October 2013

Assessment of health systems in relation tointerface between malaria control programs
and health system strengthening:
Comparative study among Lao PDR, Nepal
and Viet Nam

NCGM REPORT
October 2013

Assessment of health systems in relation tointerface between malaria control programs
and health system strengthening:
Comparative study among Lao PDR, Nepal
and Viet Nam

Researchers
Bureau of International Medical Cooperation,
National Center for Global Health and Medicine, Japan
Dr. Hiroshi Ohara
Dr. Shinichiro Noda
Dr. Yasuyo Matsumoto
Dr. Takanori Hirayama
Dr. Noriko Fujita
Dr. Yuriko Egami
Dr. Hitoshi Murakami
Dr. Hidechika Akashi
Dr. Tamotsu Nakasa

Collaborators
Survey in Lao People’s Democratic Republic (PDR)
Dr. Bounfeng Phounmmalysith (Cabinet, Lao Ministry of Health)
Dr. Bouasy Hongvanthong (Center for Malariology, Parasitology and Entomology)
Survey in Nepal
Prof. Jeevan B Sherchand (Institute of Medicine, Tribhuvan University)
Dr. Jatan B Sherchan (Faculty of Medicine, Kathmandu University)
Survey in Viet Nam
Dr. Vu Huy Nam (National Institute of Malariology, Parasitology and Entomology)
Ms. Le My Dieu (Vietnam Red Cross)

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NCGM Report October 2013

Contents

Executive summary

06

Abbreviations

10

Background

11

Objective

13

Methods

14

I. General health system

18

I-1 Outline of general health system in the three target countries

18

I-2 Characteristics of the general health system of each country201) Viet Nam
2) Nepal
3) Lao PDR
II.

Malaria control with special references to health system

25

II-1 Outline in the three countries25

II-2 Characteristics of malaria control in relation to
the health system of each country271) Viet Nam
2) Nepal
3) Lao PDR
II-3 Special notes on malaria control in relation to health systems

33

II-4 Arising problems

35

II-5 Assessment of integration between the National Malaria Control
Program and general health systems in Lao PDR

36

III.

Good practices in malaria control

38

IV.

Bottlenecks and possible interventions

40

V.

GFATM support for malaria control in the three countries

42

Discussion

44

Acknowledgements

46

Bibliographies

47

Attachment 1 (Good practices in malaria control)50

Attachment 2 (Bottlenecks and possible interventions)

52

NCGM Report October 2013

5

Executive summary

Global Health Initiatives (GHIs) such as the Global Fund against AIDS, Tuberculosis andMalaria (GFATM) and the Global Alliance for Vaccines and Immunization (GAVI) havesupported disease specific programs, resulting in effective control measures in many
developing countries. However, there is still some debate regarding the interaction
between these programs and the general health systems, as well as some bottlenecks
that hinder the smooth implementation of the programs.
This assessment was undertaken with malaria control programs in three countries (Lao
PDR, Nepal and Viet Nam) as entry points, in order to assess the interface between
malaria control programs supported by GFATM and health systems strengthening, withspecial reference to interaction between disease specific programs and general healthsystems. Good practices and bottlenecks in the implementation of the control programs
were identified, and possible solutions for these bottlenecks along with synergic healthsystem interventions to be incorporated into disease control programs were discussed.
Primary surveys in this report were conducted in Viet Nam (2009), Lao PDR (2011) and
Nepal (2012). In Viet Nam and Nepal the surveys were carried out with special emphasis
on best practices and bottlenecks in the implementation of malaria control programs,
while in Lao PDR, surveys were carried out on the integration of malaria control programs
into the general health systems. In each country, the survey was conducted at various
levels (from Ministry of Health to primary level) by document reviews, key informant
interviews, and observation of facilities. The results of the primary surveys were analyzed,
summarized in reports and submitted to HSD/WPRO. Based on these reports, updating
and supplementing more information, and comparative analysis among these three
countries, were performed.
In the three countries in this survey, malaria morbidity along with mortality rates werequite high in the past and malaria was given the highest priority in the health policyby the administration. However, since the mid-1990s, malaria controls were actively
implemented in these countries based on the National Malaria Control Programs (NMCPs)
6

NCGM Report October 2013

and principles of Roll Back Malaria, which consists of strategic priorities including vector
control and personal protection, early diagnosis and prompt treatment (EDPT), malaria
surveillance and epidemic preparedness, behavioral change communication (BCC), andimproving program management. In particular, since early 2000s, GFATM has contributed
a large budget to malaria control programs. Recently, malaria in these countries has
decreased remarkably; reaching pre-elimination levels (Viet Nam and Nepal) or is nolonger listed among from the top 10 diseases (Lao PDR).
In Viet Nam, the government has made great efforts to strengthen the existing healthsystems since the 1990s (both malaria specific and general health systems) and theinternational community also cooperated with the policy implementation of Vietnam atvarious health system levels. Malaria control measures were effectively implemented
under the strong leadership of the National Steering Committee, further strengthening
and utilizing the existing health system and mobilizing mass organizations.
In Nepal, the general health system, which was fragile in the past, was strengthened
and utilized in greater part in the malaria control program. During the period ofpolitical instability (1996-2006), health systems were affected, but the influence onmalaria control was minimal compared with other disease control programs due to thehigh governmental priority placed on malaria control and continuous support of theinternational community.
In Lao PDR, both general health systems (horizontal systems) and specific health systems
for malaria control (vertical systems) were weak. After the GFATM intervention, large
funds were invested in vertical systems and dissociation from horizontal systems became
noticeable. Integration of a malaria control program in the general health system is still
limited or partial, and budgetary dependence on GFATM is quite large.
Generally, at upper levels, collaboration among disease specific programs is limited, and ahealth staff, as well as an infrastructure, is dedicated to each program. However, there is
NCGM Report October 20137

greater integration at lower levels of health care (in Vietnam and Nepal). By coordinatingwith the community and social organizations in the village, health workers carry out
various tasks such as primary health care, implementation of national health programs,
preventive medicine, IEC activities, etc. GFATM and other assistant partners provide
support by strengthening training and supplying essential medicine and equipment.
Malaria control has gradually been more integrated with the primary health care system.
As a result from the surveys in Viet Nam and Nepal, best practices were identified. Amongthem intensified education for residents focusing on disease prevention, strengtheningof facilities at primary level such as health posts along with training of health workers,
utilization of health volunteers at the primary level, high priority attached to frontierareas, and setting up mobile teams, were noteworthy and recognized in common in
the two countries. In addition, effective implementation under the strong leadershipof National Steering Committee could be seen in Vietnam, utilizing the existing heath
system was outstanding. The management system of vertical health programs appeared
to have a good impact on the general health system.
In Lao PDR, a survey was conducted focusing on the integration between the malaria
control program and general health systems, and the results showed that the extent ofintegration was quite limited in many elements of program implementation. Particularly,
in health information, supply management (procurement, storage, and distribution), andmonitoring & evaluation, separate systems were set up between malaria control program
implementation and the general health systems. The national health management andinformation system (HMIS) was considered to be weak, incomplete and unresponsive.
Separate financing, governance and planning functions for other disease specificprograms, such as Tuberculosis and HIV, distinct from those of the general health system,
were also observed.
Bottlenecks/challenges in implementing malaria control were identified in two countries(Viet Nam, Nepal), and points in common included malaria control in frontier areas (many8

NCGM Report October 2013

hard-to-reach areas, shortage & low skill of manpower, etc.), low incentives for healthworkers, a poorly developed reporting system from the private health sector, inadequate
quality assurance system for malaria testing (particularly in Nepal). Most health workers
are concentrated in large cities and towns, while many health facilities at the primarylevel (Health Centers; HCs, Primary Health Care Centers; PHCs, Health Posts; HPs, SubHealth Posts; SHPs) and at some district hospitals the health personnel and/or medical
supplies are insufficient. Weak coordination between the local government and GFATM
in the distribution of bed nets was pointed out in Nepal. In addition, the current heavy
dependence on GFATM undermines the assurance of sustainable malaria control.
Disease specific programs such as malaria control have had some synergic effects on
the general health system, particularly at the primary level. The management system ofvertical health programs appeared to have a good impact on the general health system atvarious levels. However, it can be said that dissociation between vertical malaria control
program and horizontal general health system also exists. In addition, coordination
between malaria control programs and other disease specific programs is limited inmany cases. It is true that in implementing malaria control programs, carrying out avertical health system is important, but scaling up the malaria control program does not
automatically lead to general health system strengthening. More effort is needed torealize the maximum synergy between disease specific programs and the general healthsystem, as well as among different health programs.

NCGM Report October 20139

Abbreviations

10

ACT

Artemisinin Combination Therapy

BCC

Behavioral Change Communication

CHS

Commune Health Station

CMPE

Center for Malariology, Parasitology and Entomology (Lao PDR)DHODistrict Health Office

EPI

Expanded Program on Immunization

EDCD

Epidemiology and Disease Control Division (Nepal)

FCHV

Female Community Health Volunteers (Nepal)

GAVI

Global Alliance for Vaccines and Immunization

GFATM

Global Fund against AIDS, Tuberculosis and Malaria

GHIs

Global Health Initiatives

HC

Health Center

HMIS

Health Management Information System

HP

Health Post

HSD

Health System Development

IEC

Information, Education and Communication

IRS

Indoor Residual Spraying

ITNs

Insecticide-treated Bed nets

LLINs

Long Lasting Insecticidal Nets

MCH

Maternal and Child Health

MOH

Ministry of Health (Viet Nam, Lao PDR)

MOHP

Ministry of Health and Population (Nepal)

NCGM

National Center for Global Health and Medicine, JapanNGO

Non Governmental Organization

NIMPE

National Institute of Malariology, Parasitology and Entomology (Viet Nam)

NMCP

National Malaria Control Program

PHC

Primary Health Care Center

PHD

Provincial Health Department (Viet Nam, Lao PDR)

PR

Principal Recipient

RCC

Rolling Continuous Channel

RDT

Rapid Diagnosis Test

RHD

Regional Health Department (Nepal)

SHP

Sub-health Post

WHO

World Health Organization

NCGM Report October 2013

Background

Since 2000, Global Health Initiatives (GHIs; GFATM, GAVI, etc.) have provided a new
era for infectious disease control programs and have achieved a degree of progress
at country level. However, since their initiation, interaction between GHIs and Health
System Strengthening (HSS) has been debated: whether disease specific programs haveactually contributed to the strengthening of the general health system and whether
disease control programs are well integrated into the general health system.
In the program implementation process, smooth implementation of the disease control
programs has often been hindered by bottlenecks that exist in the health system.
Through the effective intervention to these bottlenecks, expansion of the healthprograms and strengthening of the general health system are expected, which will bring asynergic effect on other disease specific programs as well (Fig. 1).

Fig. 1
Concept of bottleneck analysis and possible interventions to scale up synergic effects on otherdiseases specific programs

NCGM Report October 2013

11

The Bureau of International Medical Cooperation, National Center for Global Health andMedicine (NCGM) in Tokyo has been designated as a WHO Collaborating Center since July2009 with the following terms of reference:
1) To undertake the assessment of health system strengthening interventions particularly
regarding their coordination with various health programs2) To provide technical consultations on health system strengthening in relation todisease control programs
With the aim of sharing lessons learned from specific country experiences with regard togood practices, bottlenecks and/or challenges in the implementation of disease specificprograms, as well as the effects of disease specific programs supported by GHIs on healthsystem strengthening, NCGM conducted surveys in Cambodia (on EPI and HIV) and
Vietnam (on malaria and EPI) in 2009 as entrusted by HSD/WPRO. The results of thesesurveys were presented at the Workshop on Synergies between Global Health Initiatives
and Health Systems, which was held at WPRO in Manila in November 2009. Subsequently
similar surveys were conducted in Lao PDR (on Malaria) in 2011 and Nepal (on Malaria) in2012.
In 2012-13, NCGM intends to review and summarize the surveys over the past 3 years
and summarize them. The present report focuses on malaria control programs supported
by GFATM, the interaction between disease specific programs and health systemstrengthening, as surveyed in three countries (Vietnam, Lao PDR and Nepal). Results are
summarized and a cross-sectional assessment has been performed.

12

NCGM Report October 2013

Objective

To assess 1) the interface between malaria control programs and health systemstrengthening, with special reference to the interaction between vertical and horizontal
health systems, 2) good practices and bottlenecks in the implementation of control
programs, and 3) synergic health system interventions to be incorporated into disease
control programs.

Specific Objectives
1) Share lessons learned from specific country experiences of interventions tobottlenecks (good practices).
2) Identify existing bottlenecks in health systems, which prevent the smooth
implementation of the malaria control programs, and discuss feasible interventions
for these bottlenecks.
3) Investigate the integration of the National Malaria Control Program into the general
health system.
4) Identify synergic health system interventions to be incorporated into disease control
programs,
5) Compare the results among the three countries.
The studies in Viet Nam and Nepal mainly focused on 1), 2) and the study in Lao PDR on 3).

NCGM Report October 201313

Methods

Primary surveys in this report were conducted in Viet Nam (2009), Lao PDR (2011) and
Nepal (2012), by setting the NMCPs supported by GFATM as entry points. In Vietnam
and Nepal, the surveys were conducted with special emphasis on good practices andbottlenecks in implementing malaria control program. In Lao PDR, the survey was
conducted on the integration of a malaria control program into the general healthprogram. The dates of the surveys and the places where the surveys were conducted areshown in Figs. 3-5. Study methods consisted of the following:
1) Document reviews:
Documents related to health systems, NMCPs, health statistics, GFATM supports, etc.
were collected and reviewed.
2) Key informant interviews:
Key informant interviews were conducted with the health staff at each level (central,regional, district, and community level) of the health facility, health managers at the
district and provincial levels, and program managers of MOH (MOHP), NGOs, and otherpartner agencies. Leading contents of the interview included an outline of the healthsystem, general information on malaria control programs in relation to health system.
Good practices and strengths to overcome bottlenecks, and on-going interventions forthe existing bottlenecks, integration between NMCP and general health system, etc.,
were also considered
3) Field surveys :In addition to surveying the capital cities of each country, malaria endemic areas
where Malaria Control Programs have been implemented with the support of GFATM
were selected. General information on health and medical care, information on healthsystem and health program implementation, etc. were collected at Provincial Health
Offices, District Health Offices, followed by surveys at health facilities at the primarylevel (or commune level )(HCs, PHCs, HPs, SHPs).

14

NCGM Report October 2013

4) Analysis:
Information obtained from the interviews, field surveys, documents were summarizedfrom the viewpoint of interface between malaria control programs and the general
health system in accordance with the 6 building blocks of a health system (Leadershipand governance, Service delivery, Workforce, Information system, Medical products
and technology, and Financing) proposed by WHO. These results were analyzed andcompared among the three countries and then assessed.
Data from the three countries was updated as long as possible, based on information
obtained by supplemental survey (in Viet Nam and Nepal) during 2012-13 and by
documents.
The framework of analysis on good practices conducted for malaria control toovercome the bottlenecks and current bottlenecks vs. possible interventions (VietNam, Nepal) were summarized in Table 1. The framework on integration between
the National Malaria Control Program and the general health system (Lao PDR) weresummarized in Fig 2 .

Table 1
Framework of Analysis (Nepal, Viet Nam)
6 building blocks of
Health System (HS)

Bottlenecks (past) /Good practices

Bottlenecks (current) /Possible solution

Effects on HS, PHC
principle, Synergy

Leadership and Governance
Service delivery
Workforce
Information system
Medical products
and technologies
Financing

NCGM Report October 201315

Fig. 2
Framework of Analysis (Lao PDR)

Fig. 3
Survey in Viet Nam

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NCGM Report October 2013

Fig. 4
Survey in Nepal

Fig. 5
Survey in Lao PDR

NCGM Report October 201317

I. General health systems

I-1. Outline of the general health system in the three targeted countries:
Health networks in the three target countries have been created from the central tocommune level in accordance with the administrative strata (eg. in Viet Nam; central provincial - district - commune levels, in Nepal; central - regional - district - commune
levels, in Lao PDR; central - provincial - district - commune levels). Curative care systems
as well as preventive care systems have also been basically constructed in accordancewith the administrative strata. (i.e. central, provincial (or regional) and district hospitals
and commune health stations, etc.). A referral system, as well as health information andsupply systems, is functioning based on this network. The preventive care systems basicallyconsist of national institutes, provincial (or regional) preventive health centers, district
preventive health centers (or preventive health teams) and commune health center andhealth stations. Fig. 6 shows the Health System in Viet Nam (including the Malaria Control
System).
Fig. 6
Health System & Malaria Control System (Viet Nam)

NIMPE Vietnam, 201218

NCGM Report October 2013

Medical institutions at the central level, which are directly under the control of Ministryof Health (MOH)(in Nepal Ministry of Health and Population; MOHP) and located in large
cities, provide the highest level of medical services (as top referral hospitals, research,
prevention and training centers, etc.).
At the provincial (regional) level, the Provincial Health Department (Regional Health
Office) is responsible for medical services. Medical institutions at this level consist ofGeneral Hospitals (at least one hospital is set up in a province), Specialized Hospitals,
Preventive Health Centers, Malaria Control Centers, Middle Level Schools or Colleges, etc.
At the district level in Viet Nam, the District Health Office (DHO) functions as the
management office of medical services in the district and the District Health Center (DHC)
is a technical agency responsible for the practice of curative and preventive medicines.
Under the DHC there are General Hospitals, District Hospitals, Regional Policlinics andPrevention Centers (or Prevention Teams), etc. The DHC is also responsible for managing
the health facilities at the primary level (CHSs, HCs, HPs, and SHPs).
Commune Health Stations (CHSs) in communes* provide health care at the primary level.
These CHSs have the tasks of providing primary health care services, treating common
diseases, attending to normal deliveries, early detection of epidemic outbreak, familyplanning practices, health promotion, etc. Activities in the CHSs are conducted in close
communication with the provincial and district level medical institutions.
There are commune (village) health workers (most of them are qualified and newly
trained or volunteers with small allowance or incentive) in each commune (village).
Village health workers are under the direct management and direction of the CHSs andvillage leaders. They conduct various tasks, such as primary health care, implementationof national health programs, preventive medicine, IEC activities, etc., in coordination withthe community and social organization in the village, and participate in first aid, disease
examination and treatment, prenatal care, and assistance in deliveries.
* Under the commune health stations there are health posts (HPs) and sub-health posts (SHPs) although this situationdiffers slightly in each country.

NCGM Report October 201319

I-2. Characteristics of the general health system of each country1) Viet Nam

Leadership and governance
Since the 1990s the government has made great effort to strengthen the general healthsystem. The international community has also cooperated with policy implementation ofViet Nam at various levels. For National Health Programs, National Steering Committees
are organized and programs are managed more intensively and efficiently with strong
leadership and intersectoral collaboration. Related major national institutes are
responsible for the executive centers of the respective health programs, as well as theprovision of technical advice, operational research and staff training (eg. The National
Institute of Malariology, Parasitology and Entomology for malaria and the National
Institute of Hygiene and Epidemiology for EPI).
Service delivery
Health programs are implemented to maximize use of the health system networkfrom the central level to the commune level, particularly preventive health network.
The local administration is organized with provincial, district and communal politicalunits which are responsible for the implementation of the programs. All medicines andmedical equipment are supplied from the government through the province and district.
Participation of health facilities under the military, police and other sectors to provide
medical services to the population has helped to increase health care coverage.
Workforce
Since the 1990s, human resources for health care have been developed bothquantitatively and qualitatively. Improvement has been observed in the capacity toincrease human resources through training. Nevertheless, the annual increase of healthworkers in the public health system is insufficient to meet the actual needs. Many wellqualified health staff hesitates to work at the grassroots level. Consequently, patientsseek health services at a higher level, leading to an overload at these facilities.

20

NCGM Report October 2013

Information system
The reporting and information system functions efficiently, where reports from thegrassroots level are transmitted to upper levels and feedback is carried out. The role ofmobile team is outstanding in transmission of information and guidance for program
implementation.
Medical products and technologies
One characteristic of the Vietnamese health sector is its focus on applying technology
to the development of pharmaceutical materials that draw on local sources of medical
plants. Particularly, extraction of artemisinin from Artemisia annua and the subsequent
manufacture and distribution of injectable Artesunate and its suppository has contributed
to the treatment of malaria. Development of the pharmaceutical industry has contributed
considerably to the implementation of essential drug policies targeting primary healthcare.
Managing drug quality according to good practice criteria is based on the standards andguidelines for drug production, quality control, storage and distribution. Currently, allfacilities are to follow the standards of Good Manufacturing Practice (GMP)-WHO.
FinancingA broad orientation of health financing was determined in the 1990s through thedevelopment of the health insurance, partial user fee policy, and the Government’s
resolution on “social mobilization” in areas of education, health and culture. The
government also focused on subsidies to users of health services, for example health carefor the poor and children under 6 years of age. The collective state health budget, as wellas national health spending including both state and private sectors, has continued toincrease along with the economic development of the country.

NCGM Report October 2013212) Nepal

Leadership and governance
A comprehensive framework for health policies, strategies and plans has been in place inaccordance with National Health Policy 1991. The current long-term health plan (19972017) aims to provide health services throughout the country, particularly extending the
primary health care system to the rural population and improving the health status ofvulnerable populations, such as women and children, the rural population, the poor, theunder-privileged and the marginalized.
Service delivery
The health system hierarchy (MOHP→ Regional→ Zonal→ District→ PHC→ HP→ SHP) has
been designed to ensure that the majority of population has access to public health carefacilities and minor treatment at affordable prices. SHPs are the first contact point forbasic health services and the venue for community-based activities such as PHC outreachclinics and EPI clinics.
Workforce
Since the establishment of the Institute of Medicine, Tribhuvan University as the first
medical school in 1980, the number of medical schools has markedly increased (20schools in 2012). The increased number of medical doctors, nurses, and other co-medical
staff has contributed to the health and medical care of the Nepalese people.
Information system
The routine monitoring system has greatly improved over the years. The management
information system in the form of the Health Management Information System (HMIS),
Logistics Management Information System (LMIS) and Fiscal Management Information
System (FMIS) has also been well developed over the last 10 years.
All health related activities are recorded and reported right from the lowest health unit:
i.e. from SHPs to district hospitals. In addition to the HMIS, there are also other sources

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NCGM Report October 2013

of information from individual programs, according to the nature of their activities.
Such information may be in the form of general or specific monitoring visit reports or
surveillance reports.
Medical products and technologies
In 2007, the National Drug Strategy was revised and the National Essential Drug List wasestablished. In order to manage the above processes effectively, HMIS is used. The pull
system for essential drug supply was expanded to all 75 districts in 2010.
Financing
Total health expenditure as a percentage of GDP has increased since 1998. In 1998, it was
5.1%, 5.2% in 2002 and 6.3% in 2010. The share of public expenditure in the total healthexpenditure declined from 67.2% in 1998 to 56.6% in 2010, whereas the share of private
expenditure increased.

3) Lao PDR
Leadership and governance
Under MOH, a sector-wide coordination mechanism consisting of MOH affiliated centers/
institutions, universities and developing partners has been organized. The secretariatof the sector-wide coordination developed a sector common work-plan and monitoring
framework, a managerial tool of the sector working group at the operational level, inorder to monitor the progress of all priority programs in the health sector.
Service delivery
Anti-malarial drugs and bed-nets are usually procured by external donors from outside
countries. Storage and distribution of these items are separately managed from otherdisease specific programs and general health system. Each province has a different
logistic system.

NCGM Report October 201323

Workforce
At the community level, averages of two nurses are employed at each health center. Eachnurse has a multi-functional role, such as being in charge of malaria, EPI, tuberculosis, or
MCH. Generally, one or two health volunteers are employed in each village. The per diem
rate given by the GFATM for each program is much higher than that of the government.
Information system
The Department of Planning and Finance (DPF) of the MOH introduced the HMIS as anational information system supported by the World Bank project in 2004. As of 2010,
91% of the districts are reporting HMIS data. However it is assumed that the proportionof the Health Centers using the HMIS is much lower. HMIS includes four indicators
relating to malaria. HMIS data is periodically sent to upper levels using designated reportforms. In addition, there are some other parallel reporting systems according to disease
specific programs and infectious disease surveillance systems. Regarding information onmalaria, the GFATM form, which includes patient information, symptoms, methods oflaboratory diagnosis, and medicine described, is used and is sent monthly from lower
levels to the upper levels.
Medical products and technologies
The quality control system in the general health system is fragile. There is no quality
control system at the district level. Quality control for malaria, HIV, and tuberculosis
testing is conducted using a GFATM budget separate from the general health system.
Finance
The proportion of the national budget spent in the health sector was approximately 4%
over the last 5 years. Periodical submission of an accounting report is required from theprovincial level to the DPF, but since decentralization in 1996 and user fee introduction,
most of the provinces do not actually do so.

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NCGM Report October 2013

II. Malaria control with special reference to healthsystems

II-1. Outline in the three countries
Previously, malaria was a major public health problem in the three countries and wasgiven highest priority in national health programs. However, after the mid-1990s, amarked decrease was observed, as shown in Figs. 7-9. Main interventions which led tosuch a rapid control of cases of malaria included the introduction of bed nets (Insecticide
Treated Nets; ITNs, Long Lasting Insecticidal Nets; LLINs) and anti-malarial drugs (eg.
Artemisinin derivatives such as Artesunate) through vertical health systems, and theeducation of residents, training of health workers, etc.
Currently malaria control activities in the three countries are implemented based on
National Malaria Control Programs and the principles of Roll Back Malaria, which consistsof strategic priorities including vector control and personal protection, early diagnosis andprompt treatment (EDPT), malaria surveillance and epidemic preparedness, behavioral
change communication (BCC), and improved program management. Implementation of
the programs has been supported by GFATM and other assistant partners.
Malaria surveillance and epidemic preparedness
In addition to existing surveillance networks, vertical surveillance systems focusing onmalaria and early warning systems for malaria outbreaks have been established in thethree countries. Emphasis has been placed on hospital based surveillance for severe
malaria and associated mortality, and monitoring of drugs and insecticide resistanceis conducted regularly at the sentinel sites (Viet Nam, Nepal). Active case detection isconducted as required. Stocks of rapid diagnosis tests (RDTs) and anti-malarial drugs havegreatly increased at the central and local levels supported by GFATM.
Vector control and personal protection
Currently, bed-nets, particularly LLINs, play a very important role in the implementationof malaria control programs. LLINs are supposed to be distributed (basically one LLIN per
2 people every three years- assuming a three year life for the LLIN) in the three countries
to all people living in high risk areas, with special emphasis given to pregnant women
receiving antenatal care. In Nepal, delivery of LLINs is managed by the Population Service
NCGM Report October 201325

International (PSI) under the supervision of EDCD. At local level, delivery is managed
by NGOs/other partners and implemented by a broad range of community basedorganizations.
At present, alphacypermethrin and pyrethroid group insecticides are used for Indoor
Residual Spraying (IRS). IRS has a lower priority in malaria control but is sometimes
carried out as an integrated vector control program.
Early diagnosis and prompt treatment (EDPT)
Diagnosis includes clinical diagnosis, microscopy and RDTs (in peripheral areas where
microscopy is not available). Quality control for microscopy and RDTs is an integral partof malaria diagnosis. All antimalarial drugs are provided free of charge at all public healthfacilities in endemic areas (and also by community health volunteers). However, a charge
is incurred at private health facilities. Treatment is conducted according to the National
Malaria Treatment Protocols of each country. Artemisinin-based combination therapy(ACT) is usually used as the standard method for laboratory-confirmed falciparum cases,
but chroloquine and quinine are also used.
Behavioral change communication (BCC)
The strategy of BCC includes five methodologies: interpersonal communication, primaryand secondary education, mass media, special events (campaigns, etc.) and high leveladvocacy.

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NCGM Report October 2013

II-2. Characteristics of malaria control in relation to the health system of
each country1) Viet Nam

A malaria program has been integrated into the health system since 1957. However,the budget for malaria control has been very limited. After the start of the National
Malaria Control Program in 1991, malaria has decreased markedly. The program has been
enforced with the strong leadership of the Government and National Steering Committee,
which consists of multi-sector members, fully utilizing the vertical malaria system alongwith general health system. The general health system has been strengthened and is also
used for malaria control program, especially clinically. NIMPE has taken the initiative inthe malaria control program. The role of mass organizations, such as women’s unions
and youth unions in the implementation of health programs (malaria control has been
given highest priority) and the collaboration with the military in hard-to-reach areas arealso noteworthy. Currently, a higher incidence of malaria is observed in Tay Nguyen area
(central highland area bordering Lao PDR and Cambodia). (Fig. 7)

Fig. 7
Transition of the number of malaria cases and mortality in Vietnam
Cases (x100)% Parasite/slides

No of cases (x100)

No of death

Parasite/slides

Report from National Institute of Malariaology, Parasitology and Entomology, Vietnam (2012)

NCGM Report October 201327

Medicines for malaria treatment (Artemisinin), insecticides, and bed nets needed for the
programs have gradually produced locally and are delivered to the peripheral level under
the proper guidance of the government. Widespread of artemisin suppositories at the
primary level has greatly contributed to a lower mortality rate. Although a user fee wasintroduced in 1993, medical fees are still set low, and the system and measures, such as
insurance, relief for poor people, and no medical fee for children under 6 years old, havecontributed to the control of malaria.
Reporting and information systems are functioning efficiently. Reports from the primarylevel are transmitted to upper levels and feedback is provided. Currently, considerable
parts of these systems are integrated into the general health system. There are many
examples of rapid and appropriate response in cases of disease outbreak. The role ofthe mobile team is outstanding in transmission of information and in the provision of
guidance for program implementation. A high literacy rate, effective use of school healtheducation and preparation of guidelines have also enabled the smooth implementationof the program. The Malaria Program in Viet Nam has achieved great success over the
past 20 years (Fig.7). Existing leading problems include limited coverage and quality ofmalaria control measures among populations living in remote areas (especially, ethnic
minorities), imported malaria from neighboring countries, and increasing resistance of
falciparum malaria to anti-malarial drugs (spread of artemisinin resistant malaria).
Viet Nam has received assistance from GFATM since 2004 (starting from round 3 formalaria control). In recent years special attention has been given to malaria in high risk
groups and high risk areas, including ① malaria in migrants (mainly ethnic minority
groups), ② border malaria (Vietnamese from non-endemic areas working in endemicareas, and immigrants from Lao PDR, Cambodia, and China) and ③ forest malaria (people
in remote mountainous areas, people staying overnight in the forest). GFATM has greatly
contributed to the expansion of the malaria program by strengthening activities for highrisk groups.

28

NCGM Report October 2013

2) Nepal

Efforts to control malaria in Nepal began in 1954 through the Insect Borne Disease
Control Program. Then in 1958, a malaria eradication program was launched. However
its objective could not be achieved due to increased DDT resistance, which was the mostcommonly used insecticide of the day, and consequently the program reverted to malaria
control in 1978.
Since 1993, the Epidemiology and Disease Control Division (EDCD) under MOHP has taken
the initiative in the malaria control program. Since 2004, GFATM (Round 2, 7, Rolling
Continuous Channel; RCC) has greatly contributed to the prevention and treatment ofmalaria, particularly through the distribution of LLINs, ACTs and RDTs in high risk areas,
along with BCC activities for the residents.
Treatment is being conducted according to the National Malaria Treatment Protocol
from the peripheral up to the top referral level. Treatment medicines are administered topatients free of charge at public medical facilities nationwide and diagnostic services formalaria are provided free of charge at all public sector health facilities in high endemicareas. Recently, GFATM has also attached high importance to health education and healthsystem strengthening at the peripheral level.
Currently, a higher incidence has been observed in Terai (southern plain area bordering
India). The National Malaria Control Strategic Plan has been implemented since 2007,
based on the principles and practices of WHO’s Global Malaria Program and the revised
Malaria Control Strategy of SEA Region, which targets of 65 out of 75 districts. This planconsists of 4 strategic priorities (vector control and personal protection, EDPT, malaria
surveillance and epidemic preparedness, and BCC), and 2 conditional priorities (improving
program management and operational research).
Through great effort by the Government of Nepal and assistant partners, malarial
infections have shown a declining trend and have reached the pre-elimination stage in
NCGM Report October 201329

2011. However, despite such marked decrease in malaria morbidity and mortality rates,
some border areas still have a high morbidity rate or resurgence of malaria. Possible
causes for this include the introduction of malaria associated with mobile populations,breakdown of control measures at the local level and inappropriate distribution of LLINs.
Although malaria cases are decreasing, rate of falciparum malaria in all malaria cases isincreasing in recent years (Fig. 8).
Fig. 8Transition of the number of malaria cases and rate of falciparum malaria in Nepal

Parasites

Pf%

Report from the Ministry of Health and Population in Nepal (2011)30

NCGM Report October 2013

3) Lao PDR

Malaria control program in Lao PDR started in the early 1960s and a control network was
established in 1975. The National Malaria Control Program, which was launched in 1997,
has been conducted based on a network involving village health volunteers integrated
in PHC focusing on distribution of ITNs, education of residents on prevention andtreatment, and EDPT. At provincial malaria stations, mobile teams detect active malaria
cases, and health volunteers have been organized at the primary level. Malaria station
staff sometimes conducts outreach activities jointly with other departments or programs.
While the stock of ACTs sometimes runs out, chloroquines and quinines are locallyprocured and are readily available. As a result, coverage of bed nets (ITNs and LLINs), casedetection, and treated cases have steadily increased and morbidity and mortality rates
have markedly decreased (Fig. 9). Malaria is no longer among the top 10 disease burdensin Lao PDR. Despite these impressive reductions in malaria burden, there remained 9
provinces in 2006 that showed an increase. In addition, in 2011-2012 a sharp increase inmorbidity and mortality was reported in the southern provinces.
Fig. 9
Incidence rate of confirmed malaria and mortality rate of probable and confirmed malaria
in Lao PDR

Incidence per 1000
Mortality per 100000

National Strategy for Malaria Control and Pre-elimination 2011-2015, Ministry of Health, Lao PDR

NCGM Report October 201331

At the central level, the Center for Malariology, Parasitology and Epidemiology (CMPE),
under the MOH, is responsible for malaria control. Supervision of malaria control
programs, such as epidemiology, entomology, data management and quality assurance of
microscopic diagnosis, is conducted with the initiative of CMPE. Although collaborationin every health system component, such as governance, planning, information system,
service delivery including medicine & equipment management, quality management,
and human resource development, has been gradually facilitated, integration of themalaria control program supported by GFATM into general health system is still far away.
Procurement and distribution of medicine and equipment from CMPE to provincial
malaria stations is carried out according to the GFATM plan. When there is a delay inbudget approval, distribution cannot be completed in time for the malaria endemic
season.
A disintegrating reporting system has been causing an increased workload, especiallyfor community health workers. The fundamental cause of these problems is that the
majority of the budget for the national malaria control program (about 97%) is provided
by GFATM. The country is said to be at the stage where dependence on GFATM should
be reduced in order to distribute risk and ensure sustainability. Effective integration of amalaria control program into the general health system of MOH along with sustainability
is a major challenge.

32

NCGM Report October 2013

II-3. Special notes on malaria control in relation to health systems:
1) Strong leadership in Viet Nam
The malaria control program in Viet Nam achieved great success in 1990s characterized
by the strong leadership of Central Steering Committee with maximum use of theexisting vertical health system, which were closely related to the People’s Committee, themilitary, and social and group organizations. The Central Steering Committee consistedof multi-sector members (department leaders or senior staff of line ministries along withleaders of institutions and professors of universities) with the Vice Prime Minister as
representative and the Minister of MOH as chairman. Budgets from the government andinternational donors were effectively allocated to implement malaria control program.
2) Political instability period and malaria control in Nepal
Nepal suffered political instability from 1996 to 2006 followed by a transition from theKingdom of Nepal to the Federal Democratic Republic of Nepal in 2008. The politicalinstability affected economic growth and compromised the delivery of social and publichealth interventions in the country.
According to the EDCD and local health offices, the influence of this instability was
minimal for malaria control compared with other control programs. This fact is due togreat effort by the government and the continuous support of foreign assistant partners
for malaria control even during this difficult time. However, upon close observation,some stagnation is suspected in implementation of the malaria control program during
this time, particularly regarding the distribution of LLINs, training of a health staff, quality
assurance of testing, etc. The frequent change of managers during this time is thought bysome to have affected program implementation.
3) Involvement of village volunteers, etc. in malaria control at the primary level
The role of mass (group) organizations, such as women’s unions and youth unions, in theimplementation of health programs in Viet Nam and the collaboration with the militaryin hard-to-reach areas are noteworthy. In Nepal and Lao PDR, Female Community Health
Volunteers (FCHVs) and village health volunteers, respectively, carry out a significant role
NCGM Report October 201333

in health care activities at the primary level.
4) Private sector
In Nepal and Viet Nam, an increasing number of private clinics and hospitals have been
set up. However, coordination between the public and private sectors is lacking. In Nepal
medical information from the private sector is dissociated from the public sector and alimited amount of information on diseases are reported to the upper levels. Anti-malarial
drugs are provided for a fee in the private sector, even in heavy malaria endemic areas,
while they are free in the public sector.
5) Malaria control in hard-to-reach areas
In the three countries, malaria control in hard-to-reach areas remains a significant issue
and most bottlenecks preventing smooth implementation of control measures are related
to control in these areas. Malaria in migrants, forests, and border malaria cases are
difficult to control. In mobile communities (mainly ethnic minorities) and communities
with border malaria, the number of village health workers is extremely insufficientcompared with other communities.

34

NCGM Report October 2013

II-4. Arising problems
The following is a list of arising problems in the three countries in recent years. Although
they are not always health system related, they do affect health systems and involvementof the approach from health system strengthening seems to be crucial for their control.
1) Population movement and imported malaria
The rate of imported malaria has increased year by year in the targeted three countries.
Malaria associated with domestic population movement due to migrants or internallydisplaced people is also on the increase. All malaria control programs are under
government control, but malaria in migrants, forest, and border malaria are difficult
to control. In Nepal, malaria from neighboring country India, mostly through migrant
Nepalese labor (2-3 million/year) and the Indian population, is a growing concern. For
example in 2004, 65% of cases were indigenous, 16% were imported and 19% were
unclassified. In 2011, 23% of the cases were imported. Recently, significant numberof refugees from Butan brought malaria into eastern Nepal and some outbreaks werereported.
2) Formation of new endemic areas
Generally, the incidence of malaria has been decreasing in the three countries in recent
years, but new endemic areas have been reported. Environmental and social factors are
suspected to be causative factors, but further studies on this issue are needed. Shift in
the distribution of vector mosquitoes to the north in Nepal due to changing climate (global
warming) and environment has been observed. Migration of population, deforestation,and hydropower development are also suspected to being related to this issue.
3) Increase of drug resistant malaria
Resistance of Plasmodium falciparum to chloroquine is widespread in the three countries
and the drug is no longer the first choice for treatment of falciparum malaria. Currently
ACT is recommended for falciparum malaria. However, artemisinin resistant malaria isalso spreading, originating from the Thailand-Cambodia border to Viet Nam.

NCGM Report October 201335

II-5. Assessment of integration between the National Malaria Control
Program and the general health system in Lao PDR
Integration between the Malaria Control Program and the general health system in Lao
PDR was intensively assessed according to the building blocks of a health system. These
results indicate that integration was limited or partial (Table 2). The contrast between
poor general health system and rich vertical system was outstanding in this investigation.
However, the management system of the vertical health program suggested a good
impact on the general health system.
Key findings:•

The NMCP uses program reporting forms introduced by the GFATM.

•

The NMCP is completely dependent on the GFATM for procurement of ACTs.

•

There were separate administration lines between public health laboratories andclinical laboratories.

•

The NMCP conducts quality assurance of laboratory diagnosis of malaria cases inparallel.

•Annual planning of the NMCP is not fully integrated into the general health system.
Two different forms of plan for malaria control were developed (one for MOH, theother for GFATM).

•

Timing of the annual budget of the GFATM differs from the government fiscal year.
As a result, joint planning between the general health system and the malaria control
program is difficult.

Assessment results on the extent of integration between the NMCP and the general
health systems, according to the criteria proposed by Coker, et al., (2010), are shown in
the following table 2.

36

NCGM Report October 2013

Table 2
Extent of integration between the Malaria Control Program and general health system in Lao PDR

Health system
functions

Elements of integration between NMCP andgeneral health systems

Extent ofintegration

Leadership andGovernanceAccountability framework

Limited*Regulatory mechanism

LimitedPlanning

LimitedMonitoring

Partial**Supervision

Limited

Health statistics report

PartialInfectious disease surveillanceNo

BudgetLimitedAccounting report

LimitedProcurement

LimitedDistribution

LimitedStorage

PartialHuman resources for laboratory testing

PartialHuman resources for care and treatment

PartialOutreach for remote villages

No

IEC activities

PartialHealth information
Finance
Medical products

Service delivery*This element is not, or only to a very limited extent, integrated into the health system as a whole,that is, this element is (quasi) exclusively under the management and control of a specific programrelated structure that is distinct from the general healthcare system.
**This element is partially integrated into the health system, or this element is integrated in some,
but not all, cases, that is, it is managed and controlled by both the general health care system and a
specific program-related structure.

NCGM Report October 201337

III. Good practices in malaria control

Tables 3, 4 (described briefly) and Attachment 1 (described in detail) summarize goodpractices in malaria control which have been carried out up to now. Among these, thefollowing practices (*) are considered to have contributed to the strengthening of thehealth system and the improvement of other health programs. In other words, activities
supported by GFATM have led to health system strengthening and brought synergic
effects to various disease controls.

Table 3
Good practices in malaria control in Viet Nam

1

Control measures were effectively implemented under the strong leadershipof National Steering Committee, utilizing the existing health system andassistance of doctors effectively.

2High Priority was attached to control in frontier areas.*3

Functions of Malaria Control Centers and Health Centers (training of staff,
equipment, medicines, etc.) were strengthened.

4

Monitoring and reporting systems were strengthened.*

5

Effective control measures were conducted at peripheral levels mobilizing
mass organization and military organization.*

6

Education on malaria for residents were intensively conducted.

7

The referral system among medical institutions was strengthened.*

8

Better treatment was ensured by preparing artemisinin suppositories at
grassroots level*Contributing to strengthning health system and scaling up health probelems

38

NCGM Report October 2013

Table 4
Good practices in malaria control in Nepal

1

Government attached high importance to promoting education amongresidents and many primary schools were constructed in rural areas.*2

Education among residents focusing on disease prevention was intensified.*3

Government supported by GFATM strengthened health posts. *4

Sentinel sites were set up for outbreak surveillance.

5

Reporting and monitoring systems from the peripheral level up to the Ministryof Health and Population (MOHP) were strengthened.*

6

The budget amount for the health programs funded by the government andrate of the health budget within the total budget were increased*

7

Female Community Health Workers were organized at the community level
for integrated activities including malaria.*

8

Training of health workers is conducted with the support of GFATM at the
peripheral level.*

9

Number of doctors and nurses was greatly increased.*10

Mobile teams were organized (prevention, diagnosis, treatment) in 25
districts.*

11

The pull system was introduced in logistics management in 75 districts.**Contributing to strengthening health system and scaling up health programs

NCGM Report October 201339

IV. Bottlenecks and possible interventions

Tables 5, 6 (described briefly) and Attachment 2 (described in detail) summarize existingbottlenecks/challenges in malaria control. Possible interventions are discussed in theattachment (on-going interventions are also included).
Table 5-1
Malaria control: current bottlenecks / challenges -1

Bottlenecks/Challenges

Viet
Nam

Nepal

A. Leadership and governance1

Weak program management capacity++

2

Increase of malaria associated with population movement

++

++

3

Fragile health system in remote (frontier & boarder) areas

+

++

4

Weak relationship between medical institutions, publicprivate sectors and laboratories+++

B. Service delivery
5Inequity of bed nets distribution (to vulnerable people)

6

Many hard-to-reach areas

7

Weak coordination between local government and GFATM inthe distribution of bed nets

++
+

++
++

C. Workforce

40

8

Shortage of health manpower in remote areas

++

++

9

Low skills of health workers in remote areas

+

+

10

Frequent change of health manpower in remote areas

+

++

11

Limited number of entomonogists

NCGM Report October 2013++

Table 5-2
Malaria control: current bottlenecks / challenges -2

Bottlenecks/Challenges

Viet
Nam

Nepal

D. Information system
12

Fragile private health sector

+

+

13

Poorly developed reporting system from the private healthsector

++++14

Weak infectious disease surveillance system+

E. Medicines and technologies
15

Inadequate quality assurance system for malaria testing16

Weak function of the National Reference Laboratory

17

Difficulty in treatment due to increasing resistance ofP. falciparum to anti-malaria drugs

+

++
++

++

++

F. Health financing
18

Shortage of health manpower in remote areas

+

++

19

Low skills of health workers in remote areas

++

++

20

Frequent change of health manpower in remote areas+++

Others21

New endemic areas have been reported (environmental andsocial factors are suspected)

++

++

22

Increase of imported malaria cases+++++: much bottlenecks/challenges, +intermediate, No mark : little

NCGM Report October 201341

V. GFATM support for malaria control in the three
countries

Since the early 2000s, malaria controls in Viet Nam, Nepal and Lao PDR have been
implemented with the support of GFATM under several rounds. Leading support items
include bed nets (ITNs, LLINs), RDTs, ACTs, microscopes and training for health workers(particularly at the primary level). Approximate proportions of GFATM budget within
total malaria control budget in each country are as follows: Viet Nam 60-65%, Nepal 7078%, and Lao PDR 97%. While remarkable progress has been observed in malaria control
after the start of GFATM support, the malaria control budgets of the three countries,
particularly Lao PDR, considerably depend on GFATM.
From 2004 to 2009, GFATM Round 2 was implemented in Nepal. The malaria component
in GFATM Round 2 supported 13 high risk districts in cooperation with the MOHP, withsuccessful outcomes. GFATM Round 7 began in 2009 as a five year project targeting 13
high risk districts in malaria components. Moreover, RCC by GFATM has been carriedout since 2011 as a consolidated stage of GFATM Round 2, targeting 18 marginal highrisk districts. Implementation of RCC is scheduled until 2015, with the main purposeof reducing the incidence of malaria to less than 2 per 1,000 persons and achieving amalaria treatment success rate of 90 per cent nationally.
As of 2013, the malaria control program in Nepal has been supported by GFATM Round
7 and RCC with a total of 31 targeted districts. Furthermore, Nepal has been attempting
to apply GFATM for Transitional Funding Mechanism. Most funds under the malaria
grant are used for procurement of LLINs to prevent malaria and ACT for treatment. The
remaining funds are utilized to create a preventive and supportive environment against
malaria along with BCC for residents. Since the start of GFATM support in 2004, theEDCD has played a crucial role as a Principal Recipient (PR) for GFATM. In addition, since
December 2005, Population Service International (PSI) has been another PR and has
contributed to the management of GFATM in close collaboration with EDCD.
Following GFATM Round 4 in Laos, Round 7 support has begun and is in Phase 2. This is
expected to provide NMCP with a total of US$16 million for the 2010–2013 period. This
42

NCGM Report October 2013

amount accounts for 97% of the total budget for malaria control.

NCGM Report October 201343

Discussion

In the three countries targeted in this survey, malaria was heavily endemic, but since theactive implementation of control programs since the 1990s, successful results have beenachieved. In the process of malaria control, the contribution by GFATM is large. Strategies
of GFATM support of the health systems included improved access to health services,institution strengthening and capacity building, and the delivery of add-on interventions,such as health education, as well as GFATM supported interventions at the community
level.
Generally, at the upper levels, collaboration among disease specific programs has been
limited, and a staff and infrastructure is dedicated to each program. At the lower levelsof health care, however, there is greater integration. Early diagnosis and treatmentof malaria have been successfully decentralized to various levels of health care, andmalaria control has gradually become more integrated with the primary care system.
These outcomes have contributed to the strengthening of the general health system andsynergy with other programs.
Disease specific programs in Lao PDR, such as malaria control, were shown to still bequite vertical and had the weakest integration with respect to the general health system.
Demand for timely reporting to funding agencies, including GFATM, and the need forvarious process and output indicators has led to the need to create parallel structures fordata collection and reporting. Facilities at the primary level greatly contribute to malaria
control in the three countries, but the health staff working at such facilities carries out
various tasks for low wages and with an insufficient number of workers. Disintegrated
reporting systems lead to an increased workload especially for community healthworkers.
As seen in the results in Lao PDR, it seems that if the general health system is weak,a strong vertical health system supported by GFATM can function separately fromthe general health system. These findings were also observed in Nepal and Viet Nam,particularly at the early stage of support by GFATM, where disease specific programs
44

NCGM Report October 2013

utilize procurement, information, monitoring systems, etc., outside of the MOH (MOHP),
with varying levels of support and input provided by the disease specific divisions.
Leading bottlenecks in malaria control in frontier areas were identified. In addition,
serious issues regarding sustainability were also seen due to the high dependency rateof the control budget by GFATM. Introduction of malaria due to population movement,
increased drug resistant malaria, and the emergence of new endemic areas havebecome growing issues in malaria control in recent years in many endemic countries.
Although these may seem to be separate from the health systems, they do affect thehealth systems in terms of governance, service delivery, medicines and technologies, andhealth financing. Such growing challenges are often related to political issues, poverty,
and a changing environment due to indiscriminate development, global warming, etc. In
order to address these growing challenges, strong government leadership, a sector-wide
approach, and intersectoral collaboration are required.
It is crucial to implement effective malaria control programs which address thesechallenges and bottlenecks, seeking their elimination. Particularly, greater efforts
to strengthen the health systems in remote areas, training of the health staff at the
peripheral level, diagnosis based on accurate quality assurance, promotion of publicprivate relationship and addressing the issue of imported malaria, are desired. To create
sustainable health systems, serious consideration of the issue of availability of domestic
resources, including workers, supplies and local participation, as well as budgetary
resources, is needed. Moreover, good practices which have been identified in this survey
are expected to provide useful lessons in the effective implementation of malaria control
in endemic countries. Addressing these issues will directly lead to further strengtheningof the health systems and eventually to the effective implementation of various healthprograms.

NCGM Report October 201345

Acknowledgements

This assessment, and the primary surveys in Viet Nam, Lao PDR and Nepal wereconducted by the National Center for Global Health and Medicine, as the WHO
Collaborating Center for Health System Research, with the Grants for International HealthResearch (22-3, 22-12, 24-5) from the Ministry of Health, Labour and Welfare, Japan
We wish to express our sincere gratitude to all the interviewees who took part in theseassessments and surveys.

46

NCGM Report October 2013

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Viet Nam•

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•

Ministry of Health, Vietnam. Vietnam Health Report 2006. 2008; pp 1-343.

•

Ministry of Health, Vietnam. Joint Annual Health Review 2008: Health financing in
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•

Ohara H, Matsumoto Y. Assessment of health systems in relation to interventions
between disease specific programs and health systems strengthening in Vietnam:
NCGM. 2009; pp 1-38.

•

Ministry of Health, Vietnam. Five-year health sector development plan 2011-2015.
2010; pp 1-56.

•

Bortel WV, Trung HD, Hoi LX et al. Malaria transmission and vector behavior in aforested malaria focus in central Vietnam and the implications for vector control.
Malaria Journal. 2010; 9: 373-381.

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USAID. Assessment of health system performance in six provinces of Vietnam. 2010;
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•

Conseil A, Mounier-Jack1S and Coker R. Integration of health systems and priority
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programmes into the general health system in Vietnam. Health Policy and Planning
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•

Ministry of Health, Vietnam. Health Statistics Yearbook 2010. 2011; pp 1-229.

•

Manh BH, Clements ACA, Thieu NQ et al. Social and environmental determinants ofmalaria in space and time in Viet Nam. Int J Parasitol. 2011; 41(1): 109–116.

•

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•

Ministry of Health and Population, Nepal. National Malaria Control Strategic Plan:
Nepal (2007/008-2011/012). 2007; pp 1-23.
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•Tragard A, Shrestha IB. System-wide effects of global fund investment in Nepal.
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•

Parajuli K, Ghimire P. Epidemiology of malaria in two Eastern districts of Nepal.
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Tragard A, Shrestha IB. System-wide effects of Global Fund investments in Nepal.
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Ministry of Health and Population, Nepal. Nepal Malaria Strategic Plan 2011-2016.
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Lao PDR•

Coker R, Balen J, Mounier-Jack S et al. A conceptual and analytical approach tocomparative analysis of country case studies: HIV and TB control programmes andhealth systems integration. Health Policy Plan.2010 Nov; 25 Suppl 1: i21-31.

•

Atun R, de Jongh T, Secci F et al. Integration of targeted health interventions into
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•

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•World Health Organization. Malaria country profile, Lao People’s Democratic
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NCGM Report October 201349

Attachment 1
Good practices

Good practices in maralia control (Viet Nam, Nepal)*Synergic effects with general health system and/or other programs are suspected
Viet Nam

A: Leadership•andgovernance•••
B: Service
delivery

•
•

•

•
•

C: Workforce

•

•

•

50

Nepal

Control measures were effectively
implemented under the strong leadershipof National Steering Committee, effectively
utilizing the existing health system andassistance of donors.
High priority was attached to control infrontier areas.*
Functions of Malaria Control Centers and
Health Centers (training of staff, equipment,
medicines, etc.) were strengthened.*
Education on malaria for residents wasintensively conducted.

•

A vertical health system was already in place
before the national malaria program began.
The functional formation of the steeringcommittee made the malaria control
program effective and integration of malaria
program into the vertical health program was
successful.
The Army Medicine, People’s Committee,
Women’s Union and other local organizations
helped in the delivery of bed nets, and otherservices in the control program.
T h e r e fe r r a l s y s t e m a m o n g m e d i c a linstitutions was strengthened.*
Better treatment was ensured by preparing
artemisinin suppositories at the primarylevel.

•

Village health workers worked for various
programs. The incentive rate has been fixedby the government (Ministry of Financing)
and there is not much difference between
programs (the current rate is between $2.5$3.0) *The government has implemented a policy
to train health workers, foreign donors also
have cooperated with this training.*
Effective control measures were conducted at
the peripheral levels, mobilizing mass (group)
organizations and the military.

•

NCGM Report October 2013

•
•
•

•
•
•
•

•

•
•

Government attached high importance to thepromotion of education among residents.
Many primary schools were constructed.*
Education among residents focusing on
disease prevention was intensified.*
The government strengthened health posts
with the support of GFATM*
A control program was implemented,
basically, using the existing health system.*

Mobile teams were organized (prevention
diagnosis, treatment) in 25 districts.*
Monitoring teams for ITNs and LLINs wereorganized at the district level.
Cold chain for vaccination was used forstorage of RDTs, etc.
RDTs and microscopy were available asdiagnosis tools for malaria at HPs.
The Logistics Management Division expanded
the pull system of essential drugs in all 75
districts in collaboration with its supporting
partners.

Female Community Health Volunteers(FCHVs) were organized at the village level
for integration activities including malaria
control.*
Tra i n i n g o f h e a l t h wo r ke rs h a s b e e n
conducted with the support of GFATM at the
peripheral level.*
The number of doctors and nurses has
greatly increased during the past 10 years.*
Training on malaria control for the healthstaff has been integrated with other disease
control.*Viet Nam
D: Information•

system

E: Medical
products andtechnology

F: Financing

•
•

•

Nepal

Supervision through the vertical healthsystems, as well as more training, wasprovided as the budget increased.

•

Refrigerators were provided to all communes
with assistance from international donors. *Production of anti-malarial drugs has
begun in Viet Nam with assistance frominternational donors.

•

The government sought to increase themalaria program budget in the beginning,
and the People’s Committee also financially
supported for the program.

•

•

•

Sentinel sites were set up for outbreaksurveillance.
Reporting and monitoring systems in the
public sector from the peripheral level up
to the Ministry of Health and Population(MOHP) level have been strengthened.*
A considerable amount of ITNs, LLINs, RDTs,
ACTs, and slide glasses for microscopic testing
were provided at the peripheral level.
Monitoring of ACT, chroloquine resistancehas begun.
The amount of the budget for healthprograms funded by the government, andthe percentage of the health budget within
the total budget were increased.

NCGM Report October 201351

Attachment 2-1

Bottlenecks and possible interventions in malaria control

Viet Nam
Current Bottlenecks
A: Leadership•andgovernanceControl in mobile communities, especially forthe malaria control program, by the healthsector alone is difficult.

Possible Interventions••

B: Service•

delivery•

C: Workforce

•

•
•

•

•

52

GFATM supports the distribution of ITNs, buttransportation costs are covered only fromthe provincial level to the district level (andthe district health department only partiallypays for transport). This does not cover the
distribution transport to communes.
High risk groups do not always receive benefit
from the malaria control program.
1) malaria in migrants (mainly ethnic minority
groups)2) border malaria (Vietnamese from nonendemic areas working in endemic area, andimmigrants from Lao PDR, Cambodia, andChina)
3) forest malaria (people in very remotemountainous areas, people staying overnightin the forest).

•

Preventive medicine cannot recruit doctors
due to a lower salary than that of clinicaldoctors.
Serious shortage of a health staff in remoteareas.
The number of microscopes has increased,
but the staff members who can properly use
the microscopes are insufficient.
Training opportunities are limited in remoteareas and areas where interventions byforeign donors have not yet been carried out.
After controlling malaria in the 1990s, young
medical staff members do not recognize
malaria symptoms since malaria endemicareas are mainly remote and forest areas,
and the medical staff rarely sees malaria
patients these days.

•

NCGM Report October 2013

•

•

•

•

If coordination between the health sector
a n d b o rd e r g u a rd fo rc e s , p o l i c e a n dlocal authorities, were closer, control ofimmigration would be easier.
Register families which members repeatedly
suffer from malaria as malaria high riskfamilies, in order for commune health staff
members to narrow the target for malaria
control.
A motorcycle or a bicycle at a commune
health center can be used for remote areas.
Obtaining the understanding and cooperationof village leader on health programs isimportant.

Among targeted high risk groups, educating
family members of persons who work in theforest and/or in the malaria endemic areas,so as to increase the number of program
collaborators, is important.
Training opportunities among health workers
should be increased in remote areas andareas where interventions by foreign donors
have not yet been carried out.
Improvement in the training curriculum
according to the conditions of the area isrequested.
Improvement of the curriculum on PHC,
health programs, rural health, etc., in underand post- graduate education is desired.

Current Bottlenecks
D: Information•

The reporting system from the private healthsector is not sufficiently developed.

••

Promotion of active surveillance is needed.
Enhancement of IEC activities to enlighten
the residents, particularly in remote areas, isrecommended.

•

Microscopes are not placed in commune
health stations despite the need for diagnosisof P, falciparum and P.vivax.
Due to increasing resistance by P. falciparum
to anti-malaria drugs, treatment has beendifficult.
The quality assurance system for malaria
testing is insufficient in remote areas.

•

Setting up an appropriate quality control
system is needed.

All the budgets are determined at the centrallevel and support by international donors is
also determined at the central level in detail,with no chance of change at the provincial
level.
More than half of the budget for malaria(2 billion VND out of 3.8 billion) has been
allocated to purchase equipment such as
microscopes, computers and medicine at thecentral level. The provincial level receives lessthan half for staff wages, training fees, andsupervision.
Anyone can receive malaria treatment freeof charge. However, bed nets are free only topoor people and many people in the remotevillages are poor.
Management costs at the commune healthstations are covered by the government, butgovernment support for transportation fees
is insufficient. A transportation fee is allowed
80,000VND ($4.50) only for the head of thecommune health station and 20,000VND($2.2) for the head of the village healthworkers.
Low incentive for health workers•

Preparing a minimum requirement costs atthe commune health stations (maintenancecost, transportation fee, etc.) is desired.
Improvement of the system to reflect theopinions and requests of the lower levels tothe upper levels is desired.

system

E: Medical
products andtechnology••
F: Financing

Possible Interventions

•

•

•

•

•

•

NCGM Report October 201353

Attachment 2-2

Bottlenecks and possible interventions in malaria control

Nepal
Current Bottlenecks
A: Leadership•andgovernance••

B: Service•

delivery••54

Possible Interventions

Population movement and imported malaria
Malaria associated with population
movement (from neighboring countries such
as India and Butan, as well as by the domestic
mobile population) is a growing concern.
Program management
Program management capacity is still weak
due to insufficient trained manpower andweak supervision and monitoring.
Coordination between local government and
GFATM
At the central level, coordination between
the government and GFATM is preferentially
carried out. However, at the local level,collaboration is insufficient,and closer
communication has been requested.

•

Distribution status and practicability of bed
nets
Bed nets are not always distributed to themost needed or vulnerable populations. The
nets are bulky and safety issues regarding
pesticides sometimes make distribution andsafe storage a challenge. Even when LLINs are
distributed, utilization rates may be low forseveral reasons: aesthetics, uncomfortable
sleeping under the net due to temperature,l a c k o f a w a re n e s s re ga rd i n g d i s e a s e
reduction.
LLIN distribution system
At the peripheral level, LLIN distribution
is often carried out separately from local
government by local NGOs. The government
system is not fully utilized for LLIN distribution(cf. monitoring after the distribution of LLIN,
treatment medicine and diagnosis kits is
conducted by government).
Hard-to-reach areas
Although hard-to-reach areas have decreasedin Nepal, there are still some areas where
the health services have not reached the
population.

•

NCGM Report October 2013

•

•

•

•

•

•

The Disease Control Unit of the EDCD should
be strengthened for more effective malaria
control implementation. Recruitment ofentomologists, epidemiologists, and support
technicians and communication specialists isneeded.
Strategies should be set for the prevention
and treatment of imported and cross-bordermalaria cases (the Nepalese government issetting up check points at border areas toaddress this problem).
A sector-wide approach is needed to address
the issues of imported malaria, cross-bordermalaria and new endemic areas.
Strengthening the district health system is a
key area to be targeted and focused on for
effective program planning and managementin each district.
Strengthening the logistic management
system including preventive, curative andemergency commodities, diagnostic materials
and basic equipment is recommended.
The EDCD and health offices in the districts
should be asked to consolidate partnershipwith PSI and widen the malaria partnership,in order to increase the use of ACT, RDT, LLINs
and IRS.
Updating and development of technicalguidelines/SOPs in key areas, based on thecurrent epidemiological situation in the
country for diagnostics, case management,
entomological surveillance, monitoring drug
and insecticide resistance, vector control, and
IEC/BCC, in order to promote improvementin key interventions, should be carried out.
G FAT M s u p p o r t s t h e e x p a n s i o n o f acontrol program to remote areas and thestrengthening of the health systems in hardto-reach areas, as well as the provision ofhealth services in these areas.

Current Bottlenecks
C: Workforce•

Manpower
There is a significant shortage of manpowerat the peripheral level. In most health posts
and sub-health posts, one health worker
bears many tasks and the amount of time
work they can devote to malaria is limited.
A large proportion of their work is said to beallocated to EPI.
Skills of FHCVAt the commune level, treatment is often
provided only based on symptoms by FHCVs
who were briefly trained and with limited
skills. Incorrect identification may lead toincreased incidence of resistance to drugs.
Frequent change of the health staff
Training of the health staff at the peripherallevel is carried out, but many staff workers
leave within a short period of time.
Number of entomologists
The number of entomologists in Nepal isquite limited. This situation prevents thesmooth implementation of malaria control
from the point of view of vector control.

••

Report from private sectors:
There are many private clinics, hospitals,
medical colleges in Nepal and increasing
number of the population goes to these places
for treatment in recent years. However
health data is only collected from government
facilities.

•

The enrollment of private medical colleges
and hospitals, as well as clinics along with
the Government hospitals, in the reporting
system is needed.

•

Drug resistant malaria
In addition to chroloquine resistant P.
falciparum, the potential emergence ofresistance to artemisinin is a major threat
to treatment effectiveness. The use of
antimalarial drugs to treat patients only
on the basis of clinical symptoms at thecommunity level may be responsible for
emergence of drug resistance in malaria
cases.

•

Q u a l i t y a s s u ra n c e s y s t e m s f o r b o t hmicroscopy and RDT need to bestrengthened.
Procurement of antigen-based RDTs should
be standardized and quality assurance of
products should be centralized and carriedout regularly.
Quality assurance of malaria control products
should follow WHO guidelines on productspecifications and be based on the current
epidemiological situation of the country.

•

•

•

D: Information
system

E: Medical
products andtechnology

Possible Interventions

•

•
•
•

•

•

Health workers especially in the SHPs, HPs
and PHCs should be trained with regards tosimple and serious cases of malaria. Thereis a need to ensure systematic annual preseason refresher training especially in highrisk transmission districts.
The EDCD, VBDTRC and Health offices should
continue capacity building, with the technicalsupport of WHO effectively. Recruitment andtraining of entomologists is crucial.
Training and development of entomologists isnecessary.
Increasing the salary and incentives to healthworkers and volunteers is necessary.
More training opportunities are needed toensure qualified health workers (both for
newly employed workers and for refresher
training).

NCGM Report October 201355

Current Bottlenecks••

F: Financing

•

•

56

Quality assurance system
The quality assurance system is inadequate
or non-existent, affecting accuracy and trust
in diagnosis for case management and formonitoring of disease burden.
Function of National Reference Laboratory
Implementation of a comprehensive quality
assurance system for malaria microscopy andRDT through the referral laboratory network
should be carried out by the VBDRTC (at the
district, regional and central levels). However,the current function of the VBDRTC as a
National Reference Laboratory is insufficient.
Sustainability of commodities supply
While ACT is highly effective, price is asignificant barrier to widespread use. The
cost of RDT is also cited as a barrier to its use.
Currently these are supported by GFATM, butsuch sustainability is doubtful.
Incentives for FHCVs
FHCVs greatly contribute to medical care andhealth promotion, including malaria control
for residents at the peripheral level. However
their incentive is quite limited.

NCGM Report October 2013

Possible Interventions•••

There is a need to develop a national malaria
diagnosis reference center. Strengthening thelinks between laboratories will complement
the network for quality control, research andtraining. The function of the VBDRTC as anational center should be strengthened.
The capacity of laboratory technicians(microscopists) at hospitals and PHC shouldbe improved.

Higher incentives for FHCVs, in order topromote motivation, is desired.

Contact details for further information
Hiroshi OHARA, M.D., P.H.D.
Bureau of International Medical Cooperation, Japan
National Center for Global Health and Medicine, Japan
Email: oharah@it.ncgm.go.jp

NCGM REPORT October 2013
Assessment of health systems in relation to interface between malaria
control programs and health system strengthening: Comparative study
among Lao PDR, Nepal and Viet Nam©2013 National Center for Global Health and Medicine, JapanAll rights reserved.
National Center for Global Health and Medicine, Japan
Bureau of International Medical Cooperation, Japan
1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655
Tel: +81-3-3202-7181 / Fax: +81-3-3205-7860
info@it.ncgm.go.jp
www.ncgm.go.jp/kyokuhp/

National Center for
Global Health and Medicine, Japan
Bureau of International Medical Cooperation