquicklybythedevelopmentofinsecticideresistance;andfinancialsupportfromexternalfundingpartnerscontinuestoflowbutwilllikelybetimelimited.

TheGovernmentmustnowseizethemomentandtakeboldstepstoensurethatmalariaisultimatelyeliminatedfromVietNam.

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1. Introduction

1.1 Objectives of the review

Theobjectivesofthisprogrammereviewwere:

y toreviewprogresstowardsmeetingnational,regionalandglobaltargetsformalariacontrolandelimination;

y toproviderecommendationstoredefinepoliciesandstrategiesandsupportprogrammetransformationtosustainhighperformance;

y toreviewperformanceofmalariacontrolandeliminationactivitiesbythematicareasatdifferentlevelsofservicedelivery;

y toproviderecommendationsfortransitioningtheapproachoftheNationalMalariaControlProgramme(NMCP)frommalariacontrol to malaria elimination;

y toinvestigateandrecommendmethodstosustainresourcesandfinancingformalariacontrol,malariaeliminationandpreventionofre-establishment;

y toinvestigateandrecommendmethodstointegratemalariacontrolandeliminationactivitiesinVietNam’sbroadercommunicablediseasecontrolandsurveillancesystem;and

y toassesstheNMCP’sapproachtocontainthespreadofartemisinin-resistantmalaria.

FulltermsofreferenceforthenationalmalariaprogrammereviewarepresentedinAnnex1.

1.2 Review methodology

Themalariaprogrammereviewcomprisedadesk-basedreviewofdocumentation,face-to-facesemi-structuredinterviews,sitevisitsanddataanalysis.Thereviewteamconsistedofexperts from theWorldHealthOrganization (WHO)headquarters, RegionalOfficefortheWesternPacificandCountryOfficeVietNam;stafffromtheNationalInstituteofMalariology,ParasitologyandEntomology(NIMPE);andindependentconsultantsfromthePeople’sRepublicofChinaandtheUnitedKingdomofGreatBritainandNorthernIreland.SixoutofeightinternationalmembersofthereviewteamwereWHOstaff.Thereviewteamhadexpertise in theareasofhealthsystemsplanningandfinance,epidemiology,malariology,entomology,vectorcontrol,researchandothers.Thereviewteamwasdividedinto four groups that each focusedon a thematic area: programmemanagement; casemanagement;surveillanceandresponse;andvectorcontrol.Eachgroupfocusedprimarilyonitsthematicareabutalsoreviewedkeyfindingsfromallotherthematicareasthroughacomprehensivereportingmatrixdevelopedbytheteam.AlistofreviewteammembersandtheirdesignationsispresentedinAnnex2.Authorsarelistedinalphabeticalorderatthebeginningofthisreport.

Theauthorssoughtinformation,viewsandsuggestionsfromabroadrangeofstakeholders,includingkeyprogrammestaffinvolvedinplanningandoversightateachlevel,technicalpartners, public sector implementers, volunteers and programme beneficiaries. Theassessment included field visits to Dien Bien, Thanh Hoa, Dak Lak and Binh Phuocprovinces.Thefieldcomponentofthereviewcoveredprovincial,district,communeandvillage levels,withgroupsvisitingadministrativeand technicaloffices, health facilitiesand target communities. Findings from each field visit were consolidated and sharedamongthegroupsbyemail.Observationsandkeyissuesforfollow-upwerealsosharedin real time through mobile messaging apps and teleconferences over the Internet.

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Reviewteambriefingsandconsultationswithstakeholdersweredonebeforeandafterthefieldvisits.AlistofpersonsmetispresentedinAnnex3.

Thedistribution,availability,conditionanduseofNMCPsuppliesandequipmentwereinvestigatedasfaraspossible,andpracticescoveredbyNMCP-supportedtrainingwereobserved.

Site selection for the reviewwascarriedoutbyNIMPEandWHO.Theaimof thesiteselectionprocesswastoprovidearepresentativeoverviewoftheNMCP.Thesiteswereselectedfromprovinceswithhigh,medium,lowandverylowendemicity;provinceswithand without support from the Global Fund to Fight AIDS, Tuberculosis andMalaria;provinceswithsupportfromNIMPEoraregionalInstituteforMalariology,Parasitologyand Entomology (IMPE) in Quy Nhon or Ho ChiMinh City; and provinceswith andwithoutinternationalborders.Theselectionalsoaimedtoensureapracticalscheduleforeachoftheteams.

At theendof thecountryvisit, the review teamgaveadebriefing forNIMPE, the tworegionalIMPEsandtheWHORepresentativetoVietNam.TheteamalsopresentedtheresultsofthemalariaprogrammereviewtotheVice-MinisterofHealth,DrNguyenThanhLong.

Limitations of the review:Timeconstraintsmeantthatonlyafewsitescouldbevisited.Therefore,thesamplemaynothavebeenfullyrepresentative.TimeconstraintsalsomeantthatitwasnotpossibleforteamstovisiteitherofthetworegionalIMPEs.Furthermore,therewasonlyverylimitedtimeforinteractionwithcurrentandpotentialpartners,andtheprivatesector(includingprivatesectorhealth-careproviders).

AsrequiredbygovernmentalauthoritiesinVietNam,visitswereplannedandannouncedwellinadvanceofthereviewteam’sarrival.Ideallysiteselectionshouldbetheprerogativeofthereviewteamandvisitstoperipheralsitesshouldbeunannouncedorannouncedonlyimmediatelypriortovisits.

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2. Overview of the malaria situation in Viet Nam

2.1 Health system

VietNamhasawell-establishedpublichealth-carenetwork.Anoverviewofthenetworkingeneral(andhowitrelatestomalariainparticular)ispresentedinAnnex4.

The Ministry of Health is in the process of integrating all vertically oriented diseaseprogrammeswithinaprovincialcentrefordiseasecontrolineachprovince.1Thisprocessshouldbecompletedbytheendof2020.

Eachcommunehasa communehealthcentre (CHC). Inmalaria-endemic (or recentlymalaria-endemic)communes,CHCshavespecially trainedstaffresponsible formalariacontrol (amongotherduties).Villagehealthworkers (VHWs)are thebackboneof thecommunity-levelhealthresponseinVietNam.VHWsareengagedinoutreachactivities,mainlyfocusedonhealthpromotionandprevention,includingreferralofsuspectedmalariacasestopublicsectorhealth-carefacilities.TheNMCPalsoworksincloseassociationwiththePeople’sCommittee,theWomen’sUnion,theYouthUnionandvillageleaders.

Theprivate sectorplaysa significant but, until recently, poorlyunderstood role in themanagementofmalariainVietNam.TheNMCPrecognizedthisimportantshortcomingandin2015partneredwithPopulationServicesInternational(PSI),whichhasextensiveexpertiseinprivatesectorengagementformalariacontrolintheGreaterMekongSubregion(see3.3.2).

2.2 Epidemiology

Theepidemiologyofmalaria inVietNam is highly complex, varying from location tolocationandfromonepopulationgrouptoanother.Whileallfivespeciesofplasmodiathataffecthumansoccur, thevastmajorityofmalariacasesarecausedbyPlasmodium falciparum(55.8%in2016)andP. vivax(42.1%in2016).Intensemalariatransmissionislargelyrestrictedtohilly,forestedareasinsouthernandcentralprovinceswheremalariatransmissiontends tobeperennialwithaseasonalpeak inDecember–February. In thenorthernregion,transmissionisincreasinglysporadic.

ThemainvectorsofmalariainVietNamandtheGreaterMekongSubregion(Anopheles dirus and An. minimus)arecharacterized,atleastseasonally,byearlyoutdoorbitinghabits.Nevertheless,aselsewhereintheWesternPacificRegion,long-lastinginsecticide-treatedbednets(LLINs)haveprovedaneffectivemeansofmalariacontrol,2,3,4 and they continue toplayacriticalroleinreducingmalariatransmission.

Thepeopleathighestriskofmalariaincludeforestandforest-fringeinhabitants(commonlyethnicminoritygroups),temporarymigrantsandseasonalworkers,andnewforestsettlers(summarized inBox 1).The levelofmalariarisk foreachof thesegroups isdependentonanumberoflocation-specificfactors,includingdegreeofendemicity,accessibilityto

1 Circular No: 26/2017/TT-BYT of the Ministry of Health on guiding functions, tasks, authorities and organizational structure of Centers for Disease Control and Prevention of provinces and cities under Central Authority.

2 Luxemburger C, Perea WA, Delmas G, Pruja C, Pecoul B, Moren A. Permethrin-impregnated bed nets for the prevention of malaria in schoolchildren on the Thai–Burmese border. Trans R Soc Trop Med Hyg.1994;88:155–9.

3 Kamol-Ratanakul P, Prasittisuk C. The effectiveness of permethrin-impregnated bed nets against malaria for migrant workers in eastern Thailand. AmJ Trop Med Hyg.1992;47:305–9.

4 Sochantha T, Hewitt S, Nguon C, Okell L, Alexander N, Yeung S, et al. Insecticide-treated bednets for the prevention of Plasmodium falciparum malaria in Cambodia: a cluster-randomized trial. Trop Med Int Health.2006;11:1166–77.

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malariacommoditiesandservices,andhealthsystemstrength.Marginalizedmobileandmigrantpopulationsandethnicminoritygroupsworkingorlivingintheforestandontheforestfringescarrythegreatestburdenofdisease.

Thedifferentsituations requiredifferentmalariacontrol strategies,adapted tosuit thespecificriskgroupsandvectorbehaviours,andadjustedtotakeintoconsiderationlocalinfrastructureandhealthservicecoverage.

Box 1. Population groups at risk of malaria in endemic areas of Viet Nam Staticpopulations

y Establishedforestandforest-fringevillagers(ethnicminoritygroupsandethnicmajority(Kinh))

y New settlements y Campsassociatedwithlarge-scaleconstructionprojects(e.g.dams,bridges) y Settlementsassociatedwithplantations(e.g.rubber,cassava,cashew,food)

Mobilepopulations

y Traditionalslash-and-burnandpaddyfieldfarmingcommunitiesvisitingtheirforestfarms(commonlyethnicminoritygroups)

y Seasonal agricultural labourers y Militarypatrols y Forestworkersintheformalsector(police,borderguards,forest/wildlifeprotectionservices)

y Forestworkersintheinformalsector(hunters,small-scalegem/goldminers,peoplegatheringforestproducts(precioustimber,constructiontimber,rattan/bamboo))

y Transientormobilecampsassociatedwithcommercialprojects(e.g.road/pipelineconstruction,large-scalelogging)

2.3 National Malaria Control Programme

TheNMCPhasadoptedamultiprongedapproachtomalariacontrolthatisbroadlyinlinewithbestpracticeintheGreaterMekongSubregion.Malariacasemanagementactivitiescoverpublic sector health facilitiesatall levelsof the health-care system,community-baseddiagnosisandtreatmentbyvolunteers(althoughonlyinaverylimitednumberofvillages in justtwoprovinces),andmostrecently,privatesectorengagement inthefivemostendemicprovincesthroughtheProgramme’spartner,PSI.Vectorcontrol isbasedon a combination of conventional insecticide-treated nets (ITNs), LLINs, long-lastinginsecticide-treatedhammocknets(LLHNs)andindoorresidualspraying(IRS).Inlinewiththerequirementsofelimination,case-basedsurveillance(wherebyeverycaseiseffectivelytreatedasanoutbreak)isintheprocessofbeingrolledoutinallbutthemostendemicareas.Information,educationandcommunication(IEC)activitiesareimplemented(primarilythroughinterpersonalcommunicationbyhealthstaffandvolunteers)toeducatehigh-riskindividualsaboutmalariapreventionandcure,andtomobilizecommunitiestoengageinandsupportmalariaeliminationefforts.Thehealthinformationsystemisbeingupdatedtosupportthestringentrequirementsassociatedwithelimination.

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Overview of the malaria situation in Viet Nam

2.4 Progress in malaria control towards elimination

ThegoaloftheNationalStrategyforMalariaControlandElimination istoactivelycontrolmalaria in moderate and high endemic areas and to eliminate malaria in areas where malariahasbeenreducedtoalowlevel.Targetsfor2020are:

y morbiditybelow0.15per1000population; y mortalitybelow0.02per100000population;and y malariaeliminatedinatleast40provinces.

Withmorethan40provincesnowmalaria-free,allofthesetargetsattheimpactlevelhavealreadybeenachieved.

Malaria burden.TheburdenofmalariaisdecreasingrapidlyinVietNam(Table1),andthediseaseisbecomingincreasinglyfocal.In2015,just211communeshadanannualparasiteincidence(API)greaterthan1,comparedto488 in2011.Duringthe last 12monthsforwhichdataareavailable(August2016–July2017),justsixprovinces(GiaLai,BinhPhuoc,QuangTri,DakNong,KhanhHoa,NinhThuan)togetheraccountedfor81%(1297/1601)ofconfirmedP. falciparummalariacases.BinhPhuocaloneaccountedfor39%.

Table 1. Malaria statistics from 2000 to 2016

2000 2005 2010 2011 2012 2013 2014 2015 2016

Malaria- clinical & confirmed 293,016 99,275 53,867 45,588 43,717 35,406 27,868 19,252 10,446

Malaria-confirmed 74,329 19,496 17,515 16,612 19,638 17,128 15,752 9,331 4,161Malariadeaths 148 18 21 14 8 6 6 3 3Numberofoutbreaks 2 5 0 0 0 0 0 0 0Morbidity(/1,000pop) 3.84 1.19 0.62 0.52 0.49 0.39 0.3 0.21 0.11API(/1,000atrisk) 0.97 0.23 0.2 1.07 1.18 0.8 1.35 0.77 0.35Mortality(/1,000pop) 0.19 0.02 0.02 0.02 0.01 0.01 0.01 0.003 0.003

ThegraphofP. falciparum and P. vivaxcaseloadbymonthinFig.1clearlydemonstratesthedramaticreductioninmalariaburdensinceearly2015.

Fig. 1. Monthly confirmed caseload in Viet Nam since January 2010

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200

400

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800

1,000

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1,400

1,600

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10

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10

Jul-1

0

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1

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-12

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16

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P.falciparum P.vivax mix

1,600

1,400

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Jan-

10A

pr-1

0Ju

l-10

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11A

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1Ju

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-11

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12A

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2Ju

l-12

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-12

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13A

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l-14

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-14

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l-15

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-15

Jan-

16A

pr-1

6Ju

l-16

Oct

-16

Jan-

17A

pr-1

7Ju

l-17

P. falciparum P. vivax mix

Source: National Institute of Malariology, Parasitology and Entomology, Viet Nam

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While theseoverall results areverypromising, further analysisof thedata at provincelevelrevealssomegeographicalvariationsinprogressoverthelast12monthsrelativetotheprevious 12months.Thesituation inQuangNam(P. vivax)and that inQuangTri (P. falciparum)bothgiveparticularcauseforconcern.Ananalysisofthedataforthesetwoprovincesduringtheperiod inquestionrevealeda4.6-fold increase invivaxmalaria inQuangNaminAugust2016relativetothesameperiodin2015,anda16-foldincreaseinfalciparummalariainQuangTriinJune–July2017relativetothesameperiodin2016(seesection3.4.2forfurtherdiscussion).

2.5 Progress on drug resistance

Delayed parasite clearancewas first detected after treatmentwith dihydroartemisinin-piperaquine (DHA-PIP) inBuDangDistrictof BinhPhuocProvince in 2009.Routinemonitoring of treatment with DHA-PIP also detected other foci of delayed parasiteclearanceinGiaLai(2010),DakNong(2011),QuangNam(2012),andKonTumandKhanhHoaprovinces(2013).

Therapeuticefficacystudies(TES)conducted inBinhPhuoc,DakLak,KhanhHoaandKonTumprovinces (N=50,45,44and 10,respectively) in2013–2014usingDHA-PIPdidnotidentifyanytreatmentfailuresdespiteaday-3positivityrateofupto36%(BinhPhuoc).

AstudyinBinhPhuoccompletedin2015revealed4outof30patientshadparasiteswithaK13mutationandhighlatetreatmentfailurerates(31.8%)followingtreatmentwithDHA-PIP. Further investigation confirmed the emergence of piperaquine resistance. RecentdatafromtheTESsiteinDakNhauCHCshowthatadequateclinicalandparasitologicalresponse(ACPR)isfurtherdecreasing(downto53.6%,22ACPR/41follow-ups).

Stepsareonlynowbeing taken to implement thechangeof thefirst-line treatment inaffectedprovinces, although the circular identifying alternate first-line treatmentswasissuedinSeptember2016(seesection3.3.2).

While the NMCP has not been able to prevent the development and/or spread ofantimalarialdrugresistance,itmaywellhaveslowedtheprocessandhascertainlymadeverysignificantprogressintermsofburdenreduction.

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3. Review findings and recommendations by programme area

3.1 Programme management

Specificobjective6inthe National Strategy for Malaria Control and Elimination Workplan 2015–2020 isto“provideeffectivemanagementandcoordinationofthenationalmalariacontrolandeliminationeffort”.TheoverallmanagementandcoordinationoftheNMCPatcentrallevelappearstobebasicallysound,asreflectedinthecurrent“B1”performanceratingforGlobalFund-supportedactivities.Theratingwasdowngradedfrom“A”becauseofprocurementdelaysbeyondtheNMCP’scontrol.However,thereviewteamdididentifyanumberofchallengesrelatedtoprogrammemanagement(3.1.2.below),andthesewillneedtobeaddressediftheprogrammeistobefullyeffective,efficientandresponsive.

3.1.1 Successes

y Overall,programmemanagementisgood,asevidencedbytheGlobalFundperformancerating.

y Programmemanagementisgenerallygoodwithinprovincialhealthdepartments(PHDs),districthealthcentres(DHCs)andCHCsinGlobalFund-supportedprovinces.

y Humanresourcescapacityisgenerallystrong. y StrongpoliticalcommitmenthasbeendemonstratedbythePeople’sCommittee,plusactiveinvolvementofWomen’sUnion,YouthUnion,etc.

y StrongVHWcommitment(someservingverylong)makestheVHWnetworkastrongpartnerforIECandbehaviourchangecommunication(BCC)andquantificationofcommodityrequirements,andpotentiallyastrongpartnerforcasemanagement,surveillanceandresponse.

y Ethnicminoritygroupsarerelativelywelltargetedbythehealthsystem. y Annualcross-borderinformationexchangemeetingsareheldwithneighbouringcountries.

y FundingisprovidedbyprovincesforIEC/BCC. y TheDistrictCommunicableDiseaseControlTeam(ledbyPeople’sCommitteemonitors)respondstooutbreaksofcommunicabledisease.

y DHCshaveanintegratedbudgetforcommunicablediseaseoutbreakinvestigationandresponse,supplementedbycontingencyfundsprovidedbythePeople’sCommitteebudgetwherenecessary.

3.1.2 Observations, challenges and recommendations

Programme management. The quality of programme management varies considerablybetweenprovinces. InThanhHoaandDienBien,managementappearstobegenerallygood,butinBinhPhuoc,whichhasthehighestmalariaburdenandthehighestlevelsofantimalarialdrugresistanceinthecountry,thesituationappearstobemorechallenging.Provincesfacingmanagementchallengesshouldbeallocatedenhancedsupport,andthosethataremoreendemicshouldbeprioritizedtoreceivethissupport.

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The degree of autonomy exercised by provinces over the NMCP guidance also variesconsiderablyfromoneprovincetoanother.InDienBien,stafffollowtheNMCPguidanceexactly,whileintheotherthreeprovincesvisited,theyadapttheirstrategicapproachtosuitlocalcircumstancesandperceptions,ofteninconsultationwithregionalIMPEsandPeople’sCommitteeofficials. Insome instances, thismaybebeneficial,but in thecaseofVHWsnot beingallowed todiagnoseand treatmalaria,5 forexample, it hasclearlybeendetrimental. This is amajor challenge to elimination andmay require legislativeamendmentstoensurealignmentwithnationalguidelines.

Integration of provincial centres for disease control (CDCs).StaffinThanhHoaProvinceexpressedsomeconcernaboutthefuturebudget,rolesandresponsibilities,andstaffingbeingimpactedwhenprovincialanddistrictCDCintegrationtakesplaceinthecomingyears (CDCswillhaveaquota for thenumberofpositions ineachprogrammearea,soabolitionofcertainpositionswillbeunavoidable).Inotherprovinces,stafffeltthattherewouldbenoimpactofCDCintegration,andinDienBienthedepartmentswerecombinedpriortorestructuring.

TheNMCPshouldviewthisasanopportunityformoreeffectivereorientationandleveragetheCDCtransitionatprovincialanddistrict levels tosupportessentialmalaria-relatedactivitiesaspartoftheintegratedapproachtocommunicablediseases.CDCintegrationshouldbeseenasanopportunityratherthanathreat.TheNMCPmustensurethatthehumanresourcescapacitynecessaryformalariacontrolisbuiltin,andthatthecapacityrequiredforeliminationismaintainedevenintothepreventionofre-establishmentperiod.ThetrainingrequiredtostrengthenhumanresourcescapacitywillneedtobefundedfromtheintegratedCDCbudgetoncedonorsupportformalariadecreases.

Non-GlobalFund-supporteddistrictscouldprovideamodeltoplananddemonstratethepost-eliminationplanningforthemalariaprogramme.Lessonscanalsobelearntfromthepolioendgamestrategyandplanningprocess.Theprogrammewillneedtoutilizesavingsandcross-programmeefficienciesformalariaelimination.

Training plans and materials integratedwith those from other communicable diseaseprogrammeswillneedtobedevelopedforCDCstaffandVHWs.CDCswillneedapoolofexpertswithabroadersetofknowledgeandskillsetstosupportintegration.

Issues relating to the health insurance scheme.Nationalhealth insurancepolicypayoutlimitsaremuchhigheratDHClevelthanatCHClevel,whichhasledtotheunderutilizationofCHCs.CHCsareasaresultunder-resourced,astheydonothaveenoughpatientstogeneratefunds.ThisinturnhasledtolowmoraleandpoormotivationamongsomeCHCstaffmembers.

Human resources. In Dien Bien Province (very low endemicity), staffing levels wereconsideredtobeadequatefordealingwithmalaria.Elsewhere,thereweresomeconcerns.InThanhHoa,staffsaidthatdoctorsinparticularwereinshortsupplyandwerehavingtodoanexcessivenumberofnightshifts.InonedistrictinBinhPhuoc,severalvillageswerewithoutVHWsduetoalackoffundingforVHWallowances.InonedistrictinDakLak,staffcomplained thatonepersonhad to respond to the requirementsofmultipleprogrammesandthatthispersonwasoverburdened.Theysawthisasamajorchallengetoelimination.TheNMCP shouldconduct an in-depth reviewof its human resourcesrequirementsatdifferentlevels(central,province,district,communeandvillage)andindifferentprogrammesettings(control,eliminationandpreventionofre-establishment)anddevelopahumanresourcesplanandgapanalysistofeedintothenextnationalstrategyandworkplan.

5 Only 2 out of 16 provinces supported by the Regional Artemisinin-resistance Initiative (RAI) grant allow VHWs to diagnose and treat patients.

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Review findings and recommendations by programme area

CHCcapacity strengthening shouldcontinue to bepromotedasapartof thenationalgrassrootsreform.TherecentlyestablishedWHO–MinistryofHealthGrassrootsReformTaskForcemustpushforstrengthenedhumanresourcescapacity,moretrainingandbetterequipmenttotreatanddiagnosecommondiseases.TheTaskForceshouldalsofacilitatechanges to the current insurance payment thresholds and regulation of autonomy atdistricthospitals.

InDakLak,itappearsthattrainingforeliminationhasbeenbasedonthe2007versionofWHO’smanual,Malaria Elimination,which is nowout of date. TheNMCP shoulddevelopitsowneliminationframeworkdocumentbasedonWHO’s2017 A Framework for Malaria Elimination,andthendeveloplocallyappropriateguidance,jobaidsandstandardoperatingprocedures(SOPs)fordisseminationtoprovincialanddistrictlevels.

Infrastructure and logistics.TheNMCPappears to have the benefitofadequateoffice,laboratoryandstoragespaceatalllevelsofthehealthsystem,andthesefacilitiesgenerallyseemtobemaintainedtoagoodstandard.Computersappeartobeuptodate,andthereisWi-FiInternetaccessdowntotheCHClevel.Thereisashortageofvehicles,butitseemsthatmotorcyclescangenerallybehiredasrequired.

Policy and strategic planning. The National Strategy for Malaria Control and Elimination in the Period 2011–2020 and Orientation to 2030 (issuedwithDecisionNo.1920/QĐ-TTgbythePrimeMinisteron27October2011)providesabroadoverviewofplannedprogrammedirection during the current decade. The National Strategy for Malaria Control and Elimination Workplan 2015–2020 providesamoredetailedaccountoftheactivitiesthatwereplannedforimplementationduring2015–2020,butthisisunderstandablysomewhatoutofstepwiththelatestguidanceoneliminationfromWHO,whichwaspublishedin2017.Theactivitiesdescribedintherecent(2017)GlobalFundfundingrequestdeviatessomewhat fromWorkplan 2015–2020 in order to follow recent WHO guidance. Theworkplanshouldbeupdatedassoonaspossiblefor2018–2020totakeintoconsiderationtheGlobalFundfundingrequestandtoreflecttherecommendationspresented inthismalariaprogramme review.Theworkplanwill require realistic bottom–upcosting thatreflectstheongoingintegrationprocess,thelikelywithdrawalofdonorsupport,andthegradual progression from control to elimination and prevention of re-establishment,whichwillhappenatdifferenttimesindifferentplaces.Theworkplanwillneedtoidentifyclearlywhichareascanbeintegratedandfinancedfromanintegratedbudgetandwhichareaswill requiremalaria-specific interventions supportedbyearmarked funding. This workplan,withitsstrongcostingandthefinancialgapanalysis,willservetosupportlocal-levelannualplanningandwillunderpinnational-leveladvocacy.Anewnationalstrategydocumentwillneedtobedevelopedin2020forthe2021–2030period.

AlthoughtheNationalStrategyforMalariaControlandEliminationisasounddocument,thereissome“disconnect”betweenwhatwaswrittenatcentrallevelandwhatisactuallyimplementedintheperiphery.ThisneedstobeaddressedthroughthedevelopmentofSOPs, jobaidsandaprogrammeofsupportivesupervisionthatreflectandsupportthenationalstrategy.

Operational planning (central and regional levels). InDakLak,eliminationroadmapsthathavebeendevelopedforeverydistrictidentifytheyearbywhicheachoneshouldreachzerocases.Incontrast,inTanhHoa,therewerenoclearplansfortransitiontoeliminationandanotablelackofresourcesinnon-GlobalFundcommunes.BinhPhuoc(highendemicity)andDienBienarestillinthecontrolphase.

Dien Bienwas apparently “stuck” in the control phase due to a very small number ofcases that hadoccurredduring the last three years in two communeswith very smallpopulations.Accordingtocurrentnationalcriteria,asinglecaseduringthelastthreeyearsinacommunewithapopulationoflessthan1000residentsrenderstheentireprovince

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in the control phase. As such, criteria for entering the elimination phase need to berevised.API thresholdsmustbeappliedatdistrict level,notcommune levelwhere thedenominatoristoosmall.Thetargetingofinterventionstomeettheneedsofriskgroupsvariedinqualityfromoneprovincetoanother.InThanhHoaandDienBien,higher-riskgroupswereeffectivelytargetedforservices.InBinhPhuoc,however,targetingcouldbefurther improved.Aswellasbeingbasedon thenational stratificationofmalaria risk,targetingof activities should takeadditional contextual factors intoconsideration. Forexample, compared tootherethnicminoritygroups, theHmongoftenexhibit lengthydelaysinseekingtreatmentduetotheiruniqueculturalbeliefs.Specificmeasuresshouldclearlybedevelopedtoaddressthis.

Incentivelevelsforpublicsectorstaffarenotalwayscommensuratewiththelevelofeffortrequiredforthevariousactivitiesthattheycarryout.Astaffmemberwhoconductsfocusinvestigationsinhard-to-reachforestlocations,forexample,receivesthesameincentiveprovidedforfocusinvestigationsatvillagelevel.All incentivelevelsshouldbereviewedandbroughtinlinewiththelevelofeffortrequiredfortheparticularactivityinquestion.

AllcommunicablediseaseprogrammesareintegratedatDHCandCHClevels.Thereissomesharingoftransportationformonitoringtripsatdistrictlevel;however,suchsharingofresourcesacrossprogrammesatdistrictlevelcouldbeimproved,andtheimportanceofsuchsharing,particularlyinlightofintegration,shouldbeemphasizedduringroutinesupportivesupervision.

Procurement and supply management. Managementofexpiringdrugsandrapiddiagnostictests(RDTs)isoverlyburdensome,resultingincreativewaysofavoidingstockexpiry,suchasusingbothRDTsandmicroscopyandnotprovidingprimaquineinless-endemicCHCs.Proceduresshouldbereviewedandrevised.

Political commitment.Politicalcommitmentappearedtovaryfromprovincetoprovinceandaccording to the level in theadministration. InThanhHoa,politicalcommitmentseemed to be relatively low at provincial level, likely due to low budget allocation formalaria-controlactivities,butitwasbetteratdistrictlevelwherethePeople’sCommitteewasactivelyinvolved.InDienBien,provincialleaderswereclearlyhappywiththecurrentsituation,buttheywerealsoconcernedaboutthepossibilityofresurgence.Theywerekeptinformedbyprovincialmalariacontrolstaffthroughnumerousmeetingsofvarioustypesand provided some limited financial support for NMCP-related activities as requestedwhenpossible.

Partnerships. NIMPE has a number of valuable long-established partnerships withnational and international institutes supporting various malaria-related operationalresearchprojects. In 2015, itdevelopeda newpartnershipwith PSI inorder toensureeffective engagement with private sector malaria case management providers – a keycomponentofthenationalstrategy.In2018,itwillformanumberofnewpartnershipswith nongovernmental organizations (NGOs) supporting the implementation of the2018–2020RAIgrant.

International exchange and cross-border cooperation. Provinces with internationalborders hold Global Fund-supported, cross-border communicable disease meetingswithcounterpartsonceayear.Additionaladhocdirectcommunicationisperformed,asnecessary.Inthepast,teamsfromthePHCinDienBienhaveactuallybeendeployedtotheLaoPeople’sDemocraticRepublictosupportoutbreakresponse(previouslyformalariabutmorerecentlyforotherdiseases).

Thecurrentregionalemphasisoncross-bordersharingofinformationshouldnotdistractfrom the more important issue of comprehensive data sharing. Malaria managers donotknowonaregularbasiswhat ishappening inneighbouringprovinces intheirowncountries, let alone what is happening in neighbouring provinces across the border.

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Given thatmobilepopulationsoften travelacrossmanyprovinces, sometimescrossinginternationalborders,managersatcentrallevelneedtoknowwhatishappeningtothemalaria situation province by province andmonth bymonth across the entire region.Thiswillallowthemtoadviseprovincialmanagersaccordinglyandmakesurethatthesemanagersareadequatelypreparedtodealwithissuesastheyarise.Thetechnologyrequiredtodothisisalreadyavailable.MappingofdatamustnotbeputonholduntilRAI’sregionalplatformfordatasharingandanalysisisfunctional.Theyareavaluabletoolforassessingprogressandidentifyingproblems,andformakingdataeasilyaccessibletopeoplefromallbackgrounds.

The intercountry component of the regional element of the RAI grant focuses oncross-bordermalaria,with activities implemented by the NGOHealth Poverty Actionin association with ministries of health on the Cambodian (Kratie/Mondulkiri) andVietnamese(BinhPhuoc)sidesoftheborder.However,theredoesnotappeartobeanyintercountrycoordinationwithintheHealthPovertyActionteamsworkingacrossborders,whichseemstounderminetheintentionoftheexercise.WHOneedstotakealeadingroleinintercountrycommunicationanddatasharing,andthisisalreadyforeseenundertheforthcomingRAIgrant.

Itwas clear that the Health Poverty Action–Ministry of Health collaboration requiredsubstantialsupportfromtwooutofsixcommunehealthworkersinoneofthekeyCHCsinvolved,whichseemsexcessivelyburdensomeontheCHC.Itistheopinionofthereviewteam that the intercountry componentwould bemore effective if itwere to focus oneliminatingtransmissioninthelargeforested“islands”whereintensetransmissionpersists,ratherthaninnarrowstripsoflandalongtheborder.Theseso-calledtransmissionislandsoftenstretchwellbeyondborderregions.RatherthantakingawayalreadyoverstretchedCHCstaff,theintercountrycomponentshouldprovidetheadditionalshort-termhumanresourcesrequiredtoeliminatemalariaintheseinaccessiblehigh-transmissionareas.

Resource mobilization and financial sustainability. Global Fund-supported districts arecurrentlydependentontheGlobalFundfor55–80%oftheirmalaria-relatedbudgets.Thesustainabilityofthisexternalfundingisuncertain.Regardless,theNMCPappearstobeadoptingaso-calledbusiness-as-usualapproach,ratherthanupdatingitsbusinessmodel,perhapsexpectinganotherdonortomaterializetofillthegapthatwillbeleftiftheGlobalFundgoes.

InThanhHoa,financialplanningseemedtorequirestrengtheninginsomeareas.Therewerenoplansforsustainability.IncreasingthestatebudgetallocationfortheCHClevelseemedunlikelyasthereisacapforeachprovinceandforeachsector,andthemajorityofthebudgetisspentonsalaries.

TheNMCPneedstoadvocateintheGovernmentofVietNamtheinclusionofabudgetlineforessentialpublichealthfunctionsandessentialprocurementinthenationalbudget,asapartofprogresstowardsintegration.ThismeansthattheProgrammeneedstoidentifytheso-calledlow-hangingfruit,whereefficiencygainscanbeobtainedthroughanintegratedapproach(e.g.integratedcommunicablediseasesurveillance,investigation,jointoutreachactivities byVHWs,communication).All thispoints to theneed for reorientationandredefiningofstaffrolesinelimination,andtheneedtomoveawayfrommalaria-onlystaffatanintegratedprimaryandsecondarycarelevelofservicedelivery.

TheProgrammeneedstoexploreopportunitiestopackagemalariaeliminationwithotherprojectsreceivingdonorsupportsuchashealth information(AsianDevelopmentBank(ADB)),healthsecurityandcommunicablediseasecontrol(WorldBank,ADB,WHOandotherbilateraldonors),andprimaryhealthcarestrengthening(WorldBankandADB).Itshouldalsoexplorepossiblepublic–privatepartnershipsforbringinginmoreresourcesatlocallevel.TheVietnamesephilanthropistswhoexpressedinterestinsupportingmalaria

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eliminationinVietNamfollowingapprovaloftheGlobalFund’sNewFundingMechanism(NFM) funding application should be approached againwith evidence of theNMCP’simpressivetrackrecordsince2015anditsnewworkplanfor2018–2020.

Measuring progress and impact. Staff at all levels are overburdened by the reportingrequirementsassociatedwithGlobalFundgrantsandotherdisease-specificprogrammes.DHCstaffhavenotimetoenterCHCandDHCdataintotheMalariaInformationSystem(MIS).TheMISandHealthManagementInformationSystem(HMIS)needlessduplicationtobefitforpurposeformalariaelimination.

Issues relating to specific indicators.Theindicator“Percentageofsuspectedmalariacasesthatreceiveaparasitologicaltest”isnotusefulasthedenominatorisnotavailable.Infact,itappearsthatthenumeratorisusuallyusedasaproxyforthedenominatorandhencetheresultisalmostalwaysreportedas100%.Theuseofannualbloodexaminationrate(ABER)iscommonineliminationsettingsand,althoughproblematic,maybepreferable.

Theindicator“Percentageofconfirmedmalariacasesthatreceivedfirst-lineantimalarialtreatmentaccordingtonationalpolicy”isnotusefulasalltreatedcasesareassumedtohavebeentreatedaccordingtonationaltreatmentguidelines.Hence,again,theresultiseffectivelyalways100%.Theindicatorisimportant,butitneedstobebasedondatafromhealthfacilityaudits.

Theusefulnessofthe indicator “Percentageofconfirmedfalciparummalariacaseswhoreceiveddirectlyobservedtreatment(DOT)inlowendemicareas”isquestionablegiventhe questionable usefulness of DOT (see section 3.3.2). The Programme should droptheDOTindicatorandreplaceitwithanewindicator“Percentageofcasesthatareslidepositiveatfollow-up(day28orday42)”.

Itwouldbeusefultoinclude“Percentageoffocifullyinvestigatedandregisteredwithin7daysofdetection(includingmalariafocusinvestigationformandfocusgeo-referencingandmapping)”asanadditionalelimination-specificindicatorineliminationareas.

Moreuseofprocessindicatorsandbetterpresentationofresultsingeneral(e.g.throughuseofmaps)wouldhelptoalerttheprogrammeanditsfundingpartnerstoimplementationissuesatanearlystage.

3.2 Vector control and personal protection

Vectorcontrolandpersonalprotection isamajorcomponentoftheNMCPintermsoffinancialandhumanresourcesaswellaslogisticsandmonitoring.AlargepercentageofthefinancesfromGlobalFundgrantsareusedtosupportandstrengthenvectorcontrolactivitiesinVietNam.

Insecticide-treated nets. Until2009,conventionalITNswereusedtoamuchgreaterextentinVietNamthanLLINs.However,sincethen,ITNshavebeenprogressivelyreplacedbyLLINsasfundshavebecomeavailablethroughGlobalFundfunding(Round7,TransitionalFundingMechanism(TFM),NFMandRAIgrants).SupplementalsingleLLINsorLLHNsarealsonowprovidedtomobilepopulationsandforest-goers.TheGovernmentofVietNamcontinuestosupportre-treatmentofconventionalnetsforthosewhoprefertousetheirownbednetsorwholiveinlessendemicareasnottargetedforLLINs(dependingonavailabilityandexpirydateof insecticides). Inaddition to the routine rollingmassdistributionofLLINs tohigh-riskpopulations inestablishedcommunities, thecurrentapproach,asoutlinedinrecentGlobalFundfundingapplications,listseightmechanismsforthedeliveryofLLINsthroughcontinuouschannels.TrainingonLLINdistribution,ITNtreatmentandassociatedcommunication forbehaviourchange isconductedatdistrictlevel.

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CoverageandutilizationratesaredeterminedannuallyforallITNs.Qualityassuranceofconventional net treatment includesdirect observationson preparation sites, quantityandconditionofequipmentandsupplies,impregnationtechnique,andhealthandsafety(includingprotectionofimpregnationteams,managementofinsecticides,processingofcontainersanddisposalofredundantinsecticides).

Indoor residual spraying with insecticide (IRS).IRS hasbeenanimportanttoolforvectorcontrolinVietNamsincetheeradicationera.Currently,IRSwithanalpha-cypermethrinformulationiscarriedoutasaroutinemasspreventivemeasureinmoreendemicareas.Itwouldalsobeusedasafocalresponsivemeasureintheeventofanoutbreak.TheNMCPalso foresees theuseof IRS in response to confirmed transmission foci in eliminationsettings, but detailed plans have not yet been developed. Training of spray teams isconductedannuallyatdistrictlevel,butconductingfocalresponsivesprayingmayrequireadifferentapproachineliminationprovinces.

Quality assuranceof IRS involvesdirect observationsof spray campaigns covering sitepreparation,quantityandconditionofequipmentandsupplies,spraytechnique,numberof structures sprayed, and adherence to safety standards. The residual efficacy of IRSisdeterminedusingWHOconebioassays inselectedsitesatsomestageduringthesixmonthspost-spray(usingeitherwild-caughtvectormosquitoesorsusceptibleinsectary-rearedmosquitoesbroughtfromNIMPE,IMPEorthePHD).

Targeted additional personal protection. Repellents have been used on a number ofoccasionsforpersonalprotectionforforest-goersinhigh-transmissionareas.

Management and correct use of public health insecticides. According to Workplan2015–2020,theMinistryofHealthwillworkwiththeMinistryofAgricultureandRuralDevelopmenttodevelopandimplementguidelinesonthemanagementandcorrectuseofpublichealthinsecticides(includingannualreportingandmappingofinsecticideusageforpublichealthandagricultureandsafedisposalofexpiredinsecticide).Thishasnotyetbeenputintoactionandthereisnoinsecticideresistancemanagementplanatpresent.

Insecticide resistance monitoring, entomological surveillance and research.Longitudinal surveys are conducted annually by NIMPE and the two IMPEs in three sentinel sitesrepresentingnorthern,centralandsouthernprovinces(oneeachwherethemainvectoris An. dirus,An. minimus and An. epiroticus).Supplementarysurveysareconductedinanadditional30–40sitesperyear,whichareselectedannuallybasedonthemalariasituationasindicatedbyannualreportstotheNMCP(andwherethereishighendemicityand/oranincreaseincases).DatacollectedincludeinformationonAnophelesspeciescomposition,densityanddistribution,parasiteinfectivityrates,andinsecticidesusceptibility.Since2014,pyrethroid6susceptibilitytestshavebeenconductedusingfield-collectedmosquitoes(F0)unfedadultscollectedbyhumanlandingcatchorindoorrestingcollectionsinhomesorcattleenclosures).ResultingdataaresummarizedinTable2(furtherdetailsarepresentedinAnnex8).

6 Lambda-cyhalothrin, alpha-cypermethrin and deltamethrin.

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Table 2. Summary of outcomes from insecticide resistance monitoring with An. dirus s.l., An. epiroticus and An. minimus s.l. by standard WHO susceptibility tests, 2010–2017*

Insecticideclass Vectorspecies Numberofsites tested

Mosquitomortality(%)

Mean Minimum MaximumPyrethroidsa An. dirus s.l. 7 99 94 100

An. epiroticus 11 81 50 97

An. minimus s.l. 20 97 79 100

Organochlorineb An. minimus s.l. 1 100 100 100

* Blue shading indicates where resistance has been confirmed (i.e. mosquito mortality < 90%). a Lambda-cyhalothrin 0.05%, alpha-cypermethrin 0.05%, deltamethrin 0.05% b Dichlorodiphenyltrichloroethane (DDT) 4.0%

DataarefromstandardWHOsusceptibilitytests.Wheremultipleinsecticideclassesortypes,mosquitospecies,ortimepointsweretested,themostrecentresistancestatusisshown.

Otherassessmentsinclude:evaluationofthevectorbio-landscape,includingtherateofopen/closedhousesasanindicationoflikelymosquitoentryandappropriatenessforIRSspraying;andthenumberofpeoplewhotravelintotheforest(suchasforfarming),howoftentheygo,andhowlongtheystayasanindicationoftheneedforadditionalpersonalprotectionmeasures.

NIMPEhascoloniesofAn. dirus (established2005),An. epiroticus (established2005),An. minimus(established1997)aswellasCulex quinquefasciatus(resistantstrain),Aedes aegypti and Ae. albopictus.IMPEQuyNhonandIMPEHoChiMinhCityhaveinsectarieswithstrainsofAn. dirus,An. epiroticus and Ae. aegypti.

Entomological research focuses on assessments of the ecology ofmalaria vectors as itrelatestohumanbehaviour,thetransmissionroleofvectors,andnewvectorcontroltools,technologies and approaches. These have included topical repellent creams,mosquitocoils,repellentcandlesandinsecticide-treatedbarrierfencing.

ThemainchallengesasidentifiedbyNIMPEaremalariavectorinsecticideresistance,theoutdoorandearlyeveningbitingbehaviourofprimaryvectors,andprovisionofeffectiveprotectionforforest-goers.

3.2.1 Successes

y ThenetworksofVHWs,villageleadersandcommunePeople’sCommitteemembersappeartobegenerallywellabletoidentifyhigh-riskgroups(e.g.poor,forest-goersandmigrantsfromelsewhere)andtoquantifyvectorcontrolandpersonalprotectionneeds.7

y VHWsarewellplacedtoprovideIECassociatedwithvectorcontrolandpersonalprotection.

y CHCsappeartodoagoodjobofcoordinatingconventionalnetre-treatments. y Entomologicalsurveillance(vectordistributionandinsecticideresistancemonitoring)issufficientandthereisclearlygoodcapacityforthisatcentrallevel.

7 The networks conduct pre-LLIN distribution surveys annually to determine how many nets of what type are already available in their communities, which individuals go to the forest, and, in less endemic target areas, which households are able to purchase nets themselves. They then formulate a list of who should be provided LLINs, LLHNs or bed-net dipping, and the commune and district authorities certify this list. The same networks also provide counts of the numbers of LLINs/LLHNs distributed and ITNs re-treated, and these counts appear to be generally accurate.

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Quantification. The quantification of LLIN/LLHN requirements has been problematicinrecentyears.Whileabottom–upplanningapproach isrecognizedatcentral levelasbeing ideal, their request to provincial level for a bottom–up LLIN gap assessment toinform the development of approximately three-yearly Global Fund funding requestshasconsistentlybeen late.Asa result,data from theperipheryhavenotbeencollatedsystematicallyandnetquantificationspresentedtotheGlobalFundhavebeeninaccurate.Thishasledtoasuboptimalmixoftop–downandbottom–upplanningforvectorcontrol.InsomeprovinceswhereLLINrequirementshavebeenunderestimated,thenumberofnetsrequestedateachlevelseemstobeadjusteddownaccordingtoallocationprovidedbytheadministrative levelabove.Planningmustbe linkedtoanupdatedstratificationbasedonrecentdata. ITN/LLIN/LLHNgapassessmentsmustbeconducted in time toinformthequantificationofrequirementsforGlobalFundapplications(itisimportanttoconsiderthethree-yearlifespanofLLINsplusthesizeofeachnettoaccuratelydefinethepopulationinneed).

QuantificationofLLIN/LLHNrequirementsshouldbebasedon thenumberofpeoplegoingtotheforest,ratherthansimplyonarateofoneperhousehold.TherequestforthisinformationfromcentralplannersshouldbesubmittedtothePHC,DHCsandCHCsatleastsixmonthspriortothefundingrequestsubmissiondeadline.

ThejobofquantificationofLLINrequirementsformobileworkershasbeenunderminedbythefactthatbigcompaniesinvolvedinconstruction,forestryandotheroperationsinendemicareasoftenunderestimatetheirnumberofemployeesinordertominimizetheirtaxandsocialsecurityobligations.TheNMCPshouldworkwithNGOpartnerstoquantifycommodityneedsassociatedwithbigcompanies,againingoodtimetoinformfundingapplicationdevelopment.

Allocation of vector control and personal protection interventions. Over-allocation ofLLINs,netre-treatmentandIRSwereobservedinsomeareas,whilethereweresignificantgapsinotherareas.Insomesituations,allocationsatcommuneandvillagelevelsseemedtobemoreforthesakeof “fairness”ratherthanbasedonanyclearscientificrationale.TargetingofLLINsandITNsshouldbetighteneduptofocusonachievingtotalcoverageforpeoplein transmission sites.Thereneedtobenationallydefinedcriteriafortargetingre-treatment programmes. Currently the full benefit of this activity is not achieved asprovincesarbitrarilydecidewheretoconductre-treatmentsbasedonfairnessratherthanneeds.

LLINs/LLHNsareonlydistributedtonamedindividualsauthorizedbycommunePeople’sCommittees.ThiseffectivelyexcludespeoplewhohavenotregisteredwiththePeople’sCommittee.HealthofficialsneedtoconvincePeople’sCommitteeofficialsthatprovidingLLINs/LLHNstoallpeopleinendemicareas,includingunregisteredmobilepeople,isinthebestinterestsoftheircommunities.

Product quality. ThequalityofLLINsandLLHNsprocuredwasinadequate.ThepolyethyleneLLINsprocuredunderRAIinVietNamweretoosmall,withuserscomplainingthattheyareunabletotucktheirnetsundertheirsleepingmats.Thesizeofnets(un-stretched)shouldbeclearlyspecifiedduringtheinitialstagesoftheprocurementprocess.Thesizeand/orrelativestiffnessofpolyethyleneLLINswereconsideredbysomeintervieweestolikelylimitutilizationandtherebyundermineimpact.Duringthe2016reviewofqualityofimplementationundertheRAIgrant,someintervieweessaidthatutilizationrateswithpolyethylenenets have fallen toas lowas 30%.Evidence, however, remainsanecdotal.IfutilizationofpolyesterLLINs is indeedgreater thanthatofpolyethyleneLLINs, thisshouldbeconvincinglydemonstratedtotheGlobalFundinordertorestrictprocurementtopolyesterLLINsinfutureandtherebymaximizeprogrammeimpact.

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HammocknetsprocuredunderRAIarepoorlydesigned.The“envelope”ofthenetisnotdeepenoughforthehammocktohangdowninto,andthecoverflapisunnecessarilylong.Asaresult,theyareuncomfortableandutilizationseemslikelytobesuboptimal.MorecaremustbetakenwithspecificationswhenprocuringLLHNsinfuture.

Lambda-cyhalothrinistheinsecticidecurrentlyusedforITNre-treatmentinVietNam.Theformulationusedhasarelativelyshortresiduallife.Inanefforttoaddressthisissue,astudyonalong-lastingformulationofdeltamethrinwasconductedbyNIMPEandIMPEs.Results, however, indicated that the formulationwas not efficacious (although studieselsewherehadconfirmedthatitremainedefficaciousafter30washes).Otherfactors,suchaspriceandquality(i.e.self-dippingcouldresultinharmtopeopleortheenvironment),also influencedthedecisionbytheNMCPnottoadoptthe long-lastingformulationofdeltamethrin.

Effective targeting. LLINs and LLHNs both need to be targeted more effectively. Assurveillance improves, LLINstrategies shouldbe reviewed to identifywaysofavoidingthe excessively costly blanket coverage currently provided inmany less endemic areas.Forexample,programmescouldrestrictmassdistributionofLLINstocommunitieswithlocal transmission observedwithin the previous three-year period. Case investigation,which isbeingrolledoutasakeycomponentoftheeliminationstrategy,willyieldthenecessaryinformationonwhetherornottransmissionislikelytobelocal.SincearestrictedapproachtoLLINdistributionwouldcarrysomelimitedrisksofsmall-scalefocalmalariaresurgence, provisionwould need to bemade for increased responsive distribution ofLLINsinconfirmedtransmissionfocisuchasthemaintenanceofstockatprovincialordistrictlevels.

Ruralgrocerystores,blacksmithsandmotorbikerepairshopsnearforestentrypointsandbordercrossingsarebeingmappedandassessedbyPSI infiveprovincesoftheGreaterMekongSubregionEliminationofMalariathroughSurveillance (GEMS)programmetoinformthecreationofanLLHNdistributionchannel.TheprogrammewaslaunchedbyPSIin2016andissupportedbytheBill&MelindaGatesFoundation.

Continuous distributions. Although recent Global Fund funding applications list eightmechanisms for thedeliveryof LLINs through continuous channels, the review teamsdidnotseeanyevidenceofLLINdeliverythroughcontinuouschannels.Netswerenotin stock at any level for rapid deployment as part of focus response. The continuouschannels for the delivery of LLINs described in recent Global Fund applicationswereconceivedtoeffectivelytargetpeopleatgreatestriskofmalaria.Theprogrammeshouldsupport their immediate roll-out. Theworkplan should be updated accordingly, SOPsshouldbedevelopedimmediately,andtrainingshouldbeprovidedtoprovinciallevelandbeyond(startinginthemostendemicareas).SufficientstocksofLLINs/LLHNswillneedtobemaintainedatprovincial,districtandcommune levels,asappropriate, tosupportcontinuousdistributionchannels.

IRS. Thecriteria forselectionofareas for IRSarevagueand the timingof IRS isoftensuboptimal,basedlargelyonavailabilityorexpiryofinsecticides.Tobefullyeffective,IRSmustbeappliedimmediatelypriortoanyseasonalincreaseintransmission,thetimingofwhichvariesfromoneregiontoanotherprimarilyaccordingtolatitude.TheNMCP’splanstouseIRS inresponsetoconfirmedtransmissionfoci ineliminationsettingswillrequire investment,assprayinghasnotconventionallybeencarriedout in theseareas.ResponsibilitiesandmechanismswithintheCDCstructurewillneedtobedetermined.

Combined ITNs/LLINs and IRS. Both pyrethroid-based IRSandpyrethroid-treatednetsweredeliveredtotargetcommunitiesinmanyareasvisitedbythereviewteams.ThispracticegoesagainstWHOguidance.8 It isan inefficientuseofresourcesandcouldpotentially

8 WHO guidance for countries on combining indoor residual spraying and long-lasting insecticidal nets. Geneva: World Health Organization; 2014 (http://www.who.int/malaria/publications/atoz/who-guidance-combining-irs-llins/en/).

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acceleratethedevelopmentofinsecticideresistance.TheNMCPshouldconsiderhaltingtheuseofIRSformasspreventioninareasadequatelyprotectedbyLLINs/ITNs,asthiswillpotentiallyfreeupasignificantamountofresources.WhereIRSistobedeployedforfocalresponseinthesameareaasLLINs/ITNs,anon-pyrethroidinsecticideshouldbeused.

Supplementary measures. Additional personal protection measures, such as repellentsandbushclearingaroundhouseholds,arealsobeingusedorpromotedinsomesettings. IEC/BCCmaterialsprovidedbytheNMCPandusedbyhealth-careworkersandVHWsindicate that these techniques impactonmalaria.However, there is no clear evidencetosupporttheassertionthattheseinterventionshaveasignificanteffectinreducingorpreventingmalariatransmission.

Monitoring and evaluation (M&E).M&EassociatedwithLLINsandIRS(coverage,qualityandutilization)isnotsystematic.GlobalFund-supportedLLINsarereportedseparatelyfromGovernment-supportedITNsandIRS,andasaresultthereisnorealclarityontheproportionofthepopulationprotectedwithvectorcontrol.M&Eandreportingonvectorcontrol and personal protection needs to be strengthened and aligned with standardprotocols.Theentomologicalsurveillanceplanshouldbecriticallyassessedandpotentiallyrevisedtoensuredatacollectedareusedtosupportvectorcontrolplanning,whichrequireslongitudinaldatafromestablishedsentinelsites.Standardformswillneedtobeupdatedto alignwith vector control process indicators (nets treated, LLINs distributed and/orIRSdeployed)and toensure the totalpopulationprotectedwithvectorcontrolcanbeadequatelycalculatedandreported.

Entomological surveillance and research. There is limited continuity in data fromsurveillancesites.Operationalresearchshouldfocusonkeystrategicquestionsrelatedtotheimpactofvectorcontrolonmalaria.Theprogrammeshouldestablishamechanismfortargetedinvestigationsincaseofpotentialissues(e.g.highLLINcoverageandusebutnodeclineincases).

3.3 Case management

Malariacasemanagementactivitiessuchasdiagnosisandtreatmentarecarriedoutbypublicsectorhealthfacilitiesatalllevelsofthehealth-caresystem,bycommunity-basedvolunteers(currentlyonlyinafewvillagesoftwoprovinces–BinhPhuocandQuangNam)andthroughmalariaposts,andmostrecently,byprivatesectorengagement inthefivemostendemicprovincesincollaborationwithPSI.

AccordingtothelatestGlobalFundfundingrequest,microscopyisthediagnosticmethodofchoiceathealthfacilitiesinVietNam.RDTsareonlyusedwhenmicroscopyservicesarenotavailable, fordiagnosisofcasesthathavealreadyreceivedsometreatment(e.g.inappropriate treatment through the private sector), and for diagnosis during focusinvestigations.

3.3.1 Successes

y Trainingandrefreshertrainingsareconductedregularly. y Mostmalariacasesarelaboratoryconfirmedbymicroscopyand/orRDTs. y Thenumberofsuspectedpatientstreatedisdecreasing. y Useofstandbytreatmentisdecreasing. y RDTsaregenerallyavailableforVHWsandmalariapostsinGlobalFund-fundedareas.

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y Adequatestocksoffirst-linetreatmentsandinjectablesareavailableinhealthfacilities.

y PrimaquineisbeingprescribedforP. vivax and P. falciparumcases. y PSI’sprivatesectorengagementstrategyiswellunderwayinfouroutoffiveofitsprogrammeprovinces.


Training methodology.RAI-fundedtrainingmaterialsdevelopedbyNIMPEforVHWsandcommunehealthworkerswerefartoocomplicatedandnotwelltailoredtotheneedsofthetwotargetaudiences,whichdiffergreatlyinskillsandknowledgelevels.NIMPEandWHOshouldworktogethertodevelopasatisfactorytechnicaloversightmechanismtosupportthedevelopmentofprogrammematerialsanddocumentation.

Supply management. In 2016–2017,due toGlobal Fundprocurement issues, therewasamajorstock-outofRDTsinall15provincessupportedbyNFMbutnotbyRAI.GlobalFund-selectedproductsdidnothavethenecessaryimportpermitorfree-salescertificaterequired by theMinistry of Health despite this requirement being flagged by NIMPEbeforethestartoftheprocurementprocess.ThismajorRDTstock-outclearlyunderscorestheneedtoretainmicroscopycapacity.

Otherthanthis,supplyseemedtobegenerallygood.

InDienBien,allmicroscopysuppliesweresufficientandofgoodquality.Pharmacystocksincludedarterakine,doxycycline,primaquine,quinineandclindamycinaswellasinjectableartesunate. Allwerewithin their expiry dates and stored and organized appropriately.Thepharmacy’snationalonlinestocktrackingsystemappearedtoworkwell.Althoughlargestocksofartemisinin-basedcombinationtherapy(ACT)werefoundexpiringinBinhPhuoc,thiscanbeattributedtotherecentdramaticreductionincaseloadinthisprovince.Drugexpiryisunavoidableinthesetypesofsituations.

Microscopy. In some laboratories, there was no evidence of integration of malariamicroscopy intobroader laboratoryservices.Allmicroscopists shouldbemulti-skilled,andmalariamicroscopyshouldbefullyintegratedintogenerallaboratoryservices.

In2017,506OlympusmicroscopeswereprocuredbytheGlobalFund.Thesepurchasessignificantlyexceededtheprojectbudget(US$3500eachinsteadofUS$1500asbudgetedbasedonaChinesebrandusedtodeveloptenderspecifications)andtheirqualityexceededtheneed.Theydidnotcomewithboxes,whicharenecessary forsafestorageandfieldtransportandwhichnowneedtobeprocuredseparatelyatanadditionalcostofUS$215each.

Furtherinvestmentinmicroscopesformalariashouldbediscouraged,asitwillbecomeoverlyburdensometomaintainthequalityofmalariamicroscopyinahugenetworkofhealthfacilitiesinaneliminationsetting.Instead,theprogrammeshouldshiftitsfocustotheuseofRDTs,withmicroscopyrestrictedtoprovincialandinsomecasesdistrictcentresofexcellence.

Microscopy quality assurance.Allpositive slidesand 10%ofnegativeslidesare sent tothedistrict,thenprovince,andthenNIMPE/IMPEsforconfirmation.Thus,slidesfromCHC levelarecross-checked three times (although inBinhPhuoc fewrecords relatingtothecross-checkingoftestswerefound,evenattheprovincialCDCandathospitals).Furthermore,thereisno“blinding”ofslidesforcross-checkingatanylevel.MicroscopyisprecededbyRDTtestingandresultsmaywellbeinfluencedbyRDTtestresults.Robustqualityassurance is the foundationofeffectivemicroscopy, socross-checkingmust be

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blinded.Whileallslidescanbesentfromoneleveltothenext,onlyarepresentativesampleneedsbecross-checkedateachlevel.

SlidebankswerenotusedinThanhHoaorBinhPhuoc,buttheywerepresent inDienBienandDakLak.InDienBien,aslidebankwasusedforon-the-jobandprovincial-leveltraining.Microscopistsareprovidedsupportivesupervisiontwotimesperyear.Duringeachsupervisoryvisit,microscopistsreview10slide-bankslides(20peryear).Comprehensivetechniqueevaluationformsarefilledoutduringsupervisoryvisits,includingspeciesandstage assessment.While the assessment formswere good, they could be improved byincorporatingareportonsensitivityandspecificity.Ineliminationsettings,whereaccesstopositiveslides isextremely limited, the frequencyofsupervisionandthenumberofslide-bankslidesreviewedpermicroscopistperyearmayneedtobeincreasedtomaintainskills.

Rapid diagnostic tests (RDTs). Generally, both RDTs and microscopy are used to testall suspectedpatientswhen bothareavailable, usually resulting indouble testingandpossiblyindoublereporting(particularlylikelytobeanissueinthecaseofannualbloodexaminationrate).However,inmanycases,thenumberofpeopletestedbybothRDTandmicroscopywasnotavailable.TestingeverypatientwithbothRDTandmicroscopyshouldbediscouragedandshouldonlyhappeninexceptionalcircumstances.Itmustnotbethenorm.

RDTsshouldbeusedtoexpanduniversalaccesstodiagnosisespeciallyamongthemostat-riskpopulationslivingandworkinginforestsandforest-fringeareas.UntilVHWsareallowedtodispenseACTs(see“Community-based case management and malaria posts” below),theyshouldreferRDT-positivepatientstoCHCsfortreatment(aclearmechanismoffollow-upmustbeestablishedtoensuretreatmentisaccessedandcompliedwith).

The NMCP should establish a mechanism to count the number of people tested bymicroscopyandbyRDTatalllevelsandinallsectors(public,privateandcommunity),notonlythenumberofpeopletestingpositive.

National treatment guidelines.TESinBinhPhuocin2015revealedDHA-PIPlatetreatmentfailureratesofmorethan30%(seesection2.5)andACPRhassincefallentobelow54%.Thenational treatmentguidelineswereupdated inSeptember2016,but theyhavenotyetbeenimplementedinthetwoprovinceswithhighlevelsofresistance.TheguidelinesneedtobeurgentlyupdatedwheneverTESfindingsindicatethatachangeintreatmentisrequired.Forthistohappen,changestotheguidelinesneedtobepredictedsothattheycanbeintroducedandimplementedrapidly.Licensingproceduresfornewantimalarialsalsoneedtobeexpeditedwithsupportfromthehighestlevelsofgovernmentwherenecessary.

ThenationaltreatmentguidelinesneedtodescribetheprovisionofACTbyVHWsinmoredetail. Primaquinedosage needs to bealignedwithWHOguidelines, andprimaquineshouldbeadministeredstartingonthefirstdayforallmalariainfections(currentNMCPguidelines call for primaquine to be administered on day 3). All associated trainings,includingmicroscopyandcasemanagementrefreshertrainingsconductedatprovincial,districtandcommunelevels,needtobestrengthenedandstandardizedandalignedtomeetthenationaltreatmentguidelines.

Facility-based case management.Alldiagnosisandtreatmentandassociatedservicesareeitherfree(RDT,ACTandotherantimalarials)orcoveredbyhealthinsurance(admission,consultation, etc.). Wealthier people, who mostly live in towns, do not have healthinsurance.Peoplefromotherprovinceswhoregisterintheprovincewheretheyarebeingtreatedmustpayforhealthinsurancetoaccessfreeservices.Peoplefromabroadmustpayforconsultationandadmission(ifnecessary),butdiagnosisandantimalarialsarefreeforall.

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Compliancewith national treatment guidelineswas generally good (doctors tended todeviatefromthemmorethanlower-levelhealthworkers).However,datainBinhPhuocindicatedthatantimalarialconsumptionwassignificantlyhigherthanitshouldhavebeengiventhenumberofconfirmedandsuspectedcasesreported.Somejobaidswereoutofdate.

Thenumberofclinicalcaseshasbeenfallingsteadilythankstostrengthenedsupervision,improved quality of diagnosis, and ensuring application of standard criteria to defineclinical cases.More however needs to be done. Therewas large-scale use of ACTs forfebrileconditionswithnegativemalariatestresultseveninhighlyendemicareaswhereimmediatetestingwithRDTs isavailable.Trainingshouldstressthe factthatRDTsarenowverysensitiveandemphasizetheimportanceoffindinganalternativeaetiologyforfebrilepatientswithnegativemalariatestresults,whoaremostlikelysufferingfromnon-malarialfevers.TheuseofACTsduetotheirantipyreticeffectsshouldbediscouragedinthesesituations.

Therewasexcessiveuseofartesunate(AS)injectioninsomecommunesinmoreendemicprovinces. Injectable AS is given first for most patients, and then usually (but notalways)followedwithanACT.Mostofthesepatientsseemtohavebeenabletotakeoralmedications.StaffcitedhighparasitedensityasareasonforprovidingAS(thoughlittleevidenceofparasitedensitywasbeingdocumented).CommunecliniciansprefertogiveASinjectionandthenreferpatientstohospitaliftheyhavefalciparummalaria,regardlessoftheirabilitytotakeoralmedication.TheindicationsforuseofinjectableASneedtobeclarifiedanditsuseaspre-referralmedicationdiscouragedunlessclinicallyindicated.

Community-based case management and malaria posts. There is limited access to diagnosis and treatment in most vulnerable communities. Community-based case managementservicesdeliveredbyVHWshavenotbeenwidelyadoptedinVietNam.VHWsareprovidedwithantimalarialsforcasemanagementinonly2ofthe16RAI-supportedprovinces,andthenonlyinveryremoteareas.NoneoftheVHWsisprovidedwithprimaquine.Immediatemeasuresshouldbetakentoimproveaccesstoquality-assureddiagnosisandtreatment,especially formigrantand seasonalworkersand indigenouspeople throughexpansionofcommunity-baseddiagnosticand treatmentservicesbyVHWs.WHOmustsupporttheNMCPtoensurethatspecialpermissionisgrantedforVHWstouseACTsinhighlyendemicprovincesaspartoftheeliminationstrategy.

TherearenodetailsatcentrallevelofwhereVHWsareandwhattheyaredoing.Inordertofacilitatemanagementandplanning,aVHWdatabaseshouldbedeveloped,listingthenameandlocationofeveryVHW,levelanddateoftraining,servicesprovided,etc.

ThemalariapostvisitedinBinhPhuocwasfunctioning.However,withonlyafewpassers-by tested,most ofwhomwerewithout fever, impact seemed likely to be limited. TheappropriatenessofthemalariapostapproachshouldbeurgentlyreviewedinlightoftherecentPresidentialdeclaration restricting forestaccess.Alternativeapproaches9 should bedevelopedifrequired.Ifthemalariapoststrategyistocontinue,thenpositioningofmalariapostsshouldbebasedonneedratherthanonequitableallocationacrossprovinces,asiscurrentlythecase(10perprovince).Proactivecasedetectionmayprovetobeamorefeasibleandeffectivemeansofaccessinghard-to-reachpopulations.

Security services. The NMCP provides insecticides, microscopy consumables (lancets,immersionoil,slidesandsometimesRDTs)tothemilitarysector.Theseareusedatarmyhealth border stations,whichareconsidered bordermicroscopypoints.These stationsreportmonthly,quarterlyandannuallytoprovincialcentres,andareincludedintheslidequalityassurancesystem.

9 Alternative approaches include provision of case management services and LLHNs by health staff based near shops known to sell supplies used by forest-goers.

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Private sector initiatives.Privatesectorhealth-careprovidersnationwideareexpectedtoreportmalariacasestotheirDHCs,buttheMinistryofHealthhasnoguidelinesregardingdistributionofcasereportingformstotheprivatesector.

Asstatedpreviously,PSIhassecuredfundingfromtheBill&MelindaGatesFoundationforacomprehensivestrategyofprivatesectorengagementandassociatedIEC/BCC.TheGEMSprogrammeisnowbeingimplementedbyPSIincollaborationwiththeNMCPinthefiveprovinceswiththehighestmalariaburden(GiaLai,BinhPhuoc,DakLak,QuangBinhandKonTum).Todate,registeredprivateclinicshavebeenmapped,assessedandthoseeligible have been trained to test, treat and reportmalaria cases in high-burdendistrictsof fouroutoffiveGEMSprogrammeprovinces.Registeredprivatepharmacieshavebeenmapped,assessedandthoseeligiblehavebeentrainedtoreferallcustomerswithfevertothenearesttrainedclinicorhealthfacility.Todate,pharmacytrainingsandpost-training “mystery”customervisits (topromptcorrectreferralpractices)havebeencompletedinthreeoutoffiveGEMSprogrammeprovinces.Worksiteshavebeenlisted,mappedandassessedtoidentifynineprioritizedworksitesinthreeofthefiveprovinces,sofar.PSIisprovidingonsitemalariatest–treat–trackservicesinfiveoftheseworksites(andZeroMalariaBCCmessagingandworker-engagementinallnineworksites).

PSI’sprivatesectorinterventionscouldbeexpandedtoadditionalhigh-burdenprovincesasrequired.Addedemphasisshouldbeplacedonaddressingtheissueofnon-antimalarialdrugcocktailsbeinginappropriatelysoldtotreatmalariathroughtrainingandenforcement.

DOT and case follow-up.Thereisoftennofollow-upoftreatmentexceptinTESsites.Insomeareas,VHWswereinformedduringtheirmonthlyreviewmeetingofmalariacasessenthomebyCHCs.However,thiswasnormallytoolatefortheVHWstotakeanyfollow-upactiontoimprovetreatmentcompliance.CHCsshouldensureeffectivecasefollow-upbyusingSMStoimmediatelyinformVHWsofanymalariacasesbeingsenthome.TheNMCPneeds toestablishclearguidelines for reportingupanddownaboutcases fromVHWtoprovinceandback,perhapsthroughtheuseofmobilemessagingapplicationssuchasWhatsApporLINE.

The value of DOT as currently practised in more endemic settings in Viet Nam isquestionable.However,supervisedtreatmentwithfollow-upwillberequiredaspartoftheendgametoeliminatemalariainVietNam.Inlessendemicsettings,alltreatmentsneedtobesupervisedtoensurecompleteadherencetothetreatmentregimenandallpatientsneedtobefollowedup(onday28or42dependingonthepartnerdrug,possiblythroughtheuseoftheVHWnetworktocollectbloodsmears)toensurethatparasiteclearancehasbeenachieved.Patientswithtreatmentfailurewillneedtobegivensecond-linetreatmentandmonitoredtoensureradicalcure.

Use of primaquine and G6PD10 deficiency.Primaquine isgenerallyissuedforbothP. vivax (14-dayregimen)and P. falciparum (singledose–0.5mg/kg) infections.Theprovisionofprimaquine isaccompaniedbyinformationoncorrectregimen,potentialside-effects(haemolysisdue toG6DPdeficiency)andactions; contraindication triggers immediatereferralandcessationoftreatment.Inlessendemicprovinces,primaquine is not stocked atCHClevelduetoconcernsovertoxicity(primaquine is included intoxictableB). Inthesesettings,primaquine ismadeavailablebythedistrictteam,whichisdeployedtothecommuneassoonastheyreceiveapositivecasereport.Thereisnocheckingofcompliance,especiallywiththe14-dayprimaquineregimenforvivaxmalaria.SuchamechanismshouldbeestablishedthroughtheVHWnetwork.VolunteerVHWswhocouldconductfollow-upvisitsduringtreatment(e.g.aroundday7)andonday14toensurefullcompliance.Whereverprimaquine isusedforthetreatmentofP. vivax,patientsshouldbegivenpapercupssothattheycancheckforhaematuriaandterminatetreatmentifnecessary.

10 G6PD stands for glucose 6-phosphate dehydrogenase.

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Standby treatment.TheuseofstandbytreatmentinVietNamhasdecreasedsignificantlyinrecentyearsfollowingpressurefromtheNMCPtoreducetheamountofACTincirculationandtherebyreducetheselectionpressureforantimalarialresistance.Neverthelessitstillaccountsforahighproportion(40%(1872/4800))ofACTusageinmoreendemicpartsofBinhPhuoc.WHOstronglydiscouragesstandbytreatmentwithACTandrecommendsimmediate cessation of the practice. Provision of RDTs for self-diagnosis could be anoption.

Quality and safety of antimalarial medicines. Antimalarial medicines are locally manufactured.Infact,asamatterofgovernmentpolicy,allgovernment-fundedmedicinesincludingantimalarialsareprocuredfromlocalmanufacturers.ThekeyagenciesresponsibleforensuringqualityandsafetyofantimalarialsinVietNamaretheDrugAdministrationof Viet Nam (DAV), the National Institute of Drug Quality Control (NIDQC) and itsprovincial network, and the National Drug Information and Adverse Drug ReactionMonitoringCentre.DAVlicensesalldrugmanufacturersandenforcescompliancetoGoodManufacturingPractice (GMP)standards.TherearecurrentlyseveralmanufacturersofantimalarialmedicinesinVietNam,butonlysomearecertifiedasGMPcompliant.Othergoodpracticestandards, suchasgooddistributionandgoodstoragepractices,arealsoenforcedtoallpharmaceuticaldistributors.TheregistrationofantimalarialmedicinesisalsoundertakenbyDAV,withlicenses(calledproductvisas)validforuptofiveyears.

The NIDQC and its provincial network are mainly responsible for post-marketingsurveillance of medicines in Viet Nam including for antimalarials. In 2011–2016, withGlobalFundfunding,WHOprovidedextensivesupporttostrengthenthepost-marketingsurveillancesystemfocusingonmedicinesforkeypublichealthprogrammes:antimalarials,tuberculosisdrugsandantiretrovirals.TheNIDQCundertakesrisk-basedsamplingandsurveillancethroughitsnetwork.

Despite these systems being in place, substantial challenges remain. An assessmentof thepharmaceutical industry in2012–2013showed theexistenceof locallyproducedformulationsofquinineandparacetamol, a seriousconcernas theseare being soldasordinaryantipyretics.ArecentstudycommissionedbyWHOshowedthatasubstantialproportion of antimalarial samples are substandard. In addition, despite a series ofGovernment-issuedordersbetween2010and2014tostopproductionoforalartemisinin-basedmonotherapies and to recall them from themarket, the survey has found thattheseproductsarestillavailableinthemarketinsomecountriesintheGreaterMekongSubregion.

The National Drug Information and Adverse Drug Reaction Monitoring Centre isresponsibleforpharmacovigilanceofallmedicinesinVietNamincludingantimalarials.Adversedrugreactionsarereportedfromconsumers,industryandhealthservicefacilities.TheNationalCentre is amemberof theUppsalaMonitoringCentre network. Reportsof severe adverse drug reactions are processed through the quality network, wherebythe National Centre undertakes causality assessment, the NIDQC is responsible forquality testing of the subject drug, andDAV initiates the recall of the products uponrecommendationoftheNationalCentreandtheNIDQC.

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3.4 Surveillance and focus/outbreak preparedness and response

Workplan2015–2020outlinesplanstoimproveandupdatetheepidemiologicalsurveillancesystem in line with the requirements associated with malaria elimination in less endemic areasandensuresufficientcapacityformalariaoutbreakresponseinmoreendemicareas.Substantialprogresshasbeenmadeinthisregard,butmoreworkisrequiredtoensurethatthesystemisfullyfunctionaland“eliminationready”.

3.4.1 Successes

y AhighproportionofsuspectedcasesarebeingtestedformalariabymicroscopyorRDTs.

y VHWsinsomeprovincesaredetectingcasesusingRDTs. y Case-basedreportinghasbeenrolledouttoGlobalFund-supportedcommunesinzone3.11

y Casenotificationwithin1–2daysseemstobeoccurringapproximately80%ofthetimeinmanyareas(althoughnotinBinhPhuoc).

y Theproportionofcaseswithcompletedcasereportformsishighinsomeareas. y Somecommunes,districtsandprovincesareanalysingdataandpreparingbulletins.

y InDienBien(verylowendemicity),theoriginsofallimportedcaseswereknown. y Afive-zonestratificationhasbeencompleteddowntocommunelevelandisunderstoodatleasttodistrictlevel.Severalcommunesdemonstratedsubcommunestratification.


Epidemiological surveillance.Theroll-outoftheMISbeganin2014buthassincestalled.Thesystemisnotfunctioningconsistentlyatanylevelduetoserverupdaterequirements.TheNMCPandWHOshouldexplorethetechnicalflexibilityof theViettel12 electronic case-based data platform to ensure compliance with data exchange standards andinteroperabilityrequirements.Circular54(C54)isnotyetfullyfunctional.ManydistrictsstilldonotenterinformationintotheelectronicCommunicableDiseasesSystem(eCDS),thesoftwareforC54,andC54doesnotcarryallofthedataitemsrequiredforelimination.TheMISwillneedtocreate linkageswithC54andbecomean integralpartof it inthefuture.TheProgrammecannotwaitforeCDStobecomefullyfunctionalif it istomeettheneedsassociatedwithelimination.ThisshouldbeplannedinthebroaderframeworkregardinganintegratedapproachforHMIS(withbothpreventiveandcurativearms).Atthesametime,themalariacasedatacollectedthroughC54shouldbemonitoredtocross-checkwithdatacollectedbytheNMCP.C54datashouldbedisaggregatedbysuspected,probableandconfirmedcases.

TherevisedMISmustensureclearlinesofinformationflowbetweencaseidentification,casenotification,case investigation,case follow-up, focus investigation, focusresponseandfocusfollow-upreports.

The NMCP’s surveillance manual needs to be updated to align with the 2017 WHOFramework for Malaria Eliminationandupcomingsurveillanceguidelines.UntilthenewMISisupandrunning,provincialmalariacentresshouldmaintainalistofallconfirmedcasestomonitorfociandconductfocusinvestigations.

11 See‘‘Stratificationofmalariarisk’’onpage24.12 ViettelisVietNam’slargestmobilephonenetworkprovider.

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Bulletinsarepreparedonanannualbasisatprovincial,districtandcommunelevels.NIMPEhasbeeneffectivelyprovidingguidanceandstructuretotheanalyses,buttemplatescouldbefurtherimprovedandannexedtoSOPs.

Stratification of malaria risk. Thecountryhasbeenstratifiedatthecommunelevelintofivezonesaccordingtomalariarisk:Zone1–Areaswithoutmalariatransmission;Zone2–Areaswithvectorsbutfreefrommalaria;Zone3–Lowmalariaendemicarea;Zone4–Moderatemalariaendemicarea;andZone5–Highmalariaendemicarea.Re-stratificationhasbeenperformed routinely every 4–5years. Targeting by zone is appropriate, but theNMCPneedstomakethismoreexplicitandconsiderhowtohandlesubprovincialstratificationforprovincial-levelactivitiesincludingfocusinvestigations.CHCstaffneedtoknowwhichstratumtheyarein,thenationaleliminationobjectiveandtheirdistrictroadmapgoals.

Thestratificationapproachneedstobereviewedinlightoftherapidreductioninmalariaburdenandadjustedifappropriate.Whateverthestratificationapproach,thestratificationshould be updated annually and activities targeted/re-targeted accordingly. Donorflexibilitywillberequiredtoaccommodatethisretargeting.Followingeachstratificationupdate,CHCstaffwillneedtobebriefedifthestratumtheyareinhaschanged.

Focus/outbreak/epidemic preparedness. Communicable disease control mobile teams at districtlevel(headedbythevice-presidentofthePeople’sCommittee)areresponsibleformonitoringoutbreaks.Inmoreendemicareas,suppliesforoutbreakresponse(includingACTandinsecticide)arekeptatprovinciallevel,butinlessendemicareas,wheresupplyroutesareadequate(takelessthan24hours),suppliesaresentorcollectedfromcentrallevel,asandwhenrequired.

Early detection of foci/outbreaks/epidemics.Inmoreendemiccommunes,weeklycaseloadisplottedonawallchart,whichshowsthemeanweeklycaseloadforthepreviousthreeyearsplustwostandarddeviationsasanoutbreakthreshold.Ifthecaseloadexceedsthisthreshold,anoutbreakisreportedtodistrictlevel.Giventherecentdramaticdeclinesinmalariaburden,thisapproachshouldnowbereplacedwithcase-basedreporting.

So far, case-based reporting has been officially rolled out to Global Fund-supportedcommunes in Zone 3, and so there is inconsistency in practice of case and focusinvestigationsbetweenGlobalFundandnon-GlobalFundareas.TheRAIgrantfocusesonP. falciparumandthisseemstohaveledtoconfusion,withcaseandfocusinvestigationsonlybeingsupportedforfalciparummalariainRAI-supportedprovinces(despitethefactthattheyalsohaveNFMsupport).Provincialanddistrict-levelstaffshouldtrytoaccountforeverycaseintheirareaandensurethatthesecasesarefolloweduptoconfirmradicalcure.Thereviewteamrecommendsthattheprogrammeshouldnowrolloutcase-basedsurveillance(forallspeciesofmalaria)toallendemicandreceptivecommunes(zones2–5inGlobalFundandnon-GlobalFundareas). Inmoreendemiccommunes(zones4–5),caseinvestigationsandfocusinvestigationsshouldbecarriedouttotheextentthatthisisfeasible(itshouldbepossibletoinvestigate100%ofcasesintheseareasatleastduringthelowtransmissionseason).Thisway,thesemoreendemicareaswillbefullycapableofimplementingcase-basedinvestigationastheyentertheeliminationphase.

TheNMCPshouldclarifysurveillanceguidancetoensureinvestigationisconductedforeverycase.Tobeofvalue,caseinvestigationsmustgobeyondsimpleformfillingandfocusonfindingoutexactlywherepatientsprobablybecameinfected(usingmapsifpossible).Theinformationgeneratedshouldbeusedsystematicallytohelpstrategicallytargetareasofpossibletransmissionwithappropriateinterventions.

With the advent of health insurance, people are increasingly bypassing CHCs andpresentingatdistrictandprovincialhospitals.Guidanceneeds tobedevelopedso thatcase reports are provided back to the commune fromdistrict and provincial hospitalsto facilitatecase investigations,andensureVHWsare informed, so theycan follow-up

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andensurefullcompliancewithtreatmentregimensandensurecompletecure,andthecommunecountsthecaseinitstotals.Caseinvestigationsarenotbeingdoneregularlyinthecommunity.

Guidanceisnotclearonwhoseresponsibilityitistoinvestigatecases,orhowtoregistercaseswhendiagnosedoutside the commune.TheNMCPmustdevelopclearguidanceonreporting, investigatingandregisteringcasesdiagnosedoutsidethecommune,fromotherprovincesandalsoimportedmalariafromothercountries.TheNMCPneedstostartreportingthenumberofimportedmalariacasesandtheircountryoforigin.

Focus investigations.Focusinvestigationsarenotregularlyconductedinanyarea.Therearenofocusregisters,andnofocusresponseSOPs.Focusinvestigationsneedtobeconductedbased on recentWHO guidance with clearly defined responsibilities. Activities to beundertakenwithinfocusinvestigationsneedtobeclarifiedandlinkedtoprogrammaticdecisions through thedevelopmentof appropriate SOPs.Theefficiencyand impactofreactivecasedetectionneedstobemonitoredandevaluatedtoimprovetheeffectivenessoftheactivity.Provincial-levelmalariastaffshouldbegintrackingmalariaincidenceandactproactivelytoconductfocusinvestigationsinareaswithhighnumbersofcases,withaviewtolimitingsuchtransmissionasearlyaspossible.

Suspectedtransmissionfociinforestcampsitesandforestfarmsarenotinvestigated.Focusinvestigationsneedtobeextendedtoincludeforestfarmsandforestcampsitesandthenecessaryincentivesoradditionalhumanresourcesrequiredforthisneedstobeprovided.TheNIMPEprojectsupportedbytheConsortiumforHealthAction,orConsortiumHA,inPhuYenProvinceprovidesagoodmodelforthis.

InDakLak,focusinvestigationformsfrom2016wereunavailableforreviewbecausetheyhadbeensentoffforreimbursement.AnyformsenttotheGlobalFundforreimbursement(focus investigations,case investigations,DOT)needstobecopiedsothatthesendinginstitutionisleftwitharecord.

Focus/outbreak/epidemic response.Thereislackofspecificguidanceonfocusresponse.TheNMCPneedstodevelopitsfocusresponsestrategyandprepareanddisseminateSOPs.Criteriaforfollow-upfocusinvestigationsforactivefoci,andforfollow-upupondetectionofcasesinresidualnon-activeorclearedfocineedtobeincorporatedintotheseSOPs.

TheQuangTrifalciparumoutbreakdescribedinsection2.4didresultinaninvestigationbyprovincialstaff,buttherewasnocross-bordercommunicationwiththeLaoauthoritiesat either national or provincial level even though it was clear that many of the casesdetectedhadbeenimportedfromtheLaoPeople’sDemocraticRepublic.Laoauthoritieswereapparentlyindependentlyawareofanoutbreakontheirsideoftheborderanddealtwithitappropriately,buttherewasnoattempttonotifyVietnameseauthorities.Clearly,cross-bordercommunicationneedstobeimproved.

The review team that visited Dak Lak felt that the intense focus of falciparum malariatransmissioninBuonDrangPhokcommuneinKrongNaDistrictwarrantedaninvestigationbyateamfromcentrallevel.

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3.5 Communication

Specificobjective5ofWorkplan2015–2020isto“improvetheknowledgeandbehaviourofpeoplerelatingtomalariacontrolsothattheycanactivelyprotectthemselvesagainstmalaria”.TheWorkplanoutlinesacomprehensiveapproachtoBCC,communitymobilizationandadvocacy.Thisincludesthedevelopmentoftargeted,locallyappropriateIEC/BCCmaterials(including interpersonal communicationaids, audio andvideo sketches/presentations,billboards, posters, brochures, articles and pamphlets) and methodologies tailored tothespecificrequirementsofthevarioustargetgroupsandtothespecificrequirementsofelimination.TheWorkplanhighlightstheuseof interpersonalcommunicationforBCC(deliveredbydistricthealthstaff,communehealthworkers,midwives,traditionalbirthattendants,VHWsandselectedcommunicatorsincludinghamletleaders,andWomen’sUnionandYouthUnionrepresentatives)andmassmediaforcommunicationatnationalandsubnationallevels(takingfulladvantageoffreeopportunitieswherepossible).TheWorkplanalsodescribes support for the socializationofmalaria byencouraging faith-based,civilsociety,charitableandnongovernmentalorganizationsandvillageleaderstobefullyinvolvedinmalariaelimination.

3.5.1 Successes

y Provincialgovernmentofficialsseemtobekeptwellinformedbyprovincialmalariacontrolstaffthroughregularmeetingsofvarioustypes(bothformalandinformal).

y Acommunicationplan,anadvocacyplanandacommunityengagementframeworkwereavailableatprovinciallevelatleastinDienBien.

y VHWsseemtoprovideaneffectivemeansofdeliveringIEC/BCCtotheircommunities.TheVHWnetworkisclearlyakeystrengthwithinVietNam’sbroaderpublicsectorhealthsystem,anditshouldcontinuetobestrengthenedtoensurecapacity,training,suppliesandempowermenttoaccessandsupportthecommunity.TheVHWnetworkconvenesmonthlymeetingswithvillagerstoremindthemtoclearbushesaroundhouses,togototheCHCforbloodsmearexaminationiftheyarereturningfromtheforestorhaveafever,tousebednetsatnight,andtotaketheirbednetstotheCHCwhenre-treatmentcampaignsareheld.Thesemeetingsareheldatthevillageleader’shouseandareattendedbyonerepresentativefromeachhousehold.IECmaterialsadviseonthecausesofmalariaandcontrolmeasures.Forest-goersareadvisedtotakeLLINs(single,double)totheforestiftheystayovernight.

y IEC/BCCannualcampaignsincludeposters,videos,picturesandhealthnewsinnewspapers.

y Ruralgrocerystores,blacksmithsandmotorbikerepairshopsnearforestentrypointsandbordercrossingsarebeingmappedandassessedbyPSIinitsfiveGEMSprogrammeprovincestoinformforest-goersregardingtheplacementsoftest/treatandBCCfacilities.

y ZeroMalariacampaignmessagesarebeingplacedbyPSIusingseveraltargetedchannelsinallfiveGEMSprogrammeprovinces(e.g.billboardsnearworksitesandbordercrossings,printmaterialsinpublicandprivatehealthfacilities,VHWstrainedtouseaninterpersonalcommunicationtool,YouTubevideotobeusedincommunityengagementandscreeningactivities,etc.)

y TheNMCPsupportsanannuallarge-scalecommunitymobilizationeventonWorldMalariaDay(25April).Thisisanimportantopportunityforhigh-leveladvocacy.

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Communication.ItwasnotclearduringthemalariaprogrammereviewtowhatextenttheplanspresentedinWorkplan2015–2020hadbeenputintoaction.Thereappearedtobesomedisconnectbetweenwhatiswrittenatcentrallevelandwhatisactuallyimplementedintheperiphery.DevelopmentofdetailedSOPsandrobusttoolsformonitoringactivitiesintheperipheryshouldhelptoensurethatplansareeffectivelyimplemented.PSIshouldbewellplacedtosupporttheNMCPinthisregard.

KeyBCCmessagesshouldcover:

y thedangersoffake,substandardandinappropriateantimalarials; y theimportanceofcompliancewiththefullcourseoftreatment; y availabilityofservices(advertisingthelocationofandservicesprovidedbyCHCs,VHWs,malariapostsandPSI-supportedprivatesectorhealth-careproviders);and

y theimportancetothecommunityofallcasesreceivingappropriatetreatmentinaneliminationsetting.

3.6 Overarching recommendations

y Intensifynationalmalariaeliminationefforts.• Continuetoadvocatefurtherpoliticalleadership,leadingtoincreaseddomesticresourcesformalariaelimination.

• ContinuestrengtheningtechnicalcapacityatNIMPEandtworegionalIMPEs.• Ensuresufficientnationalfinancingformalariaeliminationactivities,especiallyinnon-GlobalFund-fundedprovinces.

• Developanationalactionplanformalariaelimination.• Conductintensiveawareness-raisingamonghealthmanagers,cliniciansandpublichealthstaffatCDCsinallprovincesregardingchangeinstrategytoachievemalariaelimination.

• DevelopandupdateSOPsandprepareassociatedjobaids,reportingformsandsupportivesupervisionformatstoguideeliminationeffortswithinanintegratedCDCstructure.

• Establishastandardnationalcurriculumorientedtowardseliminationandensurethatallin-servicetrainingisaligned.

• Ensurethatalllevelsofthehealthsystemnationwideadoptalaser-likefocusonensuringrapiddetection,completetreatmentandfullparasiteclearanceforallmalariacasesfromnowuntilelimination.

• Establishanindependentnationaleliminationcommitteetoverifysubnationalmalariaelimination(seeguidelinesinAnnex7)andhelpadvisethecountrytoachievenationalelimination.

y ImproveaccesstoqualityassureddiagnosisandtreatmentandextendsurveillanceandresponsethroughexpansionofcasemanagementservicesimplementedbyVHWs.

y Re-evaluatethestratificationapproachtoensurethatresourcesareallocatedtothosemostatrisk.

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y Furtherexploreefficiencygainsthroughadoptinganintegratedapproachacrossprogrammes,startinginnon-GlobalFunddistricts.

• Changethecurrent“businessasusual”mindsettoonebettersuitedtotheNMCP’seliminationgoal.Astrongbusinessplan,orachangemanagementplan,withrealisticcostingandafinancialgapanalysiswillhelpbothlocalplanningandnational-leveladvocacy.

• WHO’shealthsystemsteamiswellplacedtocontinueworkingwiththemalaria/communicablediseasesgrouptosupportthebasicanalysisneededforsuchaplan.

• WithCDCintegrationstartingincountry,andthemalariaincidencereducingrapidlythetimeisnowrightforintegrationofmalariaservicesatprimarycarelevels(relevantreferencedocumentsareattachedasannexes5and6).

• StrengthenmalariaeliminationactivitiesthroughintegrationofmalariaintointegratedCDCsandbuildcapacitywithinthoseinstitutionstoacceleratecontrolandelimination.Strengthenandintegratemalariasurveillanceintocommunicablediseasesurveillanceandprioritizecase-basedsurveillance.

y Analyseanddeveloptailoredinterventionswithappropriatedeliverychannelstotargetriskgroupsbasedontheirspecificneeds.

• Thereneedstobeafargreatersenseofurgencyandfarmoreactiontoaddresstheissueofmalariainmobilepopulations.Thereshouldbemoreefforttotargetriskgroupsatgatheringpointsandatpointsofentryintoriskareas.

• Specialemphasisshouldbeplacedonstrengtheningpreventiveandcasemanagementservicesinthemilitary,ahighlymobileandparticularlycriticalriskgroup.AlocalNGO,ConsortiumHA,maybebestplacedtosupportthis.

• Asmalariaincidencedecreasestolowlevels,thereisaneedformoreprecisetargetingandbettertailoringofinterventionstospecificareasandpopulations.

• Thiscallsformicro-levelplanningforallinterventions,atleastatdistrictlevelandeventuallyatthelevelofindividualfociofresidualmalaria.Planningshouldbebasedonthoughtfulanalysisofavailabledatafromoperationalresearch,technicalsurveys,routinereporting,andfociandcaseinvestigations.Atthemoment,thisisnothappening–oratleastnottoasufficientextent;themixandmethodofdeploymentofinterventionsismostlythesameeverywhere.

• Toeliminatemalaria,VietNamwillneedtomoveprogressivelytomicro-levelplanning,whichwillrequireagreaterlevelofsupport.

y Inadditiontomorepreciseandstrategicplanning,thereisaneedtoimprovequalitycontroltoensurethatimplementationofplannedactivitiesachievestheintendedcoverageandquality.

• Thisrequiresaneffectivehierarchyofsupportivesupervision.• Leadersofmalariaeliminationwillneedaccesstoindependentassessmentsofthequalityofprogrammeimplementation,includingdataqualityaudits.

y “Operationsresearch”shouldtaketheplaceof“operationalresearch”,withtheprogramme“learningbydoing”ratherthan“learningthendoing”.

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4. Overall conclusion

TheNMCPhasmaderemarkableprogress towardseliminatingmalaria inrecentyears.VietNamisnowfacedwithacriticalwindowofopportunitytoachievetheeliminationofmalaria as mandated in the National Strategy for Malaria Control and Elimination in the Period 2011–2020 and Orientation to 2030:

y Efficaciousantimalarialcombinationtherapiesstillexist,buttheyarefailingfast. y Potenttoolsforvectorcontrolareavailable,buttheycouldbeunderminedquicklybythedevelopmentofinsecticideresistance.

y Financialsupportfromexternalfundingpartnerscontinuestoflowbutwilllikelybetimelimited.

TheGovernmentmustseize themomentandtakeboldsteps toensure thatmalaria iseliminatedfromVietNamforgood.

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Annex 1. Terms of reference for the malaria programme review

Overalltermsofreferenceandscope

1. ReviewVietNam’sprogressandstandardoperatingprocedurestowardsmeetingtheneedsfornational,regionalandglobaltargetsformalariacontrolandelimination as stated in the National Strategy for Malaria Control and Elimination for 2011–2020 and Vision for 2030,theWHO Global Technical Strategy (GTS) for Malaria 2016–2030aswellastheWHORegional Action Framework for Malaria Control and Elimination in the Western Pacific 2016–2020.

2. Providerecommendationstoredefinethepolicies,strategiesandsupportprogrammetransformationtosustainhighprogrammeperformanceinthefutureincludingreviewofnationalmalariapolicyandstrategicframeworksforplanning,management,implementationandtimelyreporting.

3. Reviewperformanceofmalariacontrolandeliminationactivitiesbythematicareas(programmemanagement,casemanagement,surveillanceandvectorcontrol)andatdifferentlevelsofservicedelivery(central,regional,provincial,district,commune,village).

4. ProvidetechnicaladviceandrecommendationsfortransitioningtheNationalMalariaControlProgrammefromamalariacontrolapproachtoamalariaeliminationapproach.

5. InvestigateandrecommendmethodstosustainresourcesandfinancingformalariacontrolandeliminationduringandafterVietNamreachesmalariaeliminationstatus.

6. InvestigateandrecommendmethodstointegratemalariacontrolandeliminationactivitiesinVietNam’sbroadercommunicablediseasecontrolandsurveillancesystem,particularlyattheprovincial,districtandcommunelevelsofthehealthsystem.

7. Assessthenationalmalariaprogramme’sapproachtocontainthespreadofartemisinin-resistantmalariainVietNamandacrossinternationalbordersintheregion,whichmaythreatenprogresstowardsmalariaelimination.

8. MakespecificrecommendationstotheNationalMalariaControlProgrammeofVietNam.

Onalloftheabove,andotherissuesashighlightedbyNIMPE:

Specifictermsofreferenceforthematicareateams

I. Programme Management Team

y InvestigateandrecommendmethodstosustainfinancingandotherresourcesformalariacontrolandeliminationafterVietNamreachesmalariaeliminationstatus,includingthroughhigh-leveladvocacy.

y AssesshumanresourcesplansandtrainingtowardsmalariaeliminationwithspecialattentionVietNam’splanstointegratediseasecontrolactivitiesattheprovinciallevelthroughtheprovincialcentrefordiseasecontrol.

y AssesscurrentstrategiesfordevelopingtheMalariaInformationSystem(MIS)andpotentiallylinkingMISwithexistingHealthManagementInformationSystem(HMIS)initiatives.

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Annex 1. Terms of reference for the malaria programme review

y ExplorepotentialcollaborativelinksandefficienciesofmalariaprogrammewithothercommunicablediseaseprogrammesinVietNam.

y Recommendmethodsofenhancingpartnershipswithstakeholders,NGOsandprivatesectorinaidoftheGovernment’sstrategyformalariaelimination.

y Determinetheappropriatenessandcompletenessofinterventionstargetinghigh-riskgroupssuchasmobilepopulations,migrantsandcross-borderpopulations.

II. Surveillance Team

y Reviewandassessmalariaepidemiology,riskstratificationandmapping. y AssessthemalariasurveillanceandresponsesystemandtheMISanddeterminewaysforwardfordevelopingandmaintainingasystemcapableofsupportingmalariatransmissionreductionandelimination.

y Reviewtheimplementationofcaseinvestigation,focusinvestigationandfocusresponse(especiallyintransmissionfociintheforest).

y Assesshumanresourcesandcapacity-buildingneedsforstaffatthelowerlevelsofinterventionspertainingsurveillanceandactivecasedetectionandresponse.

y AssesscurrentstrategiesfordevelopingtheMISandpotentiallylinkingMISwithexistingHMISinitiatives.

y ExploreoptionsforintegrationofexistingdiseasesurveillancesystemswiththeMIS.

III. VectorControlTeam

y Assessthestrategiesandproceduresofvectorcontrolmeasurestoguideprogrammeimplementationinlightofmalariaelimination.

y Reviewthetargetingandquantificationoflong-lastinginsecticide-treatedbednet(LLIN)particularlyforcontinuousdeliveryandinlightofrecentGlobalFundreprogrammingforLLINprocurements.

y ReviewmethodologyofLLINdistributioncampaigns. y Assessvectorcontrolqualityassuranceincludinginsecticideresistancemonitoring.

y Assessvectorcontrolandpersonalprotectionmeasuresexpectedtotargetthemostvulnerablepopulationssuchasmobileandmigrantpopulationsandtemporaryforestdwellers.

y Explorepotentiallinksandefficienciesofmalariaprogrammewithothercommunicablediseaseprogrammes,particularlywithothervectorcontrolprogrammessuchasdengueandZika.

IV. Case Management Team

y Determinetheefficiencyandeffectivenessofmalaria(falciparumandvivax)casemanagementfrompolicytoimplementationincludingindividualpatientfollow-up,surveillance,reportingandlinkagesbetweenthenationalmalariaprogrammeandcurative/generalhealth-carefacilities.

y Determinehowtoprovidecommunity-basedcasemanagementservicestoinaccessiblecommunitiesandhigh-riskpopulationsintheabsenceofasysteminvolvingvillagehealthworkers.

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y Assessmalariatreatmentguidelineandcasemanagementtrainingmethods. y AssessresearchactivitiesandplansandrecommendwaysinwhichthemalariaresearchagendacancontributetomalariaeliminationinVietNam.

y Assesstheresultsfromlatesttherapeuticefficacystudies,andreviewtheprogressofmonitoringofdrugefficacyanddrugqualityinlightofcontainingthespreadofartemisinin-resistantmalariainVietNamandacrossinternationalbordersintheregion.

y Assesstheeffectivenessofprocurementandsupplymanagementtomitigatestock-outsofantimalarialcommodities.

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Annex 2. Malaria programme review team members

Team1–Programmemanagement:ThanhHoaProvince,12–16September2017

1) DrMomoeTakeuchi,Coordinator,HealthSystemsDevelopment, WHOVietNam

2) DrNajibullahHabib,Malaria,otherVectorborneandParasiticDiseasesUnit, WHOVietNam

3) DrNguyenManhHung,NationalExpert,formerDirectorNIMPE

4) MrTruongMinhHieu,NIMPE(facilitator/translator)

Team2–Casemanagement:BinhPhuocProvince,12–16September2017

1) DrRabindraAbeyasinghe,Coordinator,Malaria,otherVectorborneandParasiticDiseasesUnit,WHORegionalOfficefortheWesternPacific

2) DrShuisenZhou,ChiefofMalariaDepartment,NationalInstituteofParasiticDiseases,People’sRepublicofChina

3) DrTaThiTinh,NationalExpert,DepartmentofResearchandTreatment,NIMPE

4) MrsNguyenVanHong,NIMPE(facilitator/translator)

Team3–Surveillance:ĐakLakProvince,12–16September2017

1) DrKimberlyAnnLindblade,TeamLeader,MalariaEliminationUnit, WHOHeadquarters

2) DrTranCongDai,MalariaotherVector-borneDiseasesUnit,WHOVietNam

3) DrLeXuanHung,NationalExpert,formerDeputyDirector,NIMPE

4) DrNguyenQuyAnh,EpidemiologyDepartment,NIMPE(facilitator/translator)

Team4–Vectorcontrol:DienBienProvince,12–16September2017

1) Dr Tessa Knox, Technical Officer, Entomology and Vector Control Unit, WHO Headquarters

2) Dr Sean Hewitt, Independent Malaria Expert, United Kingdom

3) Dr Vu Duc Chinh, National Expert, Head of Entomology, NIMPE

4) Mrs Lai Thi Hong Loan, NIMPE (facilitator/translator)

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Annex 3. People met

Central Level

MinistryofHealth

y DrNguyenThanhLong,ViceMinister

NIMPE/IMPEs

y AssociateProfessorTranThanhDuong,DirectorofNIMPE,DirectorofNMCP andVGFMalariaProjects(TFM,RAI)

y DrNguyenQuangThieu,DeputyDirectorofNIMPE,DeputyDirectorofNMCPandVGFMalariaProjects(TFM,RAI)

y AssociateProfessorNguyenManhHung,FormerDirectorofNIMPE,TrainingOfficerofVGFMalariaProjects–MalariaProgrammeReviewTeamMember

y AssociateProfessorLeXuanHung,FormerDeputyDirectorofNIMPE,M&EOfficerofVGFMalariaProjects–MalariaProgrammeReviewTeamMember

y DrTranQuangPhuc,Head,PlanningDepartment y DrNgoDucThang,Head,EpidemiologyDepartment y DrVuDucChinh,Head,EntomologyDepartment–MalariaProgrammeReview

Team Member y DrTaThiTinh,FormerHead,ClinicalDepartment–MalariaProgrammeReview

Team Member y DrBuiQuangPhuc,Head,ClinicalDepartment y DrNguyenQuyAnh,DeputyHead,EpidemiologyDepartment y DrCaoBaLoi,Head,TrainingandScienceDepartment y DrNguyenThiHang,DeputyHead,TrainingandScienceDepartment y MrsLaiHongLoan,Secretary,VGFMalariaProject

Partners

y DrNguyenTuanMinh,MalariaFocalPoint,PopulationServicesInternational-Viet Nam

y DrTranQuocTuy,MalariaProgrammeCoordinator,HealthPovertyAction- Viet Nam

y DrThuyTran,ProgramManager,ClintonHealthAccessInitiative-VietNam y DrColinOhrt,FoundingDirector,ConsortiumforHealthAction-VietNam

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Annex 3. People met

ThanhHoaProvince

1. CenterforMalariology,ParasitologyandEntomology y DrDoThanhTung, Director y MrLeBaKhanh,ViceDirector y MrNguyenHuuAn, HeadofEntomology y MrLeThiSau, HeadofFinance

2. Lang Chanh District Health Centre y DrDoThanhThuy, Director y DrLuongVanXuan, Vice Director y DrPhamVanTai, HeadofInfectiousDiseases y DrLuongVanPhu,HeadofDiagnostics y MrNguyenHuuGiang, Secretariat

3. Tri Nang Commune Health Centre y DrCaoVanCong, Head y MrHaVanHung, Staffinchargeofmalariacontrol

4. Tam Van Commune Health Centre y DrPhamVanSon, Head y DrPhamVanLuat, Vice-Head

5. LamPhuCommuneHealthCentre y DrHaVanTiep, Head y MrCaoVanLuan, Staffinchargeofmalariacontrol

6. Tho Xuan District Health Centre y DrNgoThiHoa, Director y MsTranThiLam, Staffinchargeofmalariacontrol

BinhPhuocProvince

1. BinhPhuocProvincialCentreforDiseaseControl y DrBuiVanQuan,Director y DrHuynhVanHanh,ChiefofPlanningandAccountancy

2. BuGiaMapDistrictHealthCentre y DrCaoVanMinh,Director y DrHoangVanTham,ChiefofCDC’sdepartment y DrNguyenKimThuy,StaffatCDC’sdepartment

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3. DakOCommuneHealthCentre y DrTranVanNhan,Head y MrPhanVanHuu,Technician y MrsHoangThiTuyen,VHWatvillage4 y MrsDieuThiDuyen,Volunteerinmalariapostatvillage4

4. BuDangDistricHealthCentre y DrNguyenVanBien,ViceDirector y MrTranThiChin,DeputyChiefofCDC’sdepartment y NguyenThiHongDuyen,StaffatCDC’sdepartment

5. Dak Nhau Commune Health Centre y DrTranDuyThao,Head y DieuThiHoai,Assistantdoctor,VHWatDangLangvillage y VuongNuHuyenTrang,VolunteerinmalariapostatDangLangvillage

6. BomBoCommuneHealthCentre y DrPhamNgocThanh,Vice-Head y DrNguyenXuanPhuoc,Privatesector

Dien Bien Province

1. DienBienProvincialProjectManagementUnit y DrNguyenChauSon,HeadofProfessionalDepartmentofDienBienProvincialHealthServices

y DrNguyenQuangNgoc,DirectorofProvincialCentreforMalariaControl(PCMC)

y DrNguyenThiMan,Vice-DirectorofPCMC y MrNguyenDanhDong,ChiefaccountantofPCMC y MrsLeThiLan,Storekeeper y MrLeKhacThong,Microscopist

2. DienBienDongDistrictHealthCentre y DrNguyenVanMinh,Director y DrCaoThiLy,Vice-Director y DrHoangVanBac,HeadofDistrictTeamofPreventiveMedicine y DrLoVanTrong,Vice-HeadoftheDistrictTeamofPreventiveMedicine y MrPhamXuanCuong,StaffmemberoftheDistrictTeam y MrNguyenDuyDai,HeadofPlanningDepartment y DrLoVanHong,StaffmemberoftheDistrictTeam y MrBuiDangBac,Accountant

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Annex 3. People met

3. NaSonCommuneHealthCentreofDienBienDongDistrict y DrLuongVanMang,Head y MrsLoThiTinh,Vice-Head y MsQuangThiPhuong,Nurse y MsTongThiHuongQuyet,Staffinchargeofmalariacontrol y LoThiLa,Midwife y QuangVanOi,VHWofNaPhatAvillage(Thaivillage) y MrLoVanTruong,HeadofNaPhatAvillage y LauThiDanh,VHWofHoCovillage(Hmongvillage)

4. TuanGiaoDistrictHealthCentre y DrTrinhDucLong,Director y DrVuongQuyNgoc,HeadofDistrictTeamofPreventiveMedicine y MrsNguyenThiQuynhHoa,Staffmemberofthedistrictteam y MrsPhamThanhThuy,HeadofExaminationDepartment(Laboratory) y DrVuaThiCua,Vice-HeadofInfectiousDiseasesDepartment y MrsNguyenThiHoa,HeadofPlanningDepartment y MrsLeThiThuy,StorekeeperinDepartmentofPharmacy

5. QuaiToCommuneHealthCentreofTuanGiaoDistrict y DrLoThiDung,Vice-Head y MrLuongVanThien,Staffinchargeofmalariacontrol y MrLoVanSang,VHWofNaHoivillage

Dak Lak Province

1. CentreforMalariology,ParasitologyandEntomology y DrHoangHaiPhuc,Director y DrHoTanTien,Vice-Director y DrNguyenChauThanh,HeadofPlanningDepartment y DrLeVanTu,HeadofEpidemiologyDepartment y MrDinhMinh,HeadofEntomologyDepartment y DrNgoThiTam,HeadofLabandParasitology y DrYDaoAyun,Vice-HeadofPlanningDepartment

2. BuonDonDistrictCentreforPreventiveMedicine y DrVuMinhHung,Director y MrYBunToan,MalariafocalpointinOutbreakControlDepartment y MrToVanDich,Vice-HeadofPlanningDepartment y MsDuongThiMinhTam,PlanningDepartment y MrTranVoHoangDung,OutbreakControlDepartment y MrLeKhoiQuyet,Staff

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3. K’rongNaCommuneHealthStation y MrYsoiHwing,DeputyDirectorandMicroscopist y MrH’XaLungKbour,Malariafocalpoint

4. Thong Nhat Village y MsPhamThiMinh,Villagehealthworker

5. K’rongBongDistrictPreventiveHealthCentre y MrNguyenTuanViet,Director y MsNguyenThiBaoTram,MalariafocalpointinOutbreakControlDepartment y MsNguyenThiNga,Accountant

6. K’rongBongDistrictHospital y RepresentativeofDepartmentofInternalMedicine,Pediatricsand InfectiousDiseases

y RepresentativeofLaboratory

7. CuPuiCommune y MrTruongVanBao,HeadofCommuneHealthstation y MrVoThiTuKa,Malariafocalpoint

8. EaRokVillageHealthPost y MrDuongVanDe,staffinchargeofEaRokVillageMalariaPost

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Annex 4. Service delivery systems

VietNamhasawell-establishedpublichealth-carenetwork.Healthserviceprovisionhastwoarms:thecurative(hospital)systemandthepreventivemedicinesystem.Currently,there are challenges in linking and coordinating the two systems in some districts. In May 2014, the Prime Minister approved Decision 37, governing a restructuring ofthefunctionsandresponsibilitiesofspecializedagenciesofthePeople’sCommitteesofdistricts, provincial towns and cities of provinces. This restructuringwill enhance thelinkagebetween thepreventiveandcurativearms.Activitiesunder theHealthSystemsStrengthening Global Fund Grant will collaborate with the National Malaria ControlProgramme(NMCP)tobuildcapacityinhealthmanagementandservicedelivery.

Specializedmalariacontrolservicesareresponsibleformalariacontrolnationwide.TheNMCPandtheNationalInstituteofMalariology,ParasitologyandEntomology(NIMPE)arecentralinstitutionsresponsiblefornationwidetechnicaldirectionandmalariacontrolactivitiesinthenorthernprovinces.TheregionalInstituteofMalariology,ParasitologyandEntomology(IMPE)QuyNhonisresponsibleformalariacontrolactivitiesinthecentralprovincesandIMPEHoChiMinhCityisresponsibleformalariacontrolactivitiesinthesouthernprovincesandLamDong (acentralprovince).ACentral SteeringCommitteetogetherwithaProvincialSteeringCommittee,DistrictSteeringCommittee,communesand other bodies work towards planning and coordinating operations. The Central SteeringCommitteemeetstwiceayeartoplanactivitiesandforoversight.

In the 24 most endemic provinces, there is a separate Provincial Center for MalariaControl(PCMC).Inlessendemicprovinces,theProvincialCentreforPreventiveMedicine managesmalariacontrolwithasmallerDepartmentforMalariaControl.Malaria-endemicdistricts (those with communes in malaria stratification zones 3-5) also each have aDepartmentforMalariaControlwithamalariafocalpoint.Theyalsohavecommunalorinter-communalmalariamicroscopypoints.Innon-endemicdistrictsanymalaria-relatedservicesareprovidedthroughadistrictcentre forpreventivemedicine.Eachcommunehas a commune health centre (CHC) and in malaria-endemic communes these havespecializedstaffresponsibleformalariacontrol.

At theperipheral level, thepolicy is to haveonevillagehealthworker (VHW) ineach village. These VHWs are members of the community who receive training from theprovincialhealthservice,oftenatthedistrictlevel,tocopewiththemostcommonmedicalneedsofthepopulationofthevillage.VHWsarethebackboneofthecommunity-levelhealthresponseinVietNam.VHWsarenotfull-timeemployedgovernmentofficials,butdoreceiveanallowancefromthegovernmentbudget forthetimestheyareengaged inoutreachactivities,mainlyfocusedonhealthpromotionandprevention.Theyareunusualin theGreaterMekong Subregion in that theyare notvolunteers and theydiffer fromCambodia’s villagemalariaworkers, for example, in that they are relatively extensivelytrained.VHWsreceiveamonthlyallowancethatisequalto30%ofthebasicsalaryofagovernmentofficer,whichtranslatestoaroundUS$15permonth.13Formoredisadvantagedcommunities,theallowanceisequalto50%ofthebasicsalary,whichisaroundUS$25per month. Generally VHWs are paid from provincial budgets but in disadvantagedcommunesthecentralbudgetwillprovidesupportforoneVHW.WherethereisaneedforVHWstoprovideadditionalservices,thisrequiresadditionalfinancialincentivesandothersupport(e.g.transportfees).Inaddition,theNMCPworksincloseassociationwithtwokeynationalcommunitygroups:theWomen’sUnionandtheYouthUnion.

13 Thebasicsalaryofagovernmentofficeris1.15milliondong(aboutUS$50).

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Role of the private sector.AsurveyconductedinBinhPhuocProvincein2011suggestedthataround13%ofresidentpatientsand23%ofmigrantswereaccessinginitialhealthcarefromtheprivatesector.14Howeverthesituationvariesfromoneprovincetoanotherandtheroleoftheprivatesectorhasbeenincreasinginrecentyears.ItfollowsthereforethattheBinhPhuocstudyresultsareprobablynotrepresentativeofthecountryasawholeandareprobablyalsoalreadyoutdated.Inreality,littleisknownatpresentabouttheprivatesector’sroleinthedeliveryofmalariacasemanagementinVietNam.TheNMCPrecognizesthat this isan importantshortcoming. Italso recognizes that ithas limitedexperiencein dealingwith private sector-related issues. In order to address this problemNIMPEthereforerecentlyengagedwiththeinternationalNGOPopulationServicesInternational(PSI), which has extensive Greater Mekong Subregion-related expertise in this field.Asaresult,acollaborationbetweenNIMPEandPSIhasbeenestablishedandstepsarenowbeing taken toaddress this importantknowledgegap.PSIhassecured funding toconductalarge-scalesurveyofprivatesectorpharmaceuticaloutletsinVietNamin2015(ACTwatch).Theresultsofthissurveywillinformthedevelopmentofanationalstrategytobetteraddresstheissueofmalariacasemanagementintheprivatesectorinfuture.Itislikelythatsubstantialadditionalfundingwillberequiredtoimplementthisnewstrategy.

14 Nguyen Quy Anh & Le Xuan Hung, unpublished data, 2011.

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Annex 5. Regional Framework for Action on Transitioning to Integrated Financing of Priority Public Health Services

Http://www.wpro.who.int/about/regional_committee/68/documents/wpr_rc68_8_annex_integrated_financing.pdf?ua=1

AWHORegionalOfficefortheWesternPacificDivisionofHealthSectorDevelopmentand Division of Communicable Diseases joint document identifies three main actionpointsrequiredforasmoothtransitionfromaverticallyfundedprogrammaticapproachto a whole-of-system approach. These are: 1) Confirm core programme elements andservicedeliveryarrangements;2)Strengthenfinancinginstitutionstomakebetteruseofavailableresources;and3)Increasedomesticfinancing.Manyoftheactivitiesproposedinthisdocumentmaybeapplicabletothemalariapost-eliminationcontext.

Annex 6. A System-wide Approach to Analysing Efficiency across Health Programmes

http://www.who.int/health_financing/documents/system-wide-approach/en/

A new WHO headquarters document that presents the steps for analysing cross-programmeefficiencieswith someguidingquestions for analysis of different elementssuchasstakeholders,servicedelivery,financing,humanresources,medicines,governanceand policydevelopmentoptions.Althoughquite theoretical, thedocument provides ausefulframeworkforanalysisandforthedevelopmentofabusinessplan.

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Annex 7. Guidelines for establishing an independent national malaria elimination advisory committee

The newWHO Framework forMalaria Elimination calls for establishing independentnational malaria advisory committees in malaria-eliminating countries (MECs). Thepurposeofthesecommitteesistoprovideanexternalviewofprogressandgapsinmalariaeliminationprogrammes,assistinadaptingWHOguidancetothenationalcontext,andreviewmalariatrendsandprogresstowardselimination.

Thecommitteeshouldbeindependentfromthenationalmalariaprogrammetoprovideafrankandopenreviewoftheprogramme’sactivities,strengthsandweaknesses.Severalcountriesthathaveestablishedsuchorsimilarcommitteeshavebenefittedfromretiredacademicorgovernmentmalariaexpertsascommitteechairpersons.

Duringtheinauguralglobalforumofcountriesthathavethepotentialtoeliminatemalariaby2020(theE-2020countries)thatwasheldinGenevafrom16to17March2017,manycountriesreportedhavingestablishedsimilarbodies;however,mostcommitteesarenotfullyoperational.Thepurposeofthisdocumentistoprovidegenerictermsofreferencethatnationalprogrammescanuse todevelop theirowntermsof referenceandrelatedoperatingprocedures.

1. Termsofreferencefortheindependentnationalmalariaeliminationcommittee

y AdvisethenationalmalariaprogrammeonimplementationoftheNationalStrategicPlanformalariaelimination.

y Monitorprogresstowardselimination. y ProvideassistanceinadaptingWHOguidelinesandpolicies. y Identifybottleneckstowardselimination,developpotentialresponsestoaddresstheseissues,andevaluatebottleneckresolution.

y SupportthenationalmalariaprogrammeinthepreparationofthenationaleliminationreporttobesubmittedtotheWHOMalariaEliminationCertificationPanel(CEP).

y Advisethenationalprogrammeontheplantopreventre-establishmentofmalariatransmission.

y Formadhoc thematicworkinggroups,e.g.surveillance,casemanagementandvectorcontrol(dependingoncountryneeds).

Subnationalverificationofmalariaeliminationisanoptionforlargecountriesthathaveachieved interruption of local transmission in certain parts of their territory (states,regions or provinces). The subnational verification ismanaged by the national healthauthoritiesofthecountryconcerned;WHOwillonlybeinvolvedinnationalcertification.The independentnationalmalariaeliminationadvisorycommitteeshouldmonitorandverifytheworkofthenationalprogrammeinsubnationaleliminationandhelpdocumentverificationofelimination(whererelevant).

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Annex 7. Guidelines for establishing an Independent National Malaria Elimination Advisory Committee

2.Compositionofthecommittee

Thecommitteeshouldbeindependentfromthenationalmalariaprogrammeandcouldcomprisethefollowingtypesofmembers:

y retiredacademicorgovernmentmalariaexperts; y healthsystemspecialists; y expertsfromothervectorbornediseases; y representative/sfromacademia; y representative/sfromresearchinstitutions; y representative/sfromprivatesector;and y expertsfrominformation,healtheducationorcommunicationforbehaviourchange.

WHOcouldbeincludedasatechnicalpartner,whileotheraidagencies,othertechnicalpartners,donorsandINGO/NGOcouldserveasobservers.

Countriesshouldidentifyaprocessforappointingmemberstothecommittee,aswellasthelengthoftheirtenure.Considerationshouldalsobegiventoinvitingrelevantgovernmentpersonnelfromotherpartsofthegovernmentandrepresentativesfromotheragenciestoserveasobserversand/ortomakespecificpresentationstothecommittee.

3.Meetingprocedures

The committee should meet on a regular basis as determined by country needs and resources.Thesecretariat(i.e.thenationalprogramme)shoulddevelopandcirculatetheagendaofthemeetinginadvance.Additionalrelevantpartnerswillbeinviteddependingontheagendaofthemeeting.Thesecretariatshouldproduceconcreterecommendationsandactionitems,alltobemadepubliclyavailableontheMinistryofHealthwebsite.

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Annex 8. Outcomes from insecticide resistance monitoring for Anopheles spp. in Viet Nam

Summary table of outcomes from insecticide resistance monitoring forAnopheles spp. in Viet Nam by standard WHO susceptibility tests, 2010–2016 Blue shading indicates where resistance has been confirmed (i.e. minimummosquitomortality<90%).

Insecticideclass Vectorspecies Numberofsites tested

% mosquito mortality

Mean Minimum Maximum

Pyrethroidsa An. aconitus 13 97% 80% 100%An. annularis 2 89% 78% 98%An. dirus s.l. 7 99% 94% 100%An. epiroticus 11 81% 50% 97%An. jamesii 2 99% 98% 100%An. jeyporiensis 7 100% 98% 100%An. kochi 12 98% 75% 100%An. maculatus s.l. 10 93% 76% 100%An. minimus s.l. 20 97% 79% 100%An. nimpe 1 100% 100% 100%An. nivipes 4 96% 87% 100%An. philippinensis 32 96% 75% 100%An. sinensis s.l. 7 53% 7% 99%An. splendidus 1 99% 98% 99%An. subpictus s.l. 2 98% 95% 100%An. tessellatus 9 98% 94% 100%An. vagus 4 63% 37% 91%

Organochlorineb An. minimus s.l. 1 100% 100% 100%a Lambda-cyhalothrin 0.05%, alpha-cypermethrin 0.05%, deltamethrin 0.05% b Dichlorodiphenyltrichloroethane (DDT) 4.0%

national malaria programme review – viet nam · 2018-08-09 · reorient the programme for malaria...

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