Research Article: A Research Agenda for Malaria Eradication: Monitoring, Evaluation, and Surveillance

Date Published: January 25, 2011

Publisher: Public Library of Science

Author(s): unknown

Abstract: The Malaria Eradication Research Agenda (malERA) Consultative Group on Monitoring, Evaluation, and Surveillance present a research and development agenda for the tools required to monitor and evaluate progress toward malaria eradication.

Partial Text: Monitoring (the systematic tracking of program actions over time) and evaluation (the examination of progress and its determinants) activities measure how well public health programs operate over time and whether they are achieving their program milestones (markers of progress within and transition between phases) and ultimate goals. In the context of malaria program scale-up, monitoring and evaluation focuses on the evaluation of burden reduction, specifically morbidity and mortality [1]. However, as programs successfully reduce transmission to near-elimination levels, the measurement of malaria-associated morbidity and mortality burden becomes increasingly difficult and insensitive, particularly since a substantial proportion of infections will be asymptomatic in countries that experienced high infection rates in the recent past. Thus, burden measures that only detect clinical illness will not provide good estimates of ongoing transmission as countries approach elimination, and malaria program monitoring and evaluation and surveillance methods will need to focus on detecting infections (with or without symptoms) and measuring transmission dynamics as the primary indicators of interest.

Several diseases other than malaria have been proposed for eradication or elimination. General lessons learned from these other disease elimination efforts have been summarized and underscore the critical role that monitoring and evaluation and surveillance play in these efforts [5]–[9]. The essential role of monitoring and evaluation and surveillance in informing elimination program efforts is particularly clear in past smallpox efforts and ongoing polio activities. Many countries have either eliminated or are in the process of pursuing malaria elimination. There is, therefore, a clear need to systematically review and summarize the monitoring and evaluation and surveillance lessons learned from both successful and unsuccessful disease elimination programs. In the context of malaria elimination, efforts are underway to summarize and disseminate recently accrued experience [2],[10]. This review work should be done even before the elimination phase.

The current Monitoring and Evaluation Framework for malaria comprises a series of activities, namely, Assessments and Planning, Inputs, Processes, Outputs, Outcomes (intermediate effects), and Impact (long-term effects; Figure 1A) [1]. Each part of this schema can be monitored with a specific set of indicators that tracks progress in program implementation. Historically, the malaria community has focused on illness and mortality reduction as indicators of impact, but will these and the other current indicators shown in Figure 1A serve us well for elimination efforts?

As noted in the Introduction, monitoring and evaluation are critically required for measurement of malaria control program success. Over time, the term “surveillance” has become somewhat synonymous to some with monitoring and evaluation, but the WHO Global Malaria Eradication Program (GMEP), which lasted from 1955 to 1969, defined surveillance quite specifically as an integral action or intervention within that eradication program (Box 1) [13].

The overall strategic approach and mix of actions to address transmission is critical, but the identification and development of key tools and actions to optimize these strategic actions is equally important. Improved diagnostics for screening and surveillance, optimal use of drugs to reduce transmission [25], better mapping and use of mapping to track foci of infections, and improved communications for timely sharing of information and response are all important.

The new strategies proposed in this paper by the malERA Consultative Group on Monitoring, Evaluation, and Surveillance for eradication have major implications for implementation, and research is needed to test best systems of delivery for acceptability, feasibility, efficiency, and cost-effectiveness. Box 2 draws our discussions together in the form of a research and development agenda for monitoring, evaluation, and surveillance.



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