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Ministry of Public Health, Islamic Republic of Afghanistan
General Directorate of Preventive Medicine
Communicable Diseases Control Directorate
National Malaria and Leishmaniasis Control Programme
National Strategy for Community-based Management of
Malaria (CBMM) in Afghanistan (2016-2020)
2016
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Table of contents
ACKNOWLDGEMENTS……………………………………………………………………….… 3
ACROYNYMS…………………………………………………………...………………………… 4
1 BACKGROUND…………………...…………………………………………………………… 6
2 SITUATION ANALYSIS ………………………………………………………………...……. 8
2.1 Health Care system…………………………………………….………………………………. 8
2.2 Challenges………………………………………………………………………..………........... 14
2.3 Malaria Stratification…………………………………………………......…………………… 15
2.4 Ongoing community-based initiatives in Afghanistan…………………….………………… 16
2.5 Pilot community-based management of malaria in Badkhshan, Kunduz, and Takhar
Province………………………………………………………………………………………… 16
3 GOAL………………………………………………………...………………………...………... 17
4 STRATEGIC DIRECTION ………………………………………………………………….. 17
5 STRATEGIC BJECTIVES…….……………………………………………………………… 17
6 STRATEGIC COMPONENTS …..………………………………………………………..….. 17
6.1 Case Management…………………………………………………………………………….... 17
6.2 Capacity Building…………………………………………………………………………...….. 18
6.3 Advocacy, community sensitization and Education…………………….…………………… 20
6.4 Risk Management Strategy…………………………………………………………………… 21
7 INSTITUTIONAL FRAMEWORK …………………………………………………….…… 22
8. MECHANISMS FOR COORDINATION……………………………………………………. 22
8.1 The National Vector Born Disease Control Task Force (VBDCTF)……………………...… 22
8.2 The Provincial Vector Born Disease Control Task Force (VBDCTF)…………….………... 23
9 IMPLEMENTATION PLAN…………………………………………………………………. 24
10 MONITORING AND EVALUATION……………………………………………………… 25
10.1 Integrated supervision ……………………………………………………………………..… 25
10.2 Quality control at point of care …………………………………………………………...…. 25
ANNEX 1 - Stratification of districts of Afghanistan based on reported malaria incidence rate
(2009 data)……………………………………………………………………………....... 31
ANNEX 2 - Current contents of CHW kit (2009)……………………………….……………...... 38
ANNEX 3 - Tally Sheets for CBMM developed in the pilot RDT and ACT
Community-based project ……………………………………………………………….. 41
ANNEX 4 - Supervision Check List on ACTs and RDTs for Community Health Supervisors. 42
ANNEX 5 Timetable of activities………………………………………………………………….. 43
ANNEX 6 Budget components and financial gaps (USD)…………………………………….…. 45
ANNEX 7: CBMM Curriculum…………………………………………………………………... 47
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ACKNOWLEDGMENT: The Ministry of Public Health would like to acknowledge the contribution made by all stakeholders
working in the first revision of National Community Based Management of Malaria Strategy (CBMM
2016 – 2020) which will ensure universal coverage of Malaria confirmation at country level.
The malaria experts from CBHC directorate, WHO, UNDP, BRAC, HN-TPO, and other partners
deserve special mention for their invaluable technical guidance and ensuring that
Afghanistan’s CBMM strategy is comprehensive, effective and will have a significant impact in terms
of control and elimination of malaria in the country.
Finally, it is important to note that this Strategy should be regarded as a working document. All
comments, feedback and additional case materials will be considered in future reviews in order to
make it more relevant.
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ACRONYMS
ACTs Artemisinin Combination Therapy
BHCs Basic Health Centres
BRAC Bangladesh Rural Accreditation Committee
CBHC Community Based Health Centre
CDC Communicable Disease Control
CIMCI Community Integrated Management of Childhood Illness
CHS Community Health Supervisor
CHWs Community Health Workers
CQ Chloroquine
EMRO East Mediterranean Regional Office
EPHS Essential Package of Hospital Services
GF R8 Global Fund Round 8
GFATM Global Fund fight against AIDS, TB and Malaria
HMIS Health Management Information System
HN-TPO Health Net- Trans cultural Psycho-social organisation
HPRO Health Protection Research Organisation
IEC Information, Education and Communication
IM Intramuscular
IMCI Integrated Management of Childhood Illness
LLIN Long Lasting Insecticidal Nets
MoPH Ministry of Public Health
NGOs Non- Governmental Organisation
NMCLP National Malaria and Leishmaniasis Programme
NMSP National Malaria Strategic Plan
ORS Oral Rehydration Salts
PHC Primary Healthcare
PHD Provincial Health Directorate
PR Principal Recipient
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RDT Rapid Diagnostic Test
HSC Health Sub centres
TB Tuberculosis
TDR Tropical Disease Research
UN United Nations
UNDP United Nations Development Program
UNICEF United Nations Childrens Fund
USAID US Agency for International Development
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1. BACKGROUND
It is estimated that the number of cases of malaria rose from 233 million in 2000 to 244
million in 2005 but decreased to 225 million in 2009. The number of deaths due to malaria is
estimated to have decreased from 985000 in 2000 to 781000 in 2009.
Malaria is an endemic disease and a public health problem in Afghanistan. It causes a great
burden on the health and economic development of individuals, families and communities
living in endemic areas. The total number of reported malaria cases were 319742 in 2013,
295050 in 2014 and 366526 in 2015. Majority of these cases were clinically diagnosed:
85.5%, 71.6 % and 71.8 % respectively (HMIS 2015). The Government of Afghanistan
remains committed to the control of this disease. For this purpose the Government developed
the National Malaria Strategy Plan 2013-2017 with a vision of a malaria free Afghanistan.
The main quality-of-care challenge posed by the recent decline in malaria is now in
identifying those cases of fever which are in fact caused by malaria amongst the clinical
malaria cases and treating the correct species of infection according to NTG. Most fever in
Afghanistan is not caused by malaria. Most malaria, in turn, is not caused by P. falciparum,
but by P. vivax. since treatment for these two species differs, identification of the species is
important for treatment outcomes. In summary, the context for deployment of RDTs should
be in improving the treatment of fever at community level and ensuring that those with
malaria are a) parasitologically confirmed cases and b) treated appropriately. Appropriate
treatment, in this context, means that those with parasites are treated with an effective
antimalarial, and those without malaria parasites are appropriately treated with non-
antimalarial drugs.
The need to identify the presence or absence of malaria parasites (at species level) in
providing treatment lends itself to mixture of diagnostic methods each of which is appropriate
to the setting. The choice is between microscopy and RDTs. Microscopy is the preferred
method in clinic settings with a relatively high throughput of patients, but is also difficult and
expensive to maintain because of the need to monitor quality of the microscopists and
relatively high fixed costs (such as microscopes and salaries). RDTs may also play a role at
clinic level (BHC, SHC and MHT), in areas where microcopy is hard to maintain.
RDTs can also be deployed at community level, through CHWs, which may improve access
to effective treatments for both malarial and non-malarial causes of fever at community level.
Programs to increase access to RDTs also encounter challenges, such as maintenance and
monitoring of quality, supply and storage of the RDTs and in training of CHWs. Despite
these challenges, there is hope that RDTs have a role to play in improving diagnosis of
malaria and non-malarial causes of fever and through accurate diagnosis, to improve the
targeting of effective treatments.
Accurate diagnosis of malaria (using RDTs and micrsocopy) is also providing more accurate
and higher resolution surveillance data in most settings where they have been deployed. Until
now, most data has been based on clinical malaria cases (i.e. where there has been no parasite
based diagnosis), which results in a persistent over estimate of malaria burden – for example
in Herat province, in 2015, around 13225 clinical cases were reported through the HMIS
system. In clinics which have microscopy (in the most endemic districts of Herat) slide
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positivity rate was 0.85 %. If this figure is applied to the number of clinical cases identified,
the estimated confirmed malaria cases among reported clinical cases will be around 2-5 cases.
This improved accuracy in surveillance can result in the directing of resources more
effectively and in earlier detection of outbreaks and epidemics. It has additional advantages in
enhancing the type of intensive surveillance that will be required if Afghanistan officially
declares the goal of elimination.
The National Strategy for Community-based Management of Malaria (CBMM) in
Afghanistan outlines the basic approach to increase access to diagnostic testing of malaria
and effective treatment at the community level in all malaria endemic areas of Afghanistan.
It aims at mobilising commitment and resources from the Government of Afghanistan, the
implementing agencies and the community themselves, providing a common strategy for
concerted action. The development of this Strategy builds on the key policy elements of the
National Malaria Strategy (NMSP) of Afghanistan (2013-2017), the Basic Package of Health
Services (BPHS) for Afghanistan (2010/1389), and the Community-Based Health Care
Policy and Strategy (2015-2020). Currently Afghanistan enjoys a strong partnership amongst
Government, UN agencies, funding agencies, and national and international NGOs, which
creates an enabling environment for successful malaria control.
The CBMM Strategy aim to progressively expand access to highly effective antimalarial
treatment with Artesunate + SP (Sulfadoxine-Pyrimethamine) for the treatment of parasite
confirmed falciparum malaria and with chloroquine for treatment of parasite confirmed vivax
malaria, guided by the use of combination RDTs at peripheral clinics (BHC, SHC and MHT)
and at community level.
First time the CBMM strategy was developed in 2011 which was Implemented phase wise in
stratum one and two provinces. The implementaton of CBMM will be expanded to the entire
country in updated strategy.
2. SITUATION ANALYSIS:
Health Care System
As a result of improvements in health services, Afghans’ health status has improved
substantially since the rebuilding began. The infant mortality ratio (IMR) has declined from
165 in 2003 to 66 deaths per 1,000 live births in 2015; during the same period, under-five
mortality has dropped from 257 to 84 per 1,000 live births. The decline in MMR also has
been dramatic, falling from 1,600 to 396 per 100,000 live births and life expectancy at birth
has increased to 59 years for men and 61 years for women.
The national health policy of Afghanistan aims at providing a standardized package of basic
services in all primary health care facilities, as described in the Basic Package of Health
Services (BPHS). The Basic Package of Health Services includes six standard types of
health facilities, ranging from community outreach provided by CHWs at Health Posts,
through outpatient care at Health Sub Centers and Basic Health Centers and provided by
Mobile Health Teams, to inpatient services at Comprehensive Health Centers and district
hospitals. The section below summarizes the services provided by each type of facility.
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Health Posts: At the community level, basic health services are delivered by CHWs from
their own homes, which function as community health posts. A health post, ideally staffed by
one female and one male CHW, cover a catchments area of 1,000– 1,500 people, which is
equivalent to 100–150 families. The CHWs offer basic curative services, including
differential diagnosis and treatment of fever as well as a wide array of communicable
diseases.
Under CBMM all health posts will be provided RDT for confirmation of clinical malaria
cases and ACT for treatment of confirmed P. faliciparum cases. This will ensure the universal
coverage of parasitological diagnosis and proper treatment of malaria in the country.
Health Sub Centers: The extremely challenging geography, especially in some parts of the
country, the scattered pockets of population, the absence of basic infrastructure such as roads
and bridges, ethnic and security issues, etc. all pose difficult questions regarding the
establishment of BPHS health facilities based on the number of people covered. A HSC is
intended to cover a population of about 3,000-7,000, often residing in remote underserved
areas. The HSC is staffed by two technical staff (a male nurse and a community midwife), as
well as a cleaner/guard. The HSC provides most of the BPHS services that are available in
BHCs. HSCs will refer severe and complicated cases to higher level facilities. The HSCs are
not equipped with adequate malaria diagnostic facilities, therefore; HSCs will also be
supplied RDT and required anti-malarial for treatment of confirmed malaria cases.
Mobile Health Teams: Given all the challenges coupled with the scarcity of trained health
workers (particularly females), it may not be feasible to establish staffed fixed centers in
some remote areas, where the population is scattered and live in small communities. The
principal idea of mobile health services is to establish a limited number of mobile health
teams in each province by dividing the province into clusters of districts. The MHT ideally
has the following staff, male health provider (doctor or nurse), female health provider
(community midwife or nurse), vaccinator and driver. The MHTs are unable to offer
microscopic confirmation of malaria and they will also be supported through CBMM to
ensure parasitological diagnosis by RDT and proper treatment.
Basic Health Center: The BHC is a small facility offering primary outpatient care,
immunizations and Maternal and Newborn care. The services of the BHC cover a population
of about 15,000–30,000, depending on the local geographic conditions and the population
density (can be less than 15,000 where the population is very isolated). The minimal staffing
requirements for a BHC are a nurse, a community midwife, and two vaccinators. Mainly
BHC offer clinical malaria diagnostic services but some health facilities are equipped with
supplies and equipment for malaria microscopy, under some grants of MoPH.
To ensure parasitological diagnosis of malaria in remaining BHCs without lab will also be
supplied with RDTs.
Comprehensive Health Centers: The CHC covers a catchment area of about 30,000–60,000
people and offer a wider range of services than does the BHC. The facility usually has limited
beds inpatient care, and a laboratory equipped with microscopes. The staff of a CHC
comprises of doctors (male and female), nurses (male and female), midwives, one (male or
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female) psychosocial counsellor and pharmacy and laboratory technicians. Irregular
attendance by the laboratory technicians due to trainings, illness, commitment to other
programme related activities, results weakened laboratory diagnostic services. Furthermore,
high patient burden and long waiting lists may also limit access to malaria microscopy at
CHCs level.
District Hospitals: Each district hospital covers a population of about 100,000–300,000.
The district hospital is staffed with a number of doctors, including female
obstetricians/gynecologists; a surgeon, an anesthetist, a pediatrician, a doctor who serves as a
focal point for mental health: psychosocial counsellors/supervisors; midwives; laboratory and
X-ray technicians; a pharmacist; a dentist and dental technician; and two physiotherapists
(male and female). HMIS data shows some proportion of malaria cases are diagnosed
clinically despite the District Hospitals are equipped with microscopy due to high patient
burdens and long waiting lists in the outpatient departments.
Review of National Policies
Community-based health care
The Community-based Health Care in Afghanistan is fully described in the Community-
Based Health Care Policy and Strategy which is recently updated for 2015-2020.
Community-based health care (CBHC) is the basic strategy of the BPHS, providing the
context for the comprehensive interaction between the health system and the communities it
serves. Its success depends upon community participation and partnership between the
community and the health staff.
The implementation of CBHC activities recognizes first that families and communities have
always looked after their own health. Religion and cultural norms and beliefs play an
important part in health practices, and families are making decisions to maintain health or
care for illness every day. In addition, community members understand and have better
information on local needs, priorities, and dynamics in addition to the available local
resources to promote health within their own community. The partnership of health services
with communities therefore has two key aspects:
• To welcome and accept the guidance and collaboration of communities in the
implementation of health programs and the acceptable provision of health services, and
encourage them to identify and solve their own problems.
• To persuade families and communities to make appropriate use of formal health services,
and where necessary to change behavior and life styles
The main purpose of the CBHC program is to increase community awareness about
importance of promotive and preventive measures and to reduce treat common causes of
mortality and morbidity, particularly among children and mothers, who, in Afghanistan are
the most vulnerable of any community
The community based health care strategy 2015 -2020 focuses on below objectives:
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COMMUNITY DEVELOPMENT Health facility
Community
Female & male CHWs
CHS
School
Family Health Action Groups
Other influential
people
Facility Shura-e-Sehi
Family Health action group
Figure 3: Community-Based Health Care System, Afghanistan
Private Provider
1. To scale up CBHC services and initiatives to 90% of uncovered and underserved areas in
rural setting and 60% of poor urban and nomad population by 2020
2. To improve the quality of community based primary health care services at household
level
3. To empower communities to identify their own health needs and take initiatives to solve
identified health problems
4. To enhance the governance of CBHC programs at all levels of health system
The Afghan CBHC system is shown in the figure below, which emphasizes the dynamic
nature of the system. Key stakeholders include:
1. Community health workers
2. Community health supervisors
3. Health shura (Shura-e-Sehie)
4. Family health action groups
Community health workers (CHWs)
CHWs are important members of the health system working as they do with the community.
A CHW has to be from the same area he/she is serving so that she/he is familiar with the
culture and language of the community; the community they serve should also select them.
A CHW provides basic health services from his/her home, which is recognized as a health
post. Usually, both a female and a male community health worker staff a health post. In the
case of the unavailability of both a male and a female CHW, just one CHW may work at the
health post but this not an ideal situation. A health post is responsible for a catchment area for
1,000 to 1,500 people, equivalent to between 100 - 150 families. The coverage of a health
post can be changed according to a geographical area.At present in 2015 there are over
28,000 CHWs serving rural populations in Afghanistan.
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CHWs are trained for between four- six months to deliver basic health services. The main
responsibilities of community health workers are as follows:
• Health education, the promotion of health and changing the health habits of the community
• Referral of patients to health facilities when needed
• Provision of first aid
• Treatment of common and simple illnesses e.g. ARI. Diarrhea and malaria based on the C-
IMCI treatment protocol
• Mother and child health
• Community mobilization for health actions
• Follow-up of TB-DOTs
• Participation in national immunization days and other relevant campaigns
• Community based rehabilitation awareness.
Community health supervisors
CHWs are supervised and monitored by a community health supervisor from the nearest
health facility. A community health supervisor is member of the health facility. S/he is the
main link between the facility and the communities in the catchment area of the facility. S/he
supervises all the CHWs in the catchment area of the health facility, and guides them on the
delivery of the basic health services. Community health supervisors conduct monthly
supervisory meetings with CHWs and ensure the regular replacement of materials in the
CHW kits. In addition, a community health supervisor collects and processes all monthly
reports from CHWs and helps them in their practical work.
Health shura
There are two types of health shura in the CBHC program:
1. A health shura at the health post level
2. A health shura at the health facility level.
The health shura at the health post level supports health related activities in the community
and selects, helps and monitors the CHWs. The health shura at the health facility level works
with CHWs and BPHS staff to adapt health related services to community needs and ensure
improved quality of services and the satisfaction of patients and clients who have used a
health facility.
Family Health Action Group (FHA Group)
An FHA Group is a support group for female CHWs whose aim is to improve the life style of
mothers and appropriate use of health services by mothers and children.
Female CHWs select a group of 10-15 women as activists/volunteers with young children,
respected within their community, and improve their knowledge about health related actions.
Malaria treatment guidelines and management of fever
The MOPH of Afghanistan has updated the national malaria treatment guidelines and adopted
Artesunate + Sulfadoxine/Pyrimethamine as first line treatment of uncomplicated
P.falciparum malaria and Chloroquine+Primaquine for P.Vavix malaria, but the pregnant
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women in first trimester with confirmed plasmodium falciparum will be treated with quinine
and P. vivax with chloroquine without Primaquine in all trimesters. The adoption of ACTs as
antimalarial treatment policy was endorsed in the EMRO region in 20031. Afghanistan’s
treatment policy was last updated in 2014. Chloroquine + primaquine is the standard
treatment of P. vivax malaria at the health facility livel, but Primaquine is not recommended
to be used at community level, therefore, confirmed P.vivax malaria will be treated with
Chloroquine only at community level. Artemether /artesunate/IM is the recommended pre-
referral treatment for severe falciparum malaria at health facilities level (HSC, BHC and
CHC) as first dose, then patient should be referred, If referral is not possible, treatment with
IM artemether/ artesunate should continue until the patient is able to receive the medication
orally.
In order to properly implement the CBMM strategy, aiming at providing universal access to
parasitological confirmation of malaria, specific algorithms for diagnosis and management of
clinical malaria cases (fever without any obvious cause) will be used.
The CBMM will be fully integrated with the Community IMCI, promoting its
implementation for the management of referrals and treatment of malaria at community level.
The introduction of RDT will enable early identification of the non-malaria fevers, which,
due to the relatively low prevalence of malaria in most parts of Afghanistan.
Algorithm for Diagnosis of Malaria at Health Post Level
Registration of the patient
Use RDT
RDT
positive
(Pf/PAN)
RDT
negative
Patient
Stable.
Treat the
patient
Patient with
danger sign
Refer to health
facility
Children less
than 5 month.
Refer to health
facility
Pregnant
women (1st
trimester)
Refer to health
facility
Treat the patient as usual
according to CHWs
guideline
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Figure 4. Algorithm for diagnosis of malaria at health posts level
Malaria Stratification
Considering the major determinants of malaria transmission (altitude, agricultural practices
and incidence), Afghanistan was initially stratified by provinces into three (3) Strata; Stratum
1 (high-risk), Stratum 2 (moderate risk) and Stratum 3 (low-risk or risk-free).
Further analysis revealed that transmission was variable within provinces so the national
program refined the stratification to the district level into four (4) Strata (high-risk, moderate-
risk, low-risk and very low-risk/risk-free). The criteria used for the district re-stratification
included incidence and slide positivity rate during 2009-2010 and the environmental risk
mapping of 2006. All districts can be categorized into district level stratification as following:
Stratum 1 (high risk districts); includes 63 districts with estimated population of
2,944,800 people, that have active transmission of malaria and accounts for 83% of
nationally confirmed reported cases.
Stratum 2 (medium risk districts); are 138 districts with estimated population of
12,133,500 people living in these areas. Malaria is controlled in mentioned districts,
but the areas are receptive to reintroduction of the disease.
If Pf
positive
treat
with
ACT
If both Pf
& PAN
positive
treat with
ACT
If only PAN
positive
treat with
Chloroquine
Pregnant women
(2nd
& 3rd
trimester) If only
PAN positive treat
with Chloroquine
Pregnant women (2nd
& 3rd
trimester) If
only Pf or both Pf &
PAN positive treat
with ACT
Patient comes back with
symptoms after treatment
Refer the patient to the
nearest health facility
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Stratum 3 (low risk districts); are 96 districts with estimated population of
5,023,200 people. The risk of malaria transmission is low in these districts, but are at
risk of epidemics / outbreaks of the disease
Stratum 4 (Very low or Malaria free districts); includes 103 districts with
estimated population of 4,168,400 people. The transmission of malaria is very low or
there is no malaria transmission at all in these districts.
Ongoing Community-Based Initiatives in Afghanistan
Based on BPHS and CBHC, the diagnosis of malaria by CHW is based on clinical diagnose
(fever without other obvious causes) and treatment with Chloroquine. The Basic Package of
Heath Services (BPHS) for Afghanistan does not yet include RDTs and ACTs in the CHW
kits which are distributed regularly.
The Key quantitative and other outputs of the CBHC strategy include:
• An increase in the number of CHWs from 18,939 to 28,250(based on information taken
from the HMIS)
• 4,447 FHA groups established (CHWs HR database and NGO reports)
CBHCC department has supported the recruitment of 219 more community health
supervisors
• The department has revised the CHW training curriculum which has been used for training
of 13,559 CHWs in 29 provinces
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• CBHCC department created position of provincial CBHC officers, and hired qualified staff
for mentioned position in 26 provinces since 2012.
Pilot Community-Based Management of Malaria in Badkhshan, Kunduz, and Takhar
Provinces
A community-based deployment of ACTs and RDTs was initiated in the Northern provinces
of Badkhshan, Kunduz, and Takhar involving community health workers at health post level.
In these provinces the pilot project was implemented by Merlin and CAF (Care for Afghan
Families), and involved 300 CHWs working in 150 health posts in 18 Districts. A total of 33
CHS have been trained to supervise the CHWs in these project areas (5 in Badkhshan, 14 in
Kunduz and 14 in Takhar).
One pilot project, was conducted with WHO TDR funding in 2007-8, evaluated the use of
RDTs by six CHWs in Nangahar and Kunduz, A second pilot project was implemented in
2011to assess the use of RDTs by community health workers using a randomised trial design.
in Kunduz and Nangahar Provinces.
Considering the results of mentioned piloted projects, the CBMM was developed (CBMM
strategy 2011-2015) and implemented into stratum 1&2 provinces of the country. Based on
revised strategy, the implementation of CBMM will be expanded to entire country.
3. GOAL
To contribute to the improvement of the health status in Afghanistan through the
Reduction of morbidity and mortality associated with malaria.
4. STRATEGIC OBJECTIVES:
To expand malaria confirmation at the community level to 100% in all malaria strata
by 2020
To reduce clinically diagnosed malaria cases to zero at community level by 2020
To ensure 100% of malaria cases are properly treated based on parasitological
confirmation at community level by 2020
5. STRATEGIC DIRECTION:
1. Ensure parasitological diagnosis and proper treatment of malaria at community level
2. Enhance community awareness on malaria prevention and control, with main focus on
accurate diagnosis and proper treatment,
Strategic direction #1: Ensure parasitological diagnosis and proper treatment of malaria at
community level
With the divergence in treatments between vivax and falciparum malaria and relative high
cost of ACT compared to chloroquine there is a need for greater emphasis on diagnosis at all
levels of the health system; if falciparum malaria is mistakenly treated as vivax treatment
failure is assured, and if vivax is treated as falciparum valuable drugs are needlessly wasted.
Malaria confirmation by RDT and treatment according to NTG should be ensured at
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community and lower health facility level. This improves efficiency and coverage and makes
better use of limited human and financial resources.
Pf/Pv RDTs should be used at the community level to distinguish Plasmodium falciparum
and Plasmodium vivax from other causes of fever. RDTs have been tested in Afghanistan and
the decision to implement this as diagnostic tool where microscopy is not available. Because
symptoms of malaria are non-specific, 70-99% of febrile illnesses submitted to microscopic
diagnosis are negative (i.e. slide positivity rates are 1-30% or less). Microscopy & RDT
diagnosis are needed to reduce wastage of anti-malarial drugs and to improve management of
patients who do not have malaria.
ACT has been incorporated into the BPHS as an essential drug and should be used for
treatment of confirmed falciparum cases. Vivax malaria should continue to be treated with
chloroquine.
Sustained high-quality diagnosis and treatment of malaria (and other diseases) can only be
achieved through regular trainings, technical monitoring and quality control of microscopy &
RDT by Quality Assurance Centres (QAC) of PHD/PMLCPs under direct supervision and
coordination through a national quality assurance unit of MoPH/NMLCP.
Interventions/activities:
1 Expansion of malaria confirmation
1.1 training for Community Health Workers and health staff of lower health facility
where microscopies are not available (BHC, SHC, MHT)
1.1.1 refresher training on malaria RDT for Community Health Workers (CHWs),
Community Health Supervisors (CHSs) and lower HFs
1.1.2 initial training on malaria RTD for newly recruited related health staff at community
and HF level
1.2 improvement of malaria diagnostic services
1.2.1 provision of malaria RDTs under CBMM strategy for HPs and health facilities
1.2.2 consumable and maintenance of malaria diagnostic services
2 Standardize malaria treatment at all health facilities
2.1 provision of update NTG for the health facilities
2.2 provision of anti-malarial drugs (ACT for HF and Community and primaquine for HFs)
3 M&E and Quality Assurance
3.1 regular monitoring of malaria case management at community and lower HFs
3.2 regular analysis and CBMM reported data
3.3 collection of the samples of tested RDTs from community and HFs for QA in PCR
Strategic direction #2: Enhance community awareness on malaria prevention and
control, with main focus on accurate diagnosis and proper treatment,
To assess the role of communication for behaviour change process, it is necessary to
understand if the lack of malaria treatment and prevention behaviour is due to a lack of
awareness that malaria is an important disease, negative attitudes towards the disease or lack
of skills or “know how” to make a change. Therefore, it is imperative to have a firm
understanding of the competitive behaviours among the target audience, whether in relation
to malaria treatment or prevention. This will allow for the most appropriate and effective
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communication intervention to be adopted. Target groups must be understood in terms of
their reasons for their actions or barriers to change. This approach aims to engage in four key
tactics, which will create competitive advantages: increasing benefits of the desired target
behaviour, decreasing the barriers and costs related to the desired behaviour, decreasing the
value of the competing behaviour and increasing the cost of the competing behaviour.
Intensification of information, education and communication efforts is needed to improve
people’s knowledge and enable them to adopt a behaviour that obviates risks of malaria
infection. The lack of essential knowledge has an adverse effect on people’s behaviour in
taking appropriate protective measures and seeking medical care once malaria is suspected.
Health education messages should emphasize the malaria risk in different geographical
localities. Messages disseminated through health forums should address clearly how the
disease is acquired and what are its manifestations to enable people to protect themselves and
seek medical care once symptoms are suspected. Messages should address measures of
prevention against malaria with special emphasis on accurate diagnosis and proper treatment.
Health care facilities should consider health education activities of relevance to malaria as
part of the routine services provided to the population. This may be through community
health workers offering counselling sessions on recognition of malaria symptoms, diagnosis,
treatment and prevention using LLINs.
Strategic Interventions/activities:
1. Enhance community awareness on malaria prevention and timely diagnosis &
treatment
1.1 Conducts community health forums for raising awareness on malaria symptoms,
transmission route and prevention
1.2 Malaria health sessions at community level by community health workers
1.3 Updating IEC materials
1.4 Distribute malaria IEC materials (poster, brochure, leaflet etc) through targeted HFs
and community
2. Assess the improvement of community behaviour on malaria prevention and
treatment
2.1 assessment of community behaviour on malaria case management
Procurement, storage and distribution
Procurement management of the GF grant related supply including CMM related shall be as
per UNDP rules and regulation and the procedures of the GF policies. The annual
procurement plan for CBMM supplies will be provided by national program with clear
specification and distribution areas.
18
Stocks will be kept at the Provincial level and delivery of RDTs and ACTs at Provincial level
will be under the responsibility of the Implementing Agencies. In principle the ACTs and
RDTs should be delivered to the BPHS implementers, in order to avoid the creation of
parallel programs. NMCLP Provincial units should be informed of the transfer of diagnostic
tests and ACTs from Implementing Agency to the BPHS implementers.
Clear guidelines are needed on management of storage and distribution to maintain the RDTs
under cool conditions. The Guidelines on Transport, Storing and Handling Malaria
Diagnostic Tests in Health Facilities and at Central and Peripheral Storage Facilities,
developed by the USAID/Deliver Project will be adapted, translated in Dari & Pashto and
duplicated for use in training and programme support activities.
Supply to BHCs and HSCs will be based on a "pull system", with demand generated by the
BHCs and HSCs. The HPs will be receive the additional supplies ACTs and RDTs+ancillary
items (not yet included in the CHW kits) through the CHCs and/or BHCs which are currently
supplying the CHW kits. Delivery of ACTs and RDTs will be managed by the BPHS
implementers, without creating new parallel systems.
Stock management
The stock management of ACT and RDTs will be the responsibility of the BPHS
implementers, after receiving specific briefing on stock management, temperature monitoring
and reporting. Quarterly reports on status of stocks will be provided by the BPHS
implementers to NMLCP in order to guide possible re-deployment on of stocks (a loan-basis)
according to needs. The NMLCP will keep a limited stock of ACT and RDTs for emergency
and response at central .
Challenges
Performance incentive balance for field workers (CHS and CHW)
Health services are supported by a multitude of Partners, creating occasional
difficulties for coordinated approaches
Logistic barriers including limited road access to many parts of the country
Lack of clarity over the integration of a historically vertical programme into the
BPHS
Low salaries/ incentives for Government staff forcing competent staff to
supplement their income through private practice or seek employment in the
private, NGO or UN sectors where income is higher
Limited mobility of women (as professional staff, health workers, household
decision-makers, and patients)
Ongoing insecurity in some areas of the country
19
6. INSTITUTIONAL FRAMEWORK
The Provincial Manager, responsible for the malaria team (often including one epidemiology
officer, two vector control officers, two technicians), has the main role of coordinating,
monitoring and supervising all malaria control activities in the province, and the malaria-
related activities implemented as part of the BPHS. The provincial malaria control program
is administratively under Provincial Health Directorate (PHD) and technically is responsible
and should report regularly to NMLCP.
The Provincial Project Manager/Focal Point of the Implementing Agency, in close liaison
with Provincial Health Director, is responsible for implementation of specific malaria
activities based on action plan and set targets. He/she manages the funds and logistics, and
generates specific reports to NMLCP and PR (UNDP). In those provinces where LLIN
distribution is planned, a LLIN officer is assigned in the implementing agency to manage
LLIN distribution and all related activities, including proper reporting.
The Community-Based Health Care (CBHC) focal point is assigned in 29 provinces who is
responsible for coordinating all activities managed at community level. In certain Provinces
this function is performed by the PHC unit, and in other a PHD Coordinating Committee is in
place to coordinate all programmes and implementing agencies (NGOs).
Implementation of the activities by Implementing Agencies (NGOs) is monitored by the
Provincial teams (PMLCP), while the central level is responsible for planning, budgeting,
training of trainers, data analysis and interpretation, including data from the HMIS relevant to
the project, and processing the reports prepared by Provincial managers.
7. MECHANISM FOR COORDINATION
In order to bring together the many players which are supporting the Ministry of Public
Health in the process of rehabilitating the health services, Task Forces are formed in the
health sector to provide a forum for discussion, planning and policy making. These task
forces play an important role in coordination and have representation from MoPH, WHO,
UNICEF, BPHS implementers, NGOs, and other sectors, including multiple stakeholders and
funding agencies.
The NMLCP has a task force to coordinate malaria control and elimination activities which is
called Vector Born Disease Control Task Force (VBDCTF). VBDCTF has the following
main term of references which is operational at both National and Provincial Levels:
8.1 The National Vector Born Disease Control Task Force (VBDCTF)
20
1. Vector Born Disease Task Force will use its available means to promote, design, monitor
and implement malaria and leishmaniasis Program within the framework of relevant
policy documents (i.e. EPHS, BPHS, NMSP, NLSP and other relevant policies)
2. VBDTF recognises that the MoPH is the leading Health agency in Malaria, Leismaniasis
and other Vector Born Diseases and has authority over policy and implementation issues;
the task force members shall coordinate closely with the relevant MoPH departments
3. VBDTF represents the main technical and policy forums for Malaria, Leishmaniasis and
other vector born diseases in Afghanistan, Where possible, Change in malaria control and
elimination policy will be approved by consensus with the VBDTF acting as the first part
of call for proposal which effect malaria and leishmaniasis control policies and practice
4. VBDTF will aim to oversee the achievement of the relevant Millennium Development
Goals and other nationally approved development targets
5. VBDTF will act to promote malaria, leishmaniasis and other vector born disease
programs at all levels
6. VBDTF will act to maximise the effectiveness of activities through proper coordination
amongst the implementing partners, stakeholder and donors
7. VBDTF will advocate for funding of projects which aim to prevent and control these
diseases
8. VBDTF will ensure evidence based programming through reviewing scientific , technical
and policy documents
9. VBDTF will actively promote gender equity in the health sector, particularly concerning
the role of women
Permanent Members of VBDCTF:
MoPH: Manager Program support coordinator, NMLCP technical advisor, other
NMLCP staff as an appropriate.
WHO: Medical Officer and National Officer, WHO Afghanistan, and other WHO
staff as appropriate
UNDP (the PR for GF NFM)
NGOs: Health Net-TPO, BRAC, HPRO
Other BPHS implementer who are SR for malaria grant, as appropriate
21
Non-permanent Members of VBDCTF:
The VBDCTF may invite either permanently, or on ad hoc basis other partners or
organisations, such as funding agencies, media, members of other task-force of MoPH, as
may be necessary to reach the objectives of the task force.
Mode of Action:
The VBDCTF will meet on the second Wednesday of each month at 10AM. In case of any
urgent issue, NMLCP manger may convene the task force before the mentioned date.
The meetings are called and organised by the Manager NMLCP (or his representative).
Decisions will be made by consensus and transparently. In the event that consensus cannot be
reached then the permanent members should vote and approve the proper and final decision.
Minutes of the meetings are public documents; they shall be communicated IN DRAFT form
to permanent members. Once finalised and approved; minutes shall be communicated to all
members, who are free to distribute them as they see fit.
8.2 The Provincial Vector Born Disease Control Task Force (VBDCTF)
The same structure established at central level is also present at Provincial level under the
coordination of the Provincial Public Health Directorate. At Provincial level the following
members contribute to the work of the Task Force:
PHD: Provincial Public Health Director, Provincial Malaria & Leishmaniasis
Control Program Manager, Provincial CDC Manager, PHA, Provincial TB
Manager, Provincial HMIS Manager, BPHS Implementer.
NGOs: implementing partner
WHO provincial sub-office, if available
UNDP
8. IMPLEMENTATION PLAN
Priorities areas and phased implementation
The Community-Based Management of Malaria (CBMM) strategy will be implemented in
the entire country.
22
The CBMM was initially piloted in 150 Health Posts (involving 300 CHWs and 33 CHS), in
the 18 districts of Badakhshan , Kunduz and Takhar which helped to consolidate the lessons
learnt and guided the implementation of the community-based management of malaria to all
Health Posts and low level health facilities (BHC, SHC, MHT), where microscopy are not
available. Moreover, consolidated experience in the use of RDTs in BHC and HSC will be
important to ensure supervision and support to CHW from the same catchment areas involved
in these activities.
Following the pilot phase, CBMM was implemented in the malaria high risk (stratum 1&2)
districts under Phase II of R8 GF malaria grant. The focus on districts with higher malaria
burden (Stratum 1&2) also enabled further improvement of the malaria stratification in the
country. Since most of the reported malaria cases are only clinical malaria cases (not
confirmed by microscopy), this strategy prioritizes the introduction of malaria diagnosis by
RDTs for areas where the majority of cases are reported based on clinical diagnosis alone.
CBMM implementation will be expanded to all four strata with support of GF NFM.
9. MONITORING AND EVALUATION
The relevant data collection forms which will be used at BHC, HSC and HP levels will be
developed by NMLCP in collaboration with HMIS Department to include ACT treatment and
testing by RDTs. As much as possible existing data flow and reporting system will be used
to monitor the implementation of the programme. Key indicators (outcome and impact)
specific for surveys will be implemented to monitor the effectiveness of the programme.
In line with the national malaria control strategic plan (2013-2017) the programme
implementation will be monitored on the basis of the data and indicators listed in Table 6,
below.
10.1 Integrated supervision
A specific checklist has been developed, combined with malaria monitoring checklist, to
monitor the CBMM implementation at HF and community level in the country. The
activities of CHWs, including CBMM implementation at community level, will be supervised
by CHS, while the supervisors of the implementing agencies will receive a specific training
on monitoring the quality of malaria case management and supervise the CBMM activities at
the health facility (BHC, SHC, MHT) and community level.
Besides, the national and provincial malaria control programs are also responsible for regular
monitoring of the CBMM activities at HF and community levels to ensure the quality
implementation of the CBMM in the country.
10.2 Quality control at point of care
23
The main activities to control the quality of RDTs and ACTs deployment at point of care
should be part of the supervision visits by CHS and programme supervisors and focus on: 1)
conditions of storage; 2) checking temperature monitoring charts; 3) direct observation of
health workers in performing the test, interpreting the results, dispensing the treatment and
recording the data on case, results and treatment.
Monitoring of the daily max temperature of the warehouses in areas exposed to high
temperature will be done before and during the implementation phase. The temperature
monitoring charts with minimum-maximum thermometer should be available in all health
facilities and warehouses in all places where the daily temperature is expected to exceed
30 °C.
24
Table 6 - Key indicators to monitor inputs, process, outcome of CBMM programm
No Indicator Formula Source of
data
Targets Level Frequency Remarks
16 17 18 19 20
1
Number of RDT received in
the country by implementing
agencies
Number of RDTs received in the
country per year by funding and
implementing agencies
Program records
National
yearly
2
Number of RDT delivered to
BPHS implementers at
provincial level
Number of RDTs delivered at
provincial level
to BPHS implementers
Program records
Provincial/
National
Every 6 months
3
Proportion of targeted BHCs
and HSCs reporting no RDT
stock outs
Numerator: Number of targeted
BHCs and HSCs reporting no
RDT stock outs per month
Denominator: Number of
targeted BHCs and HSCs
submitting monthly stock reports
on RDT
Malaria
Information
System. PMLCP/BPH
S
Provincial/
National
Quarterly
4
Proportion of targeted HPs
reporting no RDT stock outs
Numerator: Number of targeted
HPs reporting no RDT stockouts
on tally sheets
Denominator: Number of
targeted HPs submitting tally
sheets with RDT stocks
Malaria
Information
System. PMLCP/BPH
S
Provincial/
National
Quarterly
5 Number of ACT received in
the country by implementing
agencies
Number of ACTs received in the
country per year by funding and
implementing agencies Program records
National
yearly
25
6
Number of ACT delivered to
BPHS implementers at
provincial level
Number of ACTs delivered at
provincial level
to BPHS implementers (every 6
months)
Program
records
Provincial/
National
Every 6
months
7
Proportion of targeted BHCs
and HSCs reporting no ACT
stock outs
Numerator: Number of targeted
BHCs and HSCs reporting no
ACT stockouts per month
Denominator: Number of
targeted BHCs and HSCs
submitting monthly stock reports
on ACT
Malaria Information
System.
/HMIS
Provincial/
National
Quarterly
8
Proportion of targeted HPs
reporting no ACT stockouts
Numerator: Number of targeted
HPs reporting no ACT stockouts
on tally sheets
Denominator: Number of
targeted HPs submitting tally
sheets with ACT stocks
Malaria
Information System.
PMLCP/BPH
S
Provincial/
National
Quarterly
9
Proportion of malaria cases
confirmed by RDT in targeted
BHCs and HSCs
Numerator: Number of reported
malaria cases confirmed by RDT
in targeted BHCs and HSCs
Denominator: All reported
malaria cases from targeted BHCs
and HSCs
Malaria
Information
System. PMLCP/BPH
S
40
%
50
% 60%
70
%
80
%
Provincial/
National
Quarterly
10
Proportion of malaria cases
confirmed by RDT in targeted
Health Posts
Numerator: Number of reported
malaria cases confirmed by RDT
in targeted BHCs, HSCs and
Health Posts
Denominator: All reported
malaria cases from targeted
BHCs, HSCs and Health Posts
Malaria
Information
System. PMLCP/BPH
S
40
%
50
% 60%
70
%
80
%
Provincial/
National
Quarterly
26
11
Proportion of reported
falciparum cases confirmed
by RDT treated with ACTs in
targeted BHCs and HSCs
Numerator: Number of reported
falciparum cases confirmed by
RDT treated with ACTs in
targeted BHCs and HSCs
Denominator: All reported
falciparum cases confirmed by
RDT from targeted BHCs and
HSCs
Malaria
Information System.
PMLCP/BPH
S
60 65 70
80
90
Provincial/
National
Quarterly
12
Proportion of reported
falciparum cases confirmed
by RDT treated with ACTs in
targeted Health Posts
Numerator: Number of reported
falciparum cases confirmed by
RDT treated with ACTs in
targeted BHCs, HSCs and Health
Posts
Denominator: All reported
falciparum cases confirmed by
RDT from targeted BHCs, HSCs
and Health Posts
Malaria
Information System.
PMLCP/BPH
S
50 55 60
65
70
Provincial/
National
Quarterly
13
Proportion of reported non-
falciparum cases confirmed
by RDT treated with
chloroquine + primaquine in
targeted BHCs and HSCs
Numerator: Number of reported
non-falciparum cases confirmed
by RDT treated with chloroquine
+ primaquine in targeted BHCs
and HSCs
Denominator: All reported non-
falciparum cases confirmed by
RDT from targeted BHCs and
HSCs
Malaria
Information
System.
PMLCP/BPHS
60 65 70
80
90
Provincial/National
Quarterly
14
Proportion of reported non-
falciparum cases confirmed
by RDT treated with
chloroquine in targeted Health
Posts
Numerator: Number of reportd
non-falciparum cases confirmed
by RDT treated with chloroquine
in targeted Health Posts
Denominator: All reported non-
falciparum cases confirmed by
RDT from targeted HPs
Malaria
Information
System. PMLCP/BPH
S
50 55 60
65
70
Provincial/
National
Quarterly
27
The HMIS data flow in relation to malaria reporting at Provincial and Central levels is
shown in the Figure 6 below.
Figure 6. Reporting data flow (HMIS and other reporting systems relevant to CBMM)
28
ANNEX 1 - Stratification of districts of Afghanistan based on reported malaria
incidence rate (2009 data)
Stratum 1 = Districts with reported malaria cases exceeded the median of reported annual malaria
incidence rate per district, i.e. >10/1000; Stratum 2 = Districts with reported annual malaria incidence
rate between 1 and 10/1000; and Stratum 3 = Districts with reported annual malaria incidence rate of 0-
1/1000 cases.
Pop = district population data provided by Central Statistics office (2009); IR = reported annual
malaria incidence rate, based on HIMS reports of 2009
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Badakhshan Baharak 26200 14.5 Arghanjwa 14700 9.6 Eshkashem 12600 1.0
Badakhshan Darayim 56000 35.4 Keren -O- Menjan 8700 1.3
Badakhshan Darwaz 24100 24.6 Khash 34600 6.3
Badakhshan Darwazi Bala 21100 12.7 Kofab 20400 6.4
Badakhshan Fayzabad 59800 85.1 Sheikai 24000 8.9
Badakhshan Jurm 34100 19.1 Shighnan 25300 2.3
Badakhshan Khwahan 15100 47.7 Wakhan 13600 1.2
Badakhshan Kishim 73500 131.8 Yamgan (Girwan) 23400 8.8
Badakhshan Kohistan 15100 22.4 Zebak 7100 1.8
Badakhshan Raghastan 36000 11.9
Badakhshan
Shar -i-
Buzurg 47600 40.5
Badakhshan Shuhada 31400 11.5
Badakhshan
Tagab
(Kishmi
Bala) 25500 70.0
Badakhshan Tashkan 27200 46.3
Badakhshan Urgo 71300 28.2
Badakhshan Wardug 19900 14.5
Badakhshan Yaftali Sufla 48100 56.4
Badakhshan Yawan 29500 21.8
Badghis Ab Kamari 66900 2.7 Dahana-I- Ghuri 53500 0.2
Badghis Ghormach 50100 5.8 Dih Salah 29100 0.8
Badghis Jawand 71800 3.1 Dushi 60800 0.2
Badghis Muqur 21600 7.5 Nahreen 62800 0.2
Badghis Murghab 88400 2.7
Badghis Qadis 82800 2.4
Badghis Qala-I- Naw 59800 4.3
Baghlan Andarab 23200 4.4
Baghlan Baghlani Jadid 154900 7.3
Baghlan Burka 47900 4.4
Baghlan Khenjan 27700 2.1
Baghlan Pul -i- Hisar 25200 2.9
Baghlan Puli Khumri 188000 1.4
Baghlan Tala Wa Barfak 27500 4.7
29
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Balkh Khulm 63500 36.6 Chahar Bolak 73600 3.0 Balkh 108400 0.2
Balkh Sholgara 103300 18.3 Chimtal 83500 7.3 Chahar Kint 40500 0.5
Balkh Dawlatabad 95000 1.7 Dihdadi 61300 0.4
Balkh Kaldar 18200 4.3 Marmul 10300 0.0
Balkh Kishindih 44300 4.6 Nahri Shahi 40900 0.8
Balkh Mazari Sharif 326100 1.3
Balkh Shortepa 36000 9.8
Balkh Zari 39900 5.5
Bamyan Kahmard 33100 23.2 Shibar 26800 1.0 Bamyan 75500 0.3
Bamyan Shayghan 21800 19.6 Yakawlang 79500 5.0 Panjab 62000 0.2
Bamyan Waras 99300 0.1
Daykundi Gitti 30500 13.9 Mir amor 57000 8.2
Daykundi Gizab 61400 29.7 Sangi Takht 46100 1.3
Daykundi Gujran 31900 33.0
Daykundi Ishtarlee 43400 12.5
Daykundi Khadir 42400 16.7
Daykundi Nili 37100 16.9
Daykundi Shahristan 60500 15.9
Farah Lash -i- Juwayn 25500 15.9 Bakwa 32300 2.2 AnarDara 25300 0.9
Farah Gulestan 39400 4.6 Bala Buluk 65000 0.6
Farah Khaki Safed 27600 2.2 Farah 100600 0.3
Farah Pur Chaman 48600 9.3 Pusht Rod 37000 0.0
Farah Qala-I-Kah 28000 0.3
Farah Shib Koh 21300 0.1
Faryab Balcheraqh 47500 13.2 Almar 63900 1.9 Andkhoy 35300 0.1
Faryab Dawlatabad 44100 15.2 Garziwan 69000 5.0
Khani Chahar
Bagh 21100 0.0
Faryab
Khwaja Sabz
Posh 46200 51.0 Kohistan 49600 9.5 Qaramqol 17900 0.3
Faryab Maymana 71500 13.4 Qaysar 129600 7.4 Qurghan 42900 0.2
Faryab Pashtun Kot 171700 21.1
Faryab Shirin Tagab 74100 29.3
Ghazni Ab Band 25000 24.9
Bahrami Shahid
(Jaghatu) 28900 1.2 Jaghuri 160600 0.2
Ghazni Ajristan 26200 48.3 Dih Yak 44500 1.9 Malestan 74600 0.0
Ghazni Andar 113500 11.3 Ghazni 146200 4.6 Nawur 86000 0.8
Ghazni Gellan 52700 20.3 Giro 33200 6.3
Wali
Muhammadi
Shahid 18300 0.7
Ghazni Muqur 45700 33.9 Khwaja Umary 17300 6.2
Ghazni Nawa 27100 80.4 Qarabagh 129900 5.4
Ghazni Rashidan 16300 13.2 Waghaz 35100 5.4
Ghazni ZanaKhan 11500 1.6
Ghor Saghar 31600 34.3 Chaghcharan 123100 2.6 Dawlat Yar 29800 0.2
Ghor Charsada 24900 1.2 Duleena 32800 0.3
30
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Ghor Pasaband 86300 2.7
Lal-o-Sar-i-I
Jangal 101900 0.0
Ghor Shahrak 54400 5.4
Ghor Teyora 83200 5.6
Ghor Tolak 46900 3.9
Hilmand Lashkar Gah 92700 31.4 Bughran 74200 5.4 Dishu 18600 0.0
Hilmand NawZad 46300 14.4 Garm seir 80000 8.3
Hilmand Washeir 14200 46.5 Kajaki 65000 3.0
Hilmand Musa Qala 53800 5.7
Hilmand Nad Ali 107500 3.8
Hilmand Nahr -i- Sarraj 106500 2.3
Hilmand
Nawa-I- Barak Zayi 84600 6.5
Hilmand
Reg -i- khan
sheen 24000 2.7
Hilmand Sangin Qalah 54400 9.4
Hirat Chishti Sharif 21600 15.4 Adraskan 48900 6.9 Guzara 133600 0.4
Hirat Farsi 27900 21.0 Ghoryan 79600 8.5 Hirat 386600 0.1
Hirat Kushki Kuhna 41600 23.8 Gulran 85700 7.0 Injil 222500 0.3
Hirat Karukh 57900 6.2 Kohsan 49500 0.8
Hirat Kushk 112700 8.2 Obeh 68800 0.2
Hirat Zinda Jan 52000 5.5
Pashtun
Zarghun 91200 0.2
Hirat Shindand 162600 0.9
Jawzjan Khamyab 12700 13.4 Aqcha 53900 4.2
Jawzjan Mangajak 39000 27.4 Darzab 44700 3.9
Jawzjan Qarqin 22200 27.6 Fayzabad 37900 5.9
Jawzjan Qush Tepa 21400 34.1 Khanaqa 35800 10.0
Jawzjan Khwaja Du Koh 24500 7.2
Jawzjan Mardyan 35100 4.6
Jawzjan Shibirghan 149500 6.7
Kabul Kalakan 27600 14.6 Bagrami 50500 1.0 Estalif 30600 0.0
Kabul Surobi 50500 20.3 Chahar Asyab 33300 9.0 Kabul 2831400 0.7
Kabul Dih Sabz 49100 5.7
Kabul Farza 19600 2.8
Kabul Guldara 20900 8.8
Kabul Khaki Jabbar 13000 4.5
Kabul Mir Bacha Kot 47600 1.5
Kabul Musayi 21300 4.9
Kabul Paghman 110000 1.2
Kabul Qarabagh 69500 7.7
Kabul Shakardara 74900 2.9
Kandahar Arghandab 56400 16.6 Kandahar 481100 8.5 Shorabak 10400 0.4
Kandahar Arghistan 31300 48.3 Nesh 12200 5.4
Kandahar Daman 31500 42.1 Panjwayi 79200 2.4
31
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Kandahar Khak Reiz 20800 10.5 Spin Boldak 103000 5.4
Kandahar Maroof 30000 10.5 Zhari 78100 1.3
Kandahar Maywand 53400 14.9
Kandahar Shah Wali Kot 39400 37.0
Kapisa
Hisa-i-
Duwumi
Kohistan 40900 17.6 Koh Band 21400 1.2 Alasay 34400 0.6
Kapisa Mahmudi Raqi 58400 10.8 Kohistan 61900 6.9
Kapisa Tagab 73600 12.0 Nijrab 102300 2.0
Khost Bak 20100 60.9
Mando Zayi
(Ismayel Khel) 51300 4.2
Khost Gurbuz 23800 16.8 Musa Khel 37300 7.3
Khost Jaji Maydan 21900 86.3
Khost Khost(Matun) 124900 14.8
Khost Nadir Shah Kot 29000 21.7
Khost Qalandari 9300 33.8
Khost Sabari 64500 14.6
Khost Shemal 12400 12.6
Khost Spera 22200 17.1
Khost Tani 54200 14.4
Khost Terezayi 40700 11.9
Kunar Asadabad 30000 92.1
Kunar Bar Kunar 20000 143.1
Kunar Chapa Dara 28200 86.4
Kunar Chawki 32500 150.2
Kunar Dangam 15400 138.6
Kunar Dara-I-Pech 49800 71.9
Kunar Ghaziabad 17000 83.1
Kunar Khas Kunar 31800 141.4
Kunar Marawara 18600 39.3
Kunar
Narang
(Tara-gn-o-
Badil) 27500 149.1
Kunar Nari 25100 87.1
Kunar Noor Gul 28800 120.4
Kunar Sar kani 24800 158.9
Kunar Shigal O Sheltan 26600 138.3
Kunar Wata Pur 24900 101.4
Kunduz Aliabad 42900 20.3 Kunduz 277900 9.4
Kunduz Archi 76900 28.8
Kunduz Chahar Dara 66800 10.5
Kunduz
Hazrat Imam
Sahib 210500 21.5
Kunduz Khanabad 145200 30.9
Kunduz Qalay-I- Zal 62700 13.9
32
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Laghman Alingar 88000 64.9
Laghman Alishing 64900 35.7
Laghman Dawlat Shah 30200 53.0
Laghman Mihtarlam 124500 47.2
Laghman Qarghayi 89200 45.6
Logar Azra 18500 28.9 Baraki Barak 79600 2.4
Logar Kharwar 23900 17.2 Charkh 40400 2.5
Logar Khushi 21900 2.8
Logar Muhammad Agha 68700 9.0
Logar Puli Alam 96000 2.5
Nangarhar Achin 91200 74.9
Nangarhar Bati Kot 68900 134.7
Nangarhar Bihsud 103400 43.2
Nangarhar Chaparhar 54800 98.3
Nangarhar Dara-I-Nur 36700 36.6
Nangarhar Dih Bala 36700 274.4
Nangarhar Dur Baba 21200 131.9
Nangarhar Goshta 24800 137.8
Nangarhar Hisarak 28000 29.1
Nangarhar Jalalabad 183000 37.4
Nangarhar Kama 69900 67.8
Nangarhar Khogyani 118600 96.4
Nangarhar Kot 47400 179.5
Nangarhar Kuz Kunar 50100 69.2
Nangarhar LalPur 18600 335.2
Nangarhar
Muhmand
Dara 40900 205.2
Nangarhar Nazyan 13300 176.1
Nangarhar
Pachir Wa
Agam 38700 62.6
Nangarhar Rodat 62900 40.3
Nangarhar Sherzad 60300 48.9
Nangarhar Shinwar 54500 72.1
Nangarhar Surkh Rod 109600 13.9
Nimroz KhashRod 23100 1.3
Asl-i-Chakhansur 21600 0.3
Nimroz Zaranj 50700 4.0 Chahar Burjak 24100 0.0
Nimroz Kang 20400 0.8
Nuristan Barg -i- Matal 14200 49.2
Nuristan DuAb 7100 70.6
Nuristan Kamdesh 23100 30.4
Nuristan Mandol 18000 21.1
Nuristan NoorGram 29400 24.6
Nuristan Paroon 12300 33.2
33
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Nuristan Wama 10000 63.2
Nuristan Waygal 17800 77.9
Paktika Dila 22900 32.0 Barmal 31600 3.2
Paktika Gomal 7000 295.6
Paktika Jani Khel 21800 26.7
Paktika Mata Khan 22700 30.7
Paktika Nika 11300 112.7
Paktika Omna 11000 86.2
Paktika Sar Hawza 21100 34.6
Paktika Sarobi 11400 54.0
Paktika Sharan 45500 109.2
Paktika Urgoon 50300 58.3
Paktika Waza Khwa 21100 55.0
Paktika Yahya Khel 15800 22.4
Paktika Yosuf Khel 12300 47.7
Paktika
Zarghun
Shahr 27200 15.4
Paktika Ziruk 17500 14.3
Paktya Ahmadabad 25300 11.0 Chamkanay 45500 7.6 Sayid Karam 58400 1.0
Paktya
Dand Wa
Patan 24200 84.8 Wuza Zadran 32300 9.3
Paktya Gardez 75300 12.2 Zurmat 97800 9.7
Paktya Jaji 57300 20.4
Paktya JaniKhel 31800 24.7
Paktya
Lija Ahmad
Khel 20800 26.0
Paktya Shwak 5100 67.5
Panjsher Rukha 20900 13.0 Bazarak 17100 4.0 Paryan 13400 0.7
Panjsher Shutul 9900 14.2 Dara 22700 2.3
Panjsher Uanaba 16300 39.8
Hisa-I-Awal
Panjsher 36400 2.1
Parwan Bagram 94300 5.3 Ghorband 88100 0.2
Parwan Chaharikar 158800 1.4 Shekh Ali 22400 0.7
Parwan Jabalussaraj 58100 1.9 Surkhi Parsa 37200 0.2
Parwan Kohi Safi 28200 6.8
Parwan Salang 23700 3.3
Parwan Sayd Khel 41500 5.1
Parwan Shinwari 37400 2.9
Samangan Dara-I-Suf Bala 58800 1.1 Aybak 93200 0.8
Samangan Feroz Nakhchir 11900 7.3
Dara-I-Suf
Payin 65000 0.2
Samangan Hazrat -i- Sultan 37700 4.5
Khuram Wa Sarbagh 36300 0.9
Samangan Ruyi Du Ab 41500 0.1
Sari Pul Balkhab 45800 10.1 Gosfandi 51600 4.4
Sari Pul Sozma Qala 45000 19.2 Kohistanat 72800 8.4
34
Province
Name
Stratum 1 Stratum 2 Stratum 3
District
Name Pop IR District Name Pop IR District Name Pop IR
Sari Pul Sangcharak 91700 1.6
Sari Pul Sari Pul 140300 8.4
Sari Pul Sayyad 49700 3.0
Takhar Baharak 28100 21.2
Takhar Bangi 31900 34.0
Takhar ChahAb 70800 31.2
Takhar Chal 25700 25.6
Takhar Darqad 24500 34.4
Takhar Dashti Qala 29100 27.0
Takhar Eshkamish 53700 16.8
Takhar Farkhar 42500 27.8
Takhar HazarSumuch 12500 30.2
Takhar Kalafgan 32000 35.6
Takhar
Khwaja
Bahawuddin 21200 21.0
Takhar Khwaja Ghar 60800 21.2
Takhar Namak Ab 11100 98.7
Takhar Rustaq 149000 45.6
Takhar Taluqan 203300 16.5
Takhar Warsaj 34500 19.3
Takhar Yangi Qala 40200 34.0
Uruzgan Chorah 46500 5.5
Uruzgan Dihrawud 55400 9.0
Uruzgan Khas Uruzgan 51400 1.4
Uruzgan Shahidi Hassas 53700 3.6
Uruzgan Tirin Kot 93200 7.1
Wardak
Chaki
Wardak 76800 12.3 Day Mirdad 28200 5.0
Hisa-I- Awali
Bihsud 33700 0.2
Wardak Jaghatu 41600 1.5 Jalrez 48200 0.6
Wardak Maydan Shahr 36600 1.0 Markazi Bihsud 108600 0.2
Wardak Saydabad 105700 2.3 Nirkh 51800 0.7
Zabul Arghandab 29700 15.4 Daichopan 35800 6.0
Zabul Atghar 7900 57.3 Mizan 12500 2.2
Zabul Qalat 31900 37.4
Zabul Shahjoy 53200 47.2
Zabul Shamulzayi 23500 49.2
Zabul Shinkay 21400 11.6
Zabul
Tarnak -O-
Jaldak 15600 16.2
35
ANNEX 2 - Current contents of CHW kit (2009)
No Description Strength Unit Quantity New quantity Remarks
I. Monthly-based Expendable items
1 Sol Gentian Violet 1% 05ml/10ml Bottle 1 15-Feb
2 Tab Cotrimoxazole 085mg Tab 105 055
0 Packet ORS Packet 20 05 (during the
summer Jawza-
Sunbullah)
0 Coated tablet Ferrous sulfate
+folic acid
(05mg iron
+400 ug folic)
Coated
Tablet
255 055
0 Tab Chloroquine 250mg 205mg Tab 05 155 (during the
summer Jawza-
Sunbullah)
0 Tab Paracetamol 500mg 055mg Tab 105 055
7 Tetracycline Eye ointment Ointment 0 15
8 Tab Mebendazole 155mg Tab 05 155
9 Tab contraceptive ( Ethinyl
estradaiol+levonorgestrol)
Sachet 12 10
15 Tab.
Pyrimethamine+Sulfadoxine
Fansidar))
25mg+500mg Tab 12 18 all months
and 30(during
the summer
Jawza-
Sunbullah)
11 Condom Piece 155 255
12 Retinol (Vitamin A) 05555 iu Cap 05
10 Multi vitamin coated tab 055
10 Chlorine 055ml Bottle 0
10 Depo Medroxy Progesterone
Acetate(DMPA)
105mg Bottle 0
10 Zinc tab 25mg Tab 055
17 plastic bags Small size Small size
bags
105g For
distribution
of medicine
18 Referral card Sheets 155
II. Quarterly -based Expandable items
19 Chlorhexidine solution 5% 055ml Bottle 1
25 Gauze bandage hydrophyl
7.0*15
roll 10 05
36
No Description Strength Unit Quantity New quantity Remarks
21 Leucoplast(2.5*5) roll 1 0
22 Cotton 200gr roll 1
20 Gauze Pad Sterile 10*10cm Piece 0-Oct 05
20 Triangular bandage
(handkerchief )
Piece 2 Considering
Infection
prevention
20 Art paper Piece 2
20 Collared pencils or markers Dozen 1
27 Towel medium size 05*25cm Piece 1
28 Soap Bar Piece 0
29 Permanent Marker Piece 2
05 Pen Piece 0
01 Simple Plastic File Piece 1
02 Pencil Piece 1
00 Note book 155 Pages Copies 1
00 Pictorial Tally sheet Copies 1 Once every six
month.
00 sterile Gloves piece 155
00 Pencil sharpner Piece 1
07 Clean delivery kit set 5 0
III. Non-Expendable items
Note: these items can be resupplied based on assessments or demand by CHWs when old or dysfunctional.
08 Dressing forceps metallic 10.0
cm
Piece 1
09 Scissors Piece 1
05 Sterilizer small size Piece 1
01 Kidney Dish Medium Piece 1
02 Metal square tray medium Piece 1
00 Pot medium size Piece 1
00 Soap dish Piece 1
00 Table spoon Piece 1
00 Measurements glass with ml
scale ( metallic)
Piece 1
37
No Description Strength Unit Quantity New quantity Remarks
07 Bag ( locally made cloth bag ) Piece 1
08 Ruler metallic 30cm Piece 1
09 CHW manual Set 1
05 Flip chart ( Paper material) Set 1
01 Educational posters Set 1 Quality
assurance
process
suggest list
of IEC
materials to
be supplied
to HP
02 Metallic box (medium size ) Piece 1
00 Thermometer (Digital) Piece 1
00 Tape for measuring arm
circumference
Piece 1
00 Stop watch/Timer Piece 1
38
ANNEX 3 - Tally Sheets for CBMM developed in the pilot RDT and ACT
community-based project
39
ANNEX 4 - Supervision Check List on ACTs and RDTs for Community Health
Supervisors
40
ANNEX 5 Timetable of activities
The quarterly plan of implementation of the activities outlined in the CBMM Strategy is provided in
the Table below.
Year 1 Year 2 Year 3 Year 4 Year 5
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Programme
planning and
management
Writing TORs
for malaria
CBMM coordinator
X
Appoint malaria
CBMM
Coordinator
X
Development of
Guidelines
Case
management of fever
X
41
Year 1 Year 2 Year 3 Year 4 Year 5
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Fever
management
algorithms
X
RDT quality
assurance at point of care
X
RDT transport
and storage methods
X
Develop IEC
materials X
RDT
procurement
and logistics
RDT, gloves,
sharp boxes
procurement
X X X X X
Receive RDTs
(staggered delivery)
X X X X X X X X X X
Distribution of
RDT and other
supplies to the field
X X X X X X X X X X
ACT
procurement
and logistics
ACT
procurement X X X X X
Receive ACTs
(staggered delivery)
X X X X X X X X X X
Distribution of
ACTs to the field
X X X X X X X X X X
RDT Quality
Assurance
Write SOPs and
Job Aids for RDTs
X
RDT Post-
shipment lot-
testing (as
appropriate)
X X X X X
Training
Develop
training tools
for RDTs and ACTs
X
Develop
training tools for supervisors
X
42
Year 1 Year 2 Year 3 Year 4 Year 5
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Q
1
Q
2
Q
3
Q
4
Conduct
Training of
Trainers courses
X X X X X
Training of
health workers and supervisors
X X X X X X X X X X
Communication
Community
sensitization X X X X X X X X X X X X X X X X X X
Supervision
Regular
supervision X X X X X X X X X X X X X X X X X X
Monitoring and
evaluation
Review record
forms and
procedures
X
Monitoring
outcome indicators
X X X X X X X X X X X X X X X X X X
Operational
Research
Introduction of
RDTs in DH and CBC
X X X X
Evaluating
incentive
schemes for
CHWs
X X X X
Malaria
treatment
seeking behaviour
X X X X
ANNEX 6 Budget components and financial gaps (USD)
The annual budget (in USD) for the main activities outlined in the CBMM Strategy are presented in the
Table below. Funding for commodities which are already supplied by BPSH are not included, i.e. for
the procurement and distribution of chloroquine, primaquine and antibiotics for the management of
non-malaria fevers of bacterial origin. The funding gap has been calculated only for years 1 and 2, in
view of the firm commitment from the GFR8.
Activity Year 1 Year 2 Year 3 Year 4 Year 5
Development of
Guidelines
Guidelines for
RDT transport and storage
10,000
Fever
management algorithm
5,000
Supervision 5,000
43
Activity Year 1 Year 2 Year 3 Year 4 Year 5
checklists and
temp. charts
RDT procurement
and supply
management
RDT, gloves,
sharp boxes procurement
111,350 171,982 284,228 389,978 389,978
Distribution of
RDT and other
supplies to the
field (10%)
11,135 17,198 28,423 38,998 38,998
ACT procurement
and supply
management
ACT procurement 11,329 17,497 28,918 39,677 39,677
Distribution of
ACTs to the field (10%)
1,133 1,750 2,892 3,968 3,968
RDT Quality
Assurance
Post-shipment lot-
testing of RDTs (as appropriate)
100 100
Training
Instructions and
training manual for supervisors
5'000
Training of
trainers 4,620 36,805 42,644 26,991 26,991
Training of health
workers 4,896 42,982 42,670 32,559 31,452
Training of
supervisors 574 4,563 5,286 3,346 3,346
Communication
Community
sensitization
(health forum)
3,000 129,300 129,300 221,680 221,680
Supervision
Regular
supervision 4,920 38,880 12,660 29,880 44,220
Monitoring and
evaluation
Develop record
forms, survey
procedures
10,000
Health facility
survey for
outcome indicators
5,000 5,000 5,000 5,000 5,000
OR: introduction
of RDTs in DH and CBC
20,000
OR: evaluating
incentive schemes 25,000
44
Activity Year 1 Year 2 Year 3 Year 4 Year 5
for CHWs
OR: malaria
treatment seeking
behaviour
20'000
TOTAL
FUNDS
REQUIRED
188,057 486,056 607,021 792,077 805,310
BUDGET
AVAILABLE
(R8 GF malaria)*
392,573 656,528 551,610 565,313 579,701
FINANCIAL
GAP -204,516 -170,472 55,411 226,764 225,609
* calculated from approved funding Global Fund R8 malaria grant
The total core budget required to implement the 5 years strategy is USD 2,878,521. Considering the
total funding available to implement the GF R8 grant, amounting to USD 2,745,725 the funding gap
amounts to USD 132,796 for the 5 years implementation of the CBMM Strategy.
ANNEX 7: CBMM training Curriculum Contents
1. Background
2. Introduction of CBMM
What is CBMM
What CBMM offers
Why CBMM
CBMM providers
Components of CBMM
Why CHW training on CBMM
3. Necessity of the curriculum
4. Contents of the curriculum
Chapter one:
General information about malaria
What is malaria
Signs & symptoms of malaria
Causative agents of malaria
Vector of malaria
Mode of transmission of malaria
Diagnosis of malaria
Prevention of malaria
Chapter two:
Introduction of RDT
What is RDT
Advantage and disadvantage of RDT
Procedure of RDT use
Storage of RDT
Chapter three:
Practical use of RDT
Technique of blood collection from patient’s finger
Use of RDT for malaria diagnosis
Interpretation of the result of RDT
Chapter four:
Treatment of malaria
Introduction of ACT
45
Treatment of malaria by using ACT
flow chart of Malaria treatment
Chapter five:
Sessions of the training
Objective of the session
Methods of lesson
Topic of the session
Materials
Annex
1. Annex a - Instructions for the training
2. Annex b – Training schedule
3. Annex c- Pre-test
4. Annex d- Post-test
5. Annex e- pictorial instruction for RDT use
6. Annex f- Malaria Treatment Dosage Chart
7. Annex g- RDT follow up tally sheet
8. Annex h- RDT monthly Aggregated report
9. Annex i- ACT use tally sheet
10. Annex j- Monthly report on ACT use
11. Annex k - Referral form
Background
Malaria is an endemic disease and a major public health problem in many Provinces of Afghanistan. It
causes a great burden on the health and economic development of individuals, families and
communities living in endemic areas. The total number of reported malaria cases were 427,743 1n
2006, 390729 in 2009 and 390121 in 2010. Majority of these cases were clinically diagnosed: 79.77%,
83.40% and 80.04% respectively(HMIS 2010). The Government of Afghanistan remains committed to
the control of this disease. For this purpose the Government developed the National Malaria Strategy
Plan 2008-2013 with a vision of a malaria free Afghanistan. Two priority targets mentioned in NMSP
2008-2013 include:
By the end of 2013, 60% of targeted Health Posts will be able to diagnose malaria by RDTs
By the end of 2009, in order to strengthen malaria control at the community level, the
NMLCP and all PMLCPs will have a Community-Based Component including Home
Management of Malaria (CBMM)
Introduction of CBMM-
What is CBMM (Community Based Management of Malaria)
It is a care delivery strategy at community level to diagnose and provide effective treatment for
uncomplicated plasmodium falciparum malaria which will reduce the burden of morbidity and
mortality due to malaria in endemic areas.
What CBMM offers?
At present at health post level CHWs have Sulfadoxine Pyrimethamine and Chloroquine in their kit to
treat malaria. CHWs are treating malaria without any confirmed diagnosis. CBMM approach will
include RDTs and ACTs in their kits along with SP and Chloroquine. RDTs will be used for rapid
diagnosis of malaria and ACTs will be used to treat confirm uncomplicated falciparum malaria cases.
Why CBMM?
The Government of Afghanistan is committed to provide health care services to the entire nation to
improve the health condition of the people. But unfortunately in some geographical areas communities
are remotely located from the health facilities limiting access to health services. During 2010, 31,2267
malaria cases were clinically diagnosed throughout Afghanistan from which 137,670 cases i.e. 40.08%
were clinically diagnosed at health post level. Therefore CBMM will play a pivotal role in confirming
malaria diagnosis at health post level up to households. This will limit the excess use of Chloroquine &
SP as well as prevent resistance (plasmodium falciparum) to Sulfadoxine Pyrimethamine. In addition to
the treatment, CHWs will be able to differentiate the severe cases and refer to health facilities for
46
proper management. This strategy will assist weak health care systems, where women and children
cannot reach health facilities and where self-treatment is common and often misguided.
CBMM providers:
Community Health Workers will provide specific health care services (diagnosis using RDT
and treatment via ACT) at health post level.
Community Health Supervisors will monitor and supervise activities of the CHWs
Component of CBMM
Diagnosis of malaria by using RDT test
Treatment of uncomplicated Plasmodium falciparum malaria by ACT
Why CHWs training on CBMM?
A health post operates as a basic health service is delivered by the CHW. This grassroots level health
service delivery point is ideally staffed by one male and one female CHW. CHWs provide care to an
average of 27% of the total number of outpatients visiting the health facilities (2008). The numbers of
outpatients have increased with the expansion of health posts as a result of which over the past two
years, the numbers seen per health post have increased by 50%. Unlike health facilities, there is no
decline in visits during the winter months, 40% - 45% of childhood illnesses are managed by CHWs.
(CBHC Policy and Strategy, Page 9), highlighting the importance trained CHWs contributes towards
malaria diagnosis and treatment at community level.
Why this curriculum?
This curriculum is developed for training CHWs & CHS on CBMM. As mentioned above the
Government of Afghanistan is committed to control malaria in Afghanistan. Introduction of RDTs for
early diagnosis of malaria and establishment of CBMM at community level are key interventions that
will reduce morbidity and mortality of malaria. This curriculum will help to enhance their knowledge
about malaria as well as it will build their confidence to introduce RDT for early diagnosis and ACT
for treatment of falciparum malaria at community level.
Chapter one:
General information about malaria & approach to a malaria clinicalpatient
What is malaria-
Malaria is a vector borne parasitic febrile communicable disease.
Symptoms of malaria
The main symptom is fever
Fever may result in chills
Fever appears at the same time of the day
Fever disappears with sweating
After the disappearance of fever individual feels well/ healthy
Other signs and symptoms of malaria are:
Headache
Joint and body pain
Shivering
Vomiting
Diarrhoea (especially in children)
Causative agent of malaria:
Malaria is caused by a parasite called Plasmodium. There are four main types of Plasmodium.
These are-
Plasmodium falciparum (Pf)
Plasmodium vivax (Pv)
Plasmodium malariae (Pm)
Plasmodium ovale (Po)
In Afghanistan Pv is more prevalent than Pf
Vector of malaria:
Female anopheles mosquito is the vector of malaria
Mode of transmission:
47
Female anopheles bites a malarial patient and gets Plasmodium with blood
This infected mosquito bites a healthy individual and introduces Plasmodium into the blood.
Malaria undergoes a sexual cycle inside the infected individuals
After a period of time the healthy individual suffers from malaria
Figure: Mode of transmission of malaria
Diagnosis of malaria: malaria can be diagnosed
Clinically
By microscopic examination of blood of the clinicalperson
By using RDT (Rapid Diagnostic Test)
Prevention of malaria:
There are three main ways in which we try to reduce the spread of malaria:
Treat people who are sick with malaria quickly so that the microorganisms cannot be sucked
up by a mosquito,
Reduce the numbers of mosquitoes by controlling their breeding sites, and
Preventing mosquito bites by using bed nets with insecticide.
The most effective method is the use of long lasting insecticidal nets.
48
Approach to the patient:
Step 1. Register the patient. If the CHW is illiterate the family member or patient or patient’s family
member will help to register the patient.
Step 2. Please follow the procedures
1. ASK about : ( ask the patient or guardian in case of children)
The chief complaints: fever, headache, earache, throat pain, chilling, vomiting, cough,
breathing difficulties, burning micturition.
Present illness: explanation of the above symptoms eg patient complains of fever and CHW
must enquire after the fever history
Past history of the complaints: History of body feeling hot within 2-3 days, duration of the
symptoms
History of past illness: history of past episode of fever, malaria etc
2. LOOK:
Observe the appearance- ill looking/ unconsciousness/ drowsiness/ stable
3. FEEL:
Use the back of your palm to check if the patient’s forehead feels hot
4. Inspect the patient for : (more emphasise in case of children)
Ear discharge ( ask about ear pain)
Infection of the skin
Fast breathing / breathing difficulties
Sore throat ( ask about throat pain)
5. TEST
Measure body temperature with thermometer from armpit (≥37.5°C/99.5° F or above) if the
patient has fever
Use RDT (if needed)
Action to be taken By CHW:
1. If the patient’s symptoms are similar to that of malaria and his/her condition is stable without
any danger sign, use RDT. Treat the patient with ACT or Chloroquine if the result is positive
for the malaria test. Give the first dose instantly.
2. Refer the patient with danger signs to the nearest health facility.
The danger signs are:
He/she is uunable/unwilling to drink or feed (breastfeeding for children)
He/she vomits everything
History of convulsions
Presence of Lethargy / drowsiness / unconsciousness
she is severely anaemic
3. Refer the patient of less than 5 months age with RDT positive result to the nearest health
facility.
4. Refer the pregnant women (1st trimester) with RDT positive result to the nearest health facility.
N.B. Please follow the malaria flow chart and treatment guideline.
49
Chapter Two
Introduction of RDT
What is RDT (Rapid Diagnostic Test)
RDT is a malaria diagnostic device that detects malaria specific protein (antigens) which is produced
by malaria parasites.
It has
• Space A for buffer
• Space S for blood sample
• Window C for control
• Window test for Pf or PAN (Plasmodium another- P. vivax, or P. malaria or P. ovale) result
Advantages of RDT:
No need for laboratory facilities
Easy to carry
Simplicity and rapidity of the tests.
No need for electricity or laboratory equipment.
Minimal requirement for training (basic skills acquired in 1 day).
Acceptable levels of sensitivity and specificity, and
Disadvantages of RDT:
More expensive than microscopy.
Prolonged positive result after effective treatment.
Storage conditions of RDTs
Procedure of RDT use:
1-Prepare the materials needed
• RDT
• new, unopened lancet
• Alcohol swab
• disposable gloves
• timer or watch
• Safety box
• Pencil or marker for labeling the RDT
• Record book and pen for results
Take time to explain briefly to the patient what you are going to do
2- Check
- Expiration date of the RDT
- Colour of desiccant
DO NOT use expired damaged RDT or if there is a sign of exposure to humidity!
3- Wear disposable gloves.
Doing the test (1)
1) Open the RDT packet and take out device just before use
2) Label RDT with patient’s name or ID before doing the test
3) Clean the patient’s finger with an alcohol swab and let it dry before doing a finger prick
4) Discard used lancet immediately in the safety box
5) Touch the surface of the blood with the collecting tube/device to get 5L of blood
DO NOT collect too much blood as this may affect the test result
6) Slowly deliver the blood from the collecting tube onto the sample wall (S)
7) Discard the used blood collecting tube immediately in the sharp box
8) Invert the buffer bottle vertically and slowly dispense the required number of
drops into the buffer well (A)
9) Wait for the prescribed time (e.g.15-20 minutes) before reading the results
50
Storage of RDT:
• Keep RDTs in the coolest part of the room, but never freeze them. They do not need
refrigeration
• Protect RDTs from excessive heat (Keep it within 40-30
0 C)
• Store away from direct sunlight
• Do not store close to a wall or ceiling, as both absorb heat during the day
• Store a minimum of 30 cm away from walls and ceiling
• Do not store directly on the ground
• To reduce damage from moisture, water, and pests, store on a shelving unit or shelf, if
possible
Chapter Three:
Practical use of RDT
Technique of the blood collection:
Take alcohol swab and clean the patient’s finger
Let it dry before the pricking
Open the lancet
Prick the finger with lancet
Discard the lancet in to the sharp box
Swab the first drop of blood
Press the pricked finger for second drop of blood
Touch the surface of the blood with the collecting tube to get 5L of blood
Slowly deliver the blood from the collecting tube on to the sample wall (S)
Discard the used blood collecting tube immediately in the safety box
Practical use of RDT:
Participants will follow the instruction of RDT use (mentioned above)
They will follow the given Pictorial procedure of RDT use
They will apply on patients
Otherwise they will form groups and do the practical on each other.
Interpretation of the result:
• Invalid result (the test device is invalid):
a. No line in the control window or
b. No line in the control & test window
• Valid result( the test device is valid):
a. Red line only in the control window or
b. Red line in the control & test window
• Negative result
a. Red line in the control window and
b. No line in the test window
• Positive result
a. Red line in the control window and
b. Red line in the test window
Interpretation of positive result:
Picture of RDTs with result mentioned above
Picture of RDTs with result mentioned above
Picture of RDTs with result mentioned above
Picture of RDTs with result mentioned above
51
a. Red line in control window & in Pf line of test window – Pf malaria case
b. Red line in control window & in PAN line of test window – Pv malaria case
c. Red line in control window , in Pf line & PAN line of test window – mix infection
After doing the test
1) Discard used gloves, swab, and desiccant in a non-sharp waste container
2) Keep used RDTs in the box. Return used RDTs for replacement with new RDTs
3) Record results in the register.
Chapter Four:
Treatment of malaria
What is ACT:
ACT - it is artemisinin combination therapy. It includes Artesunate 50/100mg + SP (sulfadoxine500
mg +Pyrimathamine 25 mg).
Treatment of P. falciparum malaria:
Artesunate(50 mg or 100 mg ) and SP( sulfadoxine500 mg +Pyrimathamine 25 mg) the recommended
drugs for effective malaria treatment in Afghanistan
Dosage Chart
First Day Second day Third day
Remarks
Age SP Artesunate Artesunate Artesunate
5-11 months
Half tablet Half tablet
Of 50 mg
Half tablet Half tablet
Child
blister 1-6 years
One tablet One tablet
Of 50 mg
One tablet One tablet
7-13 years
Two tablets Two tablets
Of 50 mg
Two tablets Two tablets
Above 13 years
Three tablets Two tablets
Of 100 mg
Two tablets Two tablets Adult
blister
Important;
Day1 dose should be administrated as a Direct Observation therapy(DOT)
Remind the patient to complete the treatment.
Advice the patient to sleep under a long lasting insecticidal net to prevent Malaria attack
Note
The dose chart is only applicable for:
Blister 1: adult blister
Artesunate 100 and sulfadoxin +Pyrimthamine 500mg+25mg TABLET
Blister 2 Children Blister
Artesunate 50 mg and Sulfadoxin + Pyrimethamine 500 mg + 25 mg TABLET
Treatment of P. vivax malaria:
Chloroquine (150mg base tablet)
Age
(years)
Weight
(kg)
DAY 1
(no. of tablets)
DAY 2
(no. of tablets)
DAY 3
(no. of tablets)
<1 <10 ½ ½ ½
1-<3 10-<14 1 1 ½
3 –< 5 14-19 1 ½ 1 ½ ½
5-11 20-35 2 ½ 2 ½ 1
11-12 36-50 3 3 2
14+ 50+ 4 4 2
(Source: Revised National Treatment Guideline, April, 2010)
Treatment of mix infection: Treat as Pf malaria.
Picture of RDTs with result mentioned above
52
Malaria Flow Chart At Health Post Level
Registration of the patient
Use RDT
RDT
positive
(Pf/PAN)
RDT
negative
Patient
Stable.
Treat the
patient
Patient with
danger sign
Refer to health
facility
Children less
than 5 month.
Refer to health
facility
Pregnant
women (1st
trimester)
Refer to health
facility
If Pf
positive
treat
with
ACT
If both Pf
& PAN
positive
treat with
ACT
If only
PAN
positive
treat with
Chloroquin
-e
Pregnant women
(2nd
& 3rd
trimester) If only
PAN positive treat
with Chloroquine
Pregnant women (2nd
& 3rd
trimester) If
only Pf or both Pf &
PAN positive treat
with ACT
Patient comes back with
symptoms after treatment
Refer the patient to the
nearest health facility
Treat the patient as
usual according to
CHWs guideline
53
Chapter five:
Session 1: WELCOME and INTRODUCTION
During this session, the participants will:
Register
Introduce each other
Share their expectations of the training
Introduce with the rules & norms of the training
Undertake a pre-test
Introduce about goal & objectives of the training
Know about the general information of malaria
Objective:
At the end of the session the participants will be able to
Define malaria
Describe signs & symptoms of malaria
Identify the causative agent of malaria
Name the vector of malaria
Describe the mode of transmission of malaria
List the main malaria prevention methods.
Method:
Question and answer
Pictorial presentation
Lecture with discussion
Topics:
General Information about malaria
What is malaria
Signs & Symptoms of malaria
Causative agent of malaria
Vector of malaria
Mode of transmission of malaria
Prevention of malaria
Materials:
Note books
Pen, Pencil
Posters/ Pictures
Flip Chart
Session 2: Introduction of Rapid Diagnostic Test
Objective:
At the end of the session the participants will able to
Know what is RDT
Describe advantages & disadvantages of RDT
Use RDT to diagnose malaria
Store RDT at health post level
Methods:
Demonstration of RDT
Question and answer
Topics:
What is RDT
Advantage and disadvantage of RDT
Procedure of RDT use
Storage of RDT
54
Materials:
RDT Kits
Pictorial instruction about RDT use
Safety box
Register form
Session3: Practical use of RDT
Objective:
At the end of the session the participants will able to
• Collect patient’s blood for RDT
• Use RDT for diagnosis of malaria
• Interpret the result of RDT
Method:
Practical group work
Practical use of RDT
Topic:
Technique of blood collection from patient’s finger
Use of RDT for malaria diagnosis
Interpretation of the result of RDT
Material:
RDT
Lancet
Alcohol swab
Buffer
Dropper
Pictorial instruction about RDT use
Timer/ Watch
Session 4: Management of malaria
Objective:
At the end of the session the participants will able to
Define ACT
Treat the falciparum malaria cases by using ACT
Methods:
Lecture with discussion
Demonstration of ACT
Role play
Topics:
Introduction of ACT
Treatment of malaria by using ACT
Materials:
ACT (Dosage forms)
Pictorial demonstration of ACT, Dosage & treatment
Session 5: Reporting on RDT, ACT & malaria cases
Objective:
At the end of the session the participants will able to
Report on used RDT, positive & negative RDT
Report on ACT use
Report on malaria cases
Methods:
Demonstration of reporting formats
Small group discussion
55
Topics:
Reporting system about RDT
Reporting system about ACT use
Reporting system about malaria cases
Materials:
Different kinds of reporting formats
Session 6: Reporting on RDT, ACT & malaria cases
Methods:
Question and answer
Discussion
Topics:
Review of the previous lessons
Post test
End evaluation of course
Materials:
Post test sheet
Course evaluation sheet
