CONSULTANCY REPORT
MID-TERM REVIEW OF THE
UNEP/GEF PROJECT "REGIONAL PROGRAM OF
ACTION AND DEMONSTRATION OF SUSTAINABLE
ALTERNATIVES TO DDT FOR MALARIA VECTOR
CONTROL IN MEXICO AND CENTRAL AMERICA"
Por: Alberto Narváez Olalla MD, MPH, Ph.D
Marzo, 2006
EVALUATOR: Alberto Narváez Olalla
REVISED BY: Emilio
CONTENTS
CHAPTER 1 .................................................................................................................................................12
INTRODUCTION, OBJECTIVES AND METHODOLOGY ...............................................................12
1.1 INTRODUCTION ..............................................................................................................................12
1.2 STATEMENT OF THE PROBLEM ..................................................................................................13
1.3 OBJECTIVE AND SCOPE OF THE REVIEW .................................................................................15
1.4. METODOLOGY...............................................................................................................................16
1.4.1 STUDY DESIGN .........................................................................................................................16
1.4.2 SOURCES OF EVIDENCE AND CODES USED......................................................................17
1.4.3 STUDY POPULATION AND UNITS OF ANALYSIS ................................................................19
1.4.4 DATA ANALYSIS ........................................................................................................................19
1.4.5 VARIABLES ................................................................................................................................20
1.4.6 QUALITY ASSURANCE AND METHODOLOGICAL LIMITATIONS OF THE RESEARCH.20
1.4.7 FIELD RESEARCH ACTIVITIES...............................................................................................22
1.4.8 ETHICAL ISSUES.......................................................................................................................23
1.4.9 CONSTRAINT AND LIMITATION.............................................................................................23
CHAPTER 2 .................................................................................................................................................24
PROJECT PERFORMANCE....................................................................................................................24
2.1 PROJECT DEVELOPMENT ............................................................................................................24
2.1.1 Activities, products and achieved results ...................................................................................24
2.1.2 . Perception of performance, changes, advances, problems and limitations ............................38
2.1.3. Training......................................................................................................................................44
2.2. MODEL IMPLEMENTATION AND DEVELOPMENT ................................................................45
2.2.1 Structure and organization of the project ..................................................................................45
2.2.2 Control strategies and used technology .....................................................................................48
2.2.3 Vector control .............................................................................................................................57
2.2.4 Management and Resources......................................................................................................61
2.2.5 Intersectorial coordination policy and conection with other projects ......................................71
2.2.6 Community and Social participation Policy ..............................................................................74
2.2.7 Base Line, Information system and Indicators...........................................................................80
2.2.8 Indicators ....................................................................................................................................81
2.2.9 Sustainability and replicability: reached sinergies....................................................................86
CHAPTER 3 .................................................................................................................................................89
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS.........................................................89
3.1 PROJECT APPROACH .....................................................................................................................89
3.2 STRATEGY AND CONTROL METHODS......................................................................................90
3.3 HEALTH SYSTEM REINFORCEMENT .......................................................................................100
3.4 SUSTAINABILITY AND REPLICATION CAPABILITY............................................................103
3.5 MONITORING, EVALUATION AND SYSTEMATIZATION OF THE EXPERIENCE............105
3.6 DEVELOPMENT OF THE MULTI COUNTRIES NET AND EXPERIENCES EXCHANGE....115
3.7 INTER SECTORIAL AND PARTNERSHIP POLICY...................................................................116
3.8 COMMUNITARIAN PARTICIPATION ........................................................................................120
3.9 PERFORMANCE VALUATION ....................................................................................................123
3.10 LESSONS LEARNED....................................................................................................................125
3.10.1 Design and approach of the project .......................................................................................125
3.10.2 Base line and relevant indicators of evaluation.....................................................................126
3.10.3 Cooperation mechanisms, team work and alliances policy...................................................126
3.10.4 Socialization and information exchange and transference of knowledge between countries.
............................................................................................................................................................126
3.10.5 Other lessons...........................................................................................................................126
REFERENCES........................................................................................................................................128
LIST OF TABLES
Table 1. Schedule of the project development by countries, November 2005 .. 25
Table 2. Received resources and needs for the institutional development ....... 31
Table 3. Activities, Products, Inmediate Effects and Reached Results ........... 33
Table 4. Partners valuation about the success level in the project, November
2005.................................................................................................................... 38
Table 5. Advances perception, November 2005................................................ 40
Table 6. Evaluation of the model of malaria control.......................................... 41
Table 7. Perception of limitations ...................................................................... 42
Table 8. Number of trained people by topics ..................................................... 44
Table 9. Autonomy level at the human resources management and taking
decisions............................................................................................................. 46
Table 10. Number of the people who received and were trained with the
Technical Handbook and the opinion about the handbook adaptation in the
country................................................................................................................ 49
Table 11. Characteristics of the control strategy by components and countries50
Table 12. Changes caused by the project in control strategy and in the model of
services .............................................................................................................. 51
Table 13. Changes at the coverage in clinical services of malaria in clinics 2001,
2003, 2005.......................................................................................................... 55
Table 14. Changes at the quality control of the laboratories ............................. 56
Table 15. Changes in the coverage of vector control activities ......................... 61
Table 16. Activities of breeding sites, clean houses, clean yards, and limed
houses control. Mexico and Guatemala 2005.................................................... 61
Table 17. Changes in management, equity, efficiency and quality ................... 62
Table 18. None performed ascpects and the reasons of non performance ..... 63
Table 19. Opinion about the adecuation of malaria control policy, the resources
adequacy and the supporting systems functioning............................................ 64
Table 20. The most important problems of the management of the project:..... 65
Table 21. Supervision and follow up of the project activities ............................. 66
Table 22. Opinion about the technical attendance quality, received by the local
and national level ............................................................................................... 67
Table 23. Evaluation of the internal and interprojects coordination................... 68
Table 24. Activities, coordination level, type of relation and integration
mechanisms from othe institutions that work at the influence area of the project.
............................................................................................................................ 69
Table 25. Created mechanisms to formalized the relation with other institutions
............................................................................................................................ 69
Table 27. Health Staff changes at the demonstrative areas.............................. 70
Table 26. Changes in the number of health services at the demonstrative areas
............................................................................................................................ 71
Table 28. Achievements with intersectorial coordination................................... 74
Table 29. Changes the politic of communitarian and social participation.......... 74
Table 30. Politics, strategies and activities for social and communitarian
participation ........................................................................................................ 78
Table 31. Information and Surveillance system ................................................. 81
Table 32. Malariometric Indicators ..................................................................... 83
Table 33. Number and percentage of positive and high risk localities of malaria
transmission. ...................................................................................................... 84
Table 34. Estimated cost of activities for physical and bilogical control of the
breeding sites ..................................................................................................... 85
Table 35. Malaria Control Measures.................................................................. 91
Table 36. Attribution map of the strategy to control malaria of the DDT/GEF
Project ..............................................................................................................107
Table 37. Information and surveillance system................................................110
Table 38. Performance valuation of the project DDT-GEF ..............................125
ABREVIATIONS
CCA
Comisión para la Cooperación Ambiental de América del Norte
CCAD
Comité Directivo Nacional y la Comisión de Cooperación
Ambiental para el Desarrollo
CDC
Center for Desease Control
COMUDE Municipal Council for Development
COCODE Comunitarian Council for Development
EHCA
Elimination of Habitat of Anophelins Breeding Sites
HAG
Health action group
FAO
GCT
Groups of Communitarian Work
GDP
Gross Domestic Product
GEF
GIS
Georeferenced Information System
GMCE
Global Malaria Control Strategy
GPS
IEC
Information Education and Comunication
INCAP
IRET
Regional Institute of Toxicology (IRET)
MCP
Malaria Control Programme
MOH
Ministry of Health
NAP
Nattional
PAHO
Panamerican Health Organization
POP
Persistent Pesticides
RBM
Roll Back Malaria
TB
Tuberculosis
TCC
Technical Cooperation Proyect
UNON
VBD
Vector Born Diseases
UNEP
WHO
World Health Organization
EXECUTIVE SUMMARY
1. INTRODUCTION
The aims of the project are to implement demonstration projects of vector
control without DDT or other persstent pesticides that can be replicable in other
parts of the world; the strengthening of national and local institutional capacity
to control malaria without the use of DDT; and elimination of DDT stockpiles in
the eight participating countries. The project involves eight countries: Mexico,
Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and
Panama. Nine sites for demonstration projects were selected in each country.
Project duration is 36 months from august 2003 to July 2006. A mid-term
evaluation was executed at the end of the second year of the project
(september 2005).
2. METODOLOGY
The mid-term review was conducted as an in-depth evaluation using a
participatory approach. It is a descriptive multicase study, using several sources
of informartion. Four demonstrative areas were evaluated in Mexico, Panama,
Costa Rica and Guatemala.
3. PROJECT PERFORMANCE
The project oficially began in May 2003, but the intervention in the communities
began in may or june of 2005. The institutional arrangements that influenced
the delay were, the adaptation of the management mechanisms among the
national and local realities and the delay in the Regional and National
Coordinators hiring and the designation of the Focal Points.
Accomplishment of the general objective
All the countries have adapted, in demonstrative areas, techniques of vectorial
control without using persistent insecticides. Only Panama, carried out a
spraying with Sumithion in one of the demonstrative communities to control a
malaria epidemics.
Advances in Component 1: Demonstrative Projects
With the exception of Mexico, all countries executed the data gathering and
finished the reports of the base line. The personnel of the national and local
teams, from all the countries are trained and applying new approaches of
malaria control without persistent pesticides. Leaders, communitarian agents
and teachers are informed, strongly appropriated and mobilized and there is a
high participation in the activities of vectorial control.
The control strategy is a combination of several interventions with good impact
in the elimination of breeding sites and refuges of anophelines. The
interventions that embrace: elimination of mosquito breeding sites by physical
media colled EHCA, fishes sowing, clean house, clean patio and houses
whitewashing (painting with lime) with communitarian participation. In Mexico,
communitarian agents participate systematically in the pre and post evaluation
of the EHCA activities. The diagnostic and treatment coverage has been
amplified, but there are still weacknesses in the opportuneness of the
microscopic diagnostic and in the control of samples quality. There are very
important differences in: treatment schemes, in strategy of cases identification
and the elimination of the human host of plasmodium.
With the exception of Mexico, the information of cost efeectiviness of the
interventions is not being gathered and there is not a protocol and study guide,
but there are evidences about the lower cost, lower logistic necessities and the
human resources of these strategies.
All the countries are executing activities to promote the public alert about health
and environmental risks due to the DDT use. Experts from all countries were
trained to carry aout the studies about enviromental impact and the national
laboratories have the necessary equipment for this purpose.
There is a web page, periodiacally updated, but is not frecuently visited by the
national and local teams. This limitation has been surpassed through the
Regional Technical meetings and the eight phone conferences where there are
exchange of experiences, transferences of technology and the coordination of
activities.
There is an excellent development of the Georeferenced Information System
(GIS), but still is not used in the intervention monitoring. All the countries do not
have an specific computarized program for processing and analysis of data. At
regional and local level there is a monitoring system in development. Although,
all the countries are documenting the experience, there is not a format to unify
its systematization. From the indicators proposed in the hadbook, only Mexico
use them completely.
Advances in Component 2. Building Institutional capacity
All countries have developed building institutional capacity activities through the
training of national personnel and the delivery of equipment. The technical
teams, National Committees and Local Committees were constituted. The local
committees have inserted in the structures of the Ministry of Health using the
technical and management experience of the malaria control programs. Not all
the countries executed completely the operative plans from 2004 because of
the delay in personnel hiring and the funds outlays. There is an accurate intern
and interinstitutionally coordination, but the coordination between projects is not
satisfactory.
Component 3. Elimination of DDT stockpiles
All the countries have completed the upgrade of the national inventories of DDT
and other persistent plaguicides. There are still a lot of places where the
persistent insecticides are badly stored and with a high risk of environmental
pollution. There is a delay in the hiring of the company that wil carry out the
packing, transportation and elimination of DDT.
Component 4. Coordination and management
In the visited countries, the management sytem of the Project has been adapted
to the local realities and specically to the PAHO´s administrative and financial
systems. They are regularly working in the Regional Technical Committee, the
technical teams , the national operative committees, the local operative groups
and the communitarian groups. The Regional Committee, the National
Operative Committees have a multisectorial constitution, but the presence of
other sectors, as environment sector is weak. There is an effort to involve the
municipalities, the universities and the other institutions related with
environment and agriculture. The participation from the private sector,
particularly from private companies is limited.
Perception of development, sustainability and replicability
The valuation of success of the project in average goes from moderately
satisfactory to satisfactory. The major success in importance order is in: the
objectives pertinence, the community empowerment, cost effectiviness and
impact. The lowest perception is in monitoring and evaluation and financial
planning. The major development of the model is in the prevention and vector
control, cases management and community participation The minor
development is in the information and surveillance system.
The countries report the existente of plans for sustainability and replication of
the model to other areas, but it has not been done at the local level. The model
is being replied in a spontaneous way in neighbour areas to the demonstratives.
The sanitary workers and the communities have been capable to absorb and to
integrate new control and information technologies as the GISEPI. The major
threat to the sustainability of the project is the funds deflection to control
epidemics and the mitigation of storms and hurricanes impact.
4. CONCLUTIONS AND RECOMMENDATIONS
There was an initial delay because of the preparatory activies that were not
taken in mind in the project design. For this reason the most important
recommendation to the donors is to approve the extension of the project, not to
do it is going to loose the opportunity of having a highly cost effective and
reaplicable model.
The project uses an eco systemic approach, with five elements that
characterize it: i) A strategy of prevention and integral control, based in
epidemiological model of health fields, ii) multidisciplinary and multisectorial
approach. iii) the community participation as the central axis of the control
activities, iv) equity, with priority in the rural areas, of indigenous predominance
in critical poverty and malaria persistence. There are no definitions, or policies
of gender equity.
The project uses a combination of control methods in concordance with the
policy of the Global Malaria Control Startegy and the Roll Back Malaria: risk
approach and intervention focalization, selective control of vectors, rapid
diagnostic, opportune treatment and to strength the local capability of basic
information (GIS) and investigation. Have been introduced non documented
innovations in the recent international bibliography, as the elimination of the
human host of plasmodium (TDU 3x3x3), houses whitewashing. The countries
have adapted the model to the conditions, resources and local capabilities.
In Guatemala and Mexico there is a great fortress in the activities of evaluation
and entomological surveillance, but in Panama and Costa Rica there is a
weackness. There is no an uniformity in the schemes of treatment used
between the countries for the treatment and the opportune diagnostic and
treatment is not good.
In all the visited countries there are national and local teams with high technical
level and continous improvement of the skills for the application of the strategy,
the communitarian work, the GIS and the analysis capability. A still weak aspect
is the project followment and supervision. Each one of the demonstrative
projects, the control strategy has been adapted to the health system and the
specific care model. There are three models of services organization and health
care that have been inserted to the strategy: a verticalized model in Mexico and
Panama, an integrated model in Guatemala and horizontal model in Costa Rica.
The contribution from the municipalities in the control and the financing of the
activities is still weak and there is not a clear definition of the responsibilities.
The presence of epidemics, floods, twisters and tropical storms create a
deflection of the political support and resources. An opportunity to reply the
control strategy are the Global Fund Projects.
In the technical handbook, a great number of indicators are ennumerated, that
are used in Mexico, but the rest of the evaluated countries are using a few
indicators. Some of the key interventions so they can be measurables and
comparables. It is not clearly defined the methodology that is going to be used
to evaluate the project impact. The regional technical meetings are the most
important scenarios of planning, monitoring and experiences exchange, the web
pages have a limited use.
In the project, the communitarian participation is the project central axis, but its
participation in monitoring, evaluation and accountability is weak.The approach
of predominant participation is the col aboration from the community and not the
one of social mobilization. The pre and post evaluation of the EHCA activities
with communitarian participation is a good pratice that should be extended to all
the areas and interventions.
RECOMMENDATION
1. To strength the trasdisciplinary approach: integrating the Universities and
the investigation institutes to the project and designing strategies,
sceanrios and instruments that al ow the communities to participate in
monitoring and evaluation of the interventions.
2. To document systematical y the interventions.
3. To formulate a protocol of evaluation about the cost effectiveness of the
interventions and protocols of multicentric studies.
4. To elaborate a specific guide of entomology and to train assistants in
entomology and communitarian agents.
5. Standardize and to update the schemes of treatment used by the
countries and to evaluate the impact scheme TDU 3x3x3.
6. To increase the number of laboratorios and to improve the quality
control.
7. To design a computarized program to process and to analyze the
information, that can be modified or adapted to each local reality.
8. To formulate supervision guides and feedback formats.
9. To characterize the organization and care models in the rest of the non
evaluated countries, as one of the variables that influence the diferencial
impacts of the strategy, and in the sustainabilityand replicability of the
model.
10. To design in each demonstrative area a plan to guarentee the project
sustainability and replicabilit
11. To redesign the monitoring, information and surveillance system.
12. To develop GIS applications to monitor the interventions.
13. To use the phone conferences as a strategy to exchange experiences
and to include the local workers and communitarian agents in them.
14. To define the role of the municipalities in the malaria and epidemics
control.
15. To strength the approach of social mobilization and communitarian self
management.
16. To introduce, in all the demonstrative projects, pre and post evaluations
of the EHCA interventions with communitarian participation.
5. LEARNED LESSONS
The delay in the project´s implementation, suggests the necessity to define
more real times for the execution of the multi center (regional) projects, it has to
be consider a period for administrative arregements and the personnel hiring.
The national, local teams and the community have started a process of
apprenticeship to develop a model of multiple alliances, of interinstituional and
intersectorial cooperation and community movilization. The model al ows high
and quick communitarian participation. The georeferenced maps and the pre
and post EHCA evaluations are easy alternatives to monitor and to evaluate the
results of the project and to educate the community. Malaria is a priority topic of
public health in Meso America, but is still in a rear level from dengue and AIDS.
CHAPTER 1
INTRODUCTION, OBJECTIVES AND METHODOLOGY
1.1 INTRODUCTION
Malaria constitutes one of the health problems, which has remained a prioritized
concern in the world because it is a cause of substantial human suffering
(morbidity and mortality) and because it is a significant impediment to human
development in poor countries (wide distribution and high economic impact).
Each year there are more than 300 million episodes of acute malaria illness,
primarily affecting the world's poorest populations mainly in Africa. Over a
million people die each year with malaria and most of them are children. Severe
episodes can result in a 25% loss of household earnings. Malaria-affected
countries lose as much as 6% of their GDP (Gross Domestic Product) because
of the disease (WHO/RBM, 1999b).
Over the last three decades malaria-related deaths rates have fallen in many
regions, particularly in Latin America and Asia, but the global rates due to
malaria are no longer falling and are even increasing in Africa (Navarro, 1999b)
and in most endemic countries of South America (PAHO/WHO, 2000) and
Mesoamerica (Mexico and Central America). This situation reflects the
emergence of drug resistance parasites, climate changes, population
movements and a reduction in public health capacity within national health
services (Navarro, 1999a).
During the last fifty years, international policies to control malaria have been
formulated. In 1955, the World Malaria Eradication Campaign began (Najera et
al, 1992). Its goal was to eradicate malaria in five or ten years. Semi-
autonomous governmental agencies were created (Schmunis and Dias, 2000).
The control strategy was based mainly in chemical control through the
treatment of fever cases with anti-malarial drugs and residual indoor spraying
with DDT. The eradication objective was abandoned in the 70's when the 31st
World Health Assembly adopted a strategy of malaria control aimed at least at
reducing mortality and the negative and social effects of the disease (Najera et
al, 1992).
In 1992, the Ministerial Conference on Malaria formulated the Global Malaria
Control Strategy (GMCE) to face the deterioration of malaria in the world,
especially in Africa. The global objectives of the GMCS implementation plan
were (WHO, 1992) that by the year 1997 at least 90% of malaria endemic
countries will implement appropriate malaria control programmes, and malaria
mortality will be reduced by at least 20% compared to 1995 in at least 75% of
the endemic countries.
Despite the fact that many countries declared their agreement with GMCS,
malaria control efforts in many countries have been undertaken with adverse
circumstances: under-funding, staff shortage, and lack of social participation
(WHO/RBM, 1999). Due to these constraints, from 1992 to 1998, the
epidemiological malaria situation did not improve in many countries: mortality
trends maintain almost the same levels in Africa, and in the Central and South
America an extended epidemic appeared after "ENSO 1997-1998"
(PAHO/WHO, 2000), Katrina and Mitch Hurricanes (PAHO-UNEP-GEF, 2003).
In 1998, WHO launched the Roll Back Malaria Initiative (RBM), which is
considered a social movement with the objective of significantly reducing the
global burden of malaria through interventions adapted to local needs and
reinforcements of the health sector (WHO/RBM, 1999). In the last three years,
(1998-2001) an inception process had been carried out in many countries
(Alnwick, 2000). RBM was launched when new paradigms and international
policies were applied throughout the world: the most important being the
globalisation and the structural adjustment and in health the Health Sector
Reform.
1.2 STATEMENT OF THE PROBLEM
It is estimated that 89`128.000 people in Mesoamerica live in areas
environmentally suitable for the transmission of malaria, of which 23`445.000
(35%) live in endemic areas. Several countries, such Mexico adopted the
Global Malaria Control Strategy (GMCS) in 1994 and accepted the Roll Back
Malaria Initiative in 1999. In order to apply this recommendation, some policies
to transform the malaria control programme were formulated and implemented.
The implementations of these strategies were done in the context of economic,
political and debt crisis, structural adjustment process, frequent change of
health authorities and staff, emergencies due to natural disasters, the reduction
of the number of governmental workers, reduction of the governmental budget,
etc.
At the same time, in the region a Health Sector Reform policy process was
implemented during the last decade (1990s). Some changes in the health care
model have been implemented, such as decentralisation of the central
administrative power towards the district, participation of the populations in
financing the cost of health services, reduction of personnel as well as attempts
to improve inter-sector co-ordination.
Despite the fact that the GMCS and RBM were adopted, malaria has remained
a public health priority in Mesoamerica. Economic loss due to malaria was and
probably still is as high as that of all other diseases put together and
represented an important burden to health services and the economy of poor
household (Ruiz and Kroeger, 1994; World Bank, 2000).
DDT has been extensively used as an insecticide for malaria vector control and
in agriculture in Mexico and Central America since 1950´s; sprayed not only in
households but also on water surfaces in an attempt to control mosquito
breeding. DDT is highly stable toxic compounds that persist in the environment
for many years and can accumulate in living organism.
Central American countries are particularly vulnerable to natural hazards such
as hurricanes. In 1998, approximately one ton of DDT was washed into
Caribbean Sea in Nicaragua as effect of Mitch Hurricane. The existing DDT
stockpiles in Central America and Mexico (stored in improper conditions)
represent a great risk of water contamination. In order to face this problem a
project call "Regional Program of Action and Demonstration of Sustainable
Alternatives to DDT for Malaria Vector Control in Mexico and Central America"
was implemented from September 2003. This project was developed to support
the "Contaminant-based" Operational Programme 10 and "...help demonstrate
ways of overcoming barriers to the adoption of best practices that limit
contamination of the International Waters environment".
The aims of the project are to implement demonstration projects of vector
control without DDT or other persistent pesticides that can be replicable in other
parts of the world; the strengthening of national and local institutional capacity
to control malaria without the use of DDT; and elimination of DDT stockpiles in
the eight participating countries.
The overall objective of the project is to demonstrate methods for malaria vector
control without DDT or other persistent pesticides that are replicable, cost-
effective and sustainable, thus preventing the reintroduction of DDT in the
region. Human health and the environment will be protected in Mexico and
Central America by promoting new approaches to malaria control, as part of an
integrated and coordinated regional program. The establishment of a regional
network will facilitate the exchange of best practices and lessons learned
among neighboring countries. A major outcome will be increased government
and local community awareness of DDT and other pesticides hazards to the
environment and human health, and adjustment of future behavior regarding the
use of persistent pesticides.
The scope of the project is regional involving eight countries in Mexico and Latin
America: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico,
Nicaragua, and Panama. The results of the project will be disseminated to other
parts of the world experiencing similar problems, through the proposed GEF
projects for Africa, Middle East and North Africa, Southeast Asia and Western
Pacific, and India. PAHO and WHO will, using their own networks, disseminate
and replicate the results of the project using their own funding as well as other
non-GEF funding (such as Global Fund for HIV/AIDS, TB and Malaria). Prior to
this project nine sites for demonstration projects were defined and delimited in
each country.
The project is implemented by UNEP and executed by the Pan American Health
Organization (PAHO) under the overall responsibility of the Director, Division of
Health and Environment and National Executing Agencies (i.e. Ministries of
Health).
There are four components of activities in the project:
1) Demonstration Projects and Dissemination.
2) Strengthening of national institutional capacity to control malaria
without DDT.
3) Elimination of DDT stockpiles.
4) Coordination and Management.
Project duration is 36 months starting August 2003. The project document was
approved and signed for internalization by UNON on September 9th, 2003.
A mid-term evaluation was carried out at the end of the second year of the
project (September 2005). At the time of the mid-term review, the project might
have achieved: i) preparation of technical guidelines for the demonstration sites,
including the baseline survey and indicators to be used during the
demonstration activities for monitoring purposes; i ) preparation of all nine
demonstration sites through local consultations; iii) further development of the
web-based information system; iv) inventories of obsolete DDT and other
insecticide pesticides, requiring disposal; and all eight countries are signatories
to the convention and three countries Honduras, Panama and Mexico have
ratified the convention.
1.3 OBJECTIVE AND SCOPE OF THE REVIEW
The objective of this mid-term review is to review and evaluate the
implementation of planned project activities and outputs against actual outputs
so far and if possible establish project results and impact, sustainability and
execution performance. The focus was on four questions:
1. Are the institutional arrangements adequate, effective and timely to
develop a sustainable region-wide network, establish inter-sectoral
coordination mechanisms at the national and local levels and involve
stakeholders actively at the demonstration sites?
2. To what extent are the new malaria control methods demonstrated by
this project accepted and adopted by the participating countries and
stakeholders, and can these methods effectively serve as reference
models for up scaling at national and regional levels?
3. The project has identified performance indicators. To what extent these
indicators are adequately and effectively, monitoring the results and
impacts achieved at the demonstration sites, and are these indicators in
combination with the project's performance indicators an effective tool for
measurement of project impact?
4. Can the project effectively help catalyze new activities based on
collaboration with other DDT-related malaria control projects, GEF and
non-GEF, particularly with emphasis on the linkages to environmental
aspects such as water resources management?
The review has assessed:
1. The main changes that the project has caused to the malaria control strategy
in the demonstrative places.
2. How the countries have applied and adapted the guide at local level?
3. The structural and functional conditions of programs at local level and
identify the favorable and unfavorable factors that have facilitated or limited the
implementation of the project.
4. Current situation of projects in relation to: structure and organization of the
program, definition of policies and plans, application of control strategies,
technology use, program manager, leadership and personnel's training, system
of managerial information, intersector coordination and community participation.
5. Delivered outputs: Assessment of the project's success so far in producing
each of the programmed outputs, both in quantity and quality as well as
usefulness and timeliness.
6. Project outputs, outcomes and impact. Evaluation of the project's success
so far in achieving its outcomes.
7. Sustainability of the project.
8. The cost effectiveness of the interventions.
9. Execution performance: Determination of effectiveness and efficiency of
project management and supervision of project activities.
1.4. METODOLOGY
The mid-term review was conducted as an in-depth evaluation using a
participatory approach where by the task manager and other relevant staff was
kept informed and regularly consulted throughout the evaluation.
1.4.1 STUDY DESIGN
This is a multiple comparative descriptive study of cases (Yin, 1994) of the
implementation of the malaria control strategy in Mexico and Central America
from 2003 to 2005.
The study was carried out in several scenarios:
1. Regional Technical Committee Meeting of the Project for evaluation of
advances. It had the attendance of the NAP and Institutional Focal Points of the
8 participant countries, PAHO experts, the Commission of Environmental
Cooperation for America of the North (CCA), the Regional Institute of
Toxicology (IRET) with headquarters in Costa Rica and the University of San
Luis Potosi of Mexico, partners of the initiative of the project DDT/GEF. The
modality was of presentations of advances of the project, it debates on the
advances of the results and experts' recommendations in the matter. The
modality was presentations of advances of the project and forums of
recommendations.
2. Visit to four countries, in which three activity types were executed:
· Interviews with health national authorities and of PAHO, for the case of
Mexico and Guatemala.
· Presentation of advances in the provincial capitals
· Presentation of advances in the departmental or county capital where are
the demonstrative towns.
· Visits to demonstrative communities:
1. Mexico, Jurisdiction of Puerto Escondido, State of Oxaca and visits to
towns.
2. Panama, Bocas del Toro-Talamanca, Barranco Montaña town.
3. Costa Rica, Talamanca District, Sixaola County and visit to Paraiso
Town
4. Guatemala, Coban (Alta Verapaz) and Ixcan, demonstrative towns.
1.4.2 SOURCES OF EVIDENCE AND CODES USED
The complexity and extension of the subject and the multi-theoretical approach,
chosen for this study, presupposes a methodological pluralism, therefore a
combination of strategies and research techniques were used. In this study, four
different sources of evidence were used: three of them involve qualitative methods
(documentation, semi-structured collective interviews and participant observation)
and one quantitative method (archival records).
The sources of information were coded as follows: "RCI" interviews to regional
coordinator; "NI": individual interviews to national staff, "LI" individual interviews to
local staff; "NCI": collective self administrate interviews to national staff;
"LCI"col ective self administrated interviews; "PO": participant observation; "RTC":
Regional Technical Committee; "D": documents (TR= trimester report). These
codes will be quoted throughout the text to ensure that the source of information is
clear. The quotations of documents and interviews were translated from Spanish
to English by the author.
Interviews
Semi-structured and unstructured interviews with individuals or groups of actors
or key informants were carried out. All the interviews, group discussions and
workshop were tape-recorded and transcribed.
Type of interviews
The unstructured interviews were carried out during the field visits:
· Mexico; Interviews and field visits to Puerto Escondido,
· Guatemala: Interviews and field visits to Coban and Ixcan in Guatemala,
· Costa Rica. Interviews, and field visits to sites Talamanca and
Changuinola in Panama
Self administrate Col ective Interviews
A guide was designed for collective self administrate interviews (see Appendix 1).
Based on the results of the unstructured interviews, field visits and documents
analysis. The objectives of these interviews were to obtain information about the
process (formulation, implementation and evaluation), the strategies implemented
and institutional structure. These interviews were applied after the field visits by to
National and Local committee members.
Informal conversations without recording
During the Technical Committee (San Jose, Costa Rica), field visits informal
conversations without recording were conducted as informal conversations. The
main ideas of these conversations were register in a notebook.
Participant Observation
The participant observations were made using two techniques according to the
circumstances (Bowling, 1997):
1. Direct observation. Unstructured observations of the work of health personnel
and community members during the field visits, which were recorded in note
forms.
2. Participant observation in national, local and community meetings and field
visit evaluations.
Workshops: Evaluator participated in two national meetings in Mexico and
Guatemala, six local meetings (Mexico 2, Panama 2, Guatemala 2) and
workshops or meetings. All the meetings were recorded and transcribed and the
author took additional notes of relevant issues (minutes). In addition, documents
and presentation presented in workshops were collected (in order to include the
participant observation as part of a triangulated research methodology).
Archival records
In the self-auto-administrate collective interview, national and local staff collected
data from archival records. Several sources were used. The most important were:
· Morbidity and other epidemiological (malariological) data from surveil ance
system.
· Mortality and hospitalised records from vital statistics systems
· Meteorological records from statistical meteorological records
· Service records from management information systems.
· Organisational records: organisational tables, budgets.
1.4.3 STUDY POPULATION AND UNITS OF ANALYSIS
Units of analysis
In terms of units of observation, Yin (1994) recognizes two types of designs: i)
about individuals and ii) about organisations. In the present study the unit of
observation is the malaria demonstrative project of each country and in three
levels:
Central Level: Headquarters of PAHO and Ministry of Health (MOH).
Local Level: Headquarters of demonstrative projects.
Community Level: localities direct involved in the project
Within each level there are various target groups:
At Central Level: authorities, national committee members.
At Local Level: authorities, staff, majors, interested groups and
individuals.
At Community Level: leathers, schoolteachers and community members
that participate in the project.
1.4.4 DATA ANALYSIS
Four methods of analysis were used according to the type of evidence and the
variables involved in the study:
1. Analysis of document contents. The content of each document was
analysed using a matrix of content analysis. The most relevant findings
were classified and grouped according to the research variables.
2. Meaning categorization. The contents of interviews and meetings records
were classified and grouped by the same procedure as the document
analysis (Kvale, 1996).
3. Statistical analysis. Epi-Info 6.04 was used to process the quantitative
data.
4. Epidemiological Data. For a descriptive analysis of epidemiological,
service production and performance data, the number of events,
percentages, rates and ratios were used. Increase Ratios (IR) were
calculated to demonstrate increase or reduction (Dever, 1991). The
formulae are given in the respective chapter.
The Annual Parasite Rate (API) is influenced by the case detection rates. These
have had a large variation among countries. The API was standardised using
the case detection effort (ABER) for the year 2000 by applying the following
formula (Roberts, 1997):
APIs = (EMPSx / Population x) per 1000
APIs = Annual Parasite Rate standardised by sampling effort
x= year
EMPS= Estimate of Malaria Positive Slides
The calculations were as fol ows:
1. Calculate ABER for each year
ABER = (number of slides examined/total population) per 100
2. Calculate the Slide positive rate (SPR) for each year (x).
SPRx= (number of positive slides / number of slides examined) per 100
3. Select the year of comparison. In the present thesis, year 2000 was
chosen as the comparison year, because in that year the ABER had the
peak during the study period.
4. Calculate the revised estimate of the total number of slides examined for
each year multiplied by the ABER of 2000 (standard year) for the
population of each year (RESE)
RESEx = (ABER2000/100) (Population x)
5. Calculate the estimated malaria positive slides (EMPSx) by multiplying
the original proportion of positive slides for each year (SPRx) by the
revised estimate of the total number of slides examined (RESEx):
EMPSx = (SPRx) x (RESEx)
6. Then divide the estimate of malaria positive slides (EMPS) by the total
population of Ecuador for each year in the series. These quotients,
multiplied by 1,000 produced APIs standardised for sampling effort
(ABER). Calculate the APIs for each year.
APIsx = (EMPSx / Population x) per 1,000
1.4.5 VARIABLES
The main variables of study are:
· Existence of a plan or program and contents
· Control strategies and used technology
· Structure and organization of the program
· Administration and Managerial Resources
· Policy of intersector coordination
· Policy of social and community participation
· information System
· Changes in the administration system
· Strategies of control of the program used in the project.
· Outputs, outcomes and impact achieved
1.4.6 QUALITY ASSURANCE AND METHODOLOGICAL LIMITATIONS
OF THE RESEARCH
Strategies for quality assurance
The combination of qualitative and quantitative techniques and several sources
of evidence were used in order to reduce the influence of the cultural context on
the researcher's interpretation and understanding of the concepts (Mackie and
Marsh 1995). In order to assure the quality and capacity for analytical inference,
four criteria were used (Yin, 1994):
Validity
In order to construct validity, regional, national and local coordinators, and
PAHO officials revised the draft of the case study report. The triangulation
strategy was also used to allow convergence and to assure internal validity. In
order to assure external validity an explanatory strategy for qualitative data was
used.
Reliability
In order to guarantee that the operations of a study (data col ection and
processing) can be repeated with the same results, the following requirements
were applied: the creation of database study and the application of same criteria
and techniques in each country.
Representative ness
Due to the short time to make, the evaluation only official documents produced
were collected, but they are a good sample of documents. The key interviews
have a good representation of the different actors involved in the process. Due
to time and access limitations, the collective interviews of Local Headquarters to
evaluate the malaria situation had three limitations. First, they were no
homogeneous groups, which limited the participation of malaria workers and
civil servants in presence of line managers. Second, the sample of
demonstrative areas involves only four areas. Finally, the size and composition
of each group was different.
This lack of representative ness may have produced results indicating that the
situation of the project was better evaluated than it really was. The use of other
sources of evidence (interviews, observation and archival analysis) reduces this
limitation.
Validation of sources of information
Defined criteria were used to design the interview guides. Permission was asked
to tape record and in a few cases, where this was a problem the researcher
made brief notes, which were immediately rewritten and analysed. The results of
the interviews were used to emphasise relevant topics in future interviews.
Bias and bias control
In order to reduce the author's subjectivity, the evidences were chosen in order
of the authorship (official or non-official) and representative ness: the official
documents evidences were the first evidences taken, then the non-official
documents and interviews, and finally the author's observation. Only official
data were used for archival analysis.
1.4.7 FIELD RESEARCH ACTIVITIES
The research activities of the study were planned and executed in three phases:
First Phase
Due to the evaluator did not receive the project documentation and the technical
guideline before traveling; the visit to Mexico was conducted as an exploratory
field visit. The exploratory study was completed with the participation in San
Jose Regional Technical Committee. With these inputs a guideline for
participant observation and interviews were designed and applied in the rest of
country visits.
The participant observation of the appraiser was carried out with the regional
coordinator participation, the national teams (NAP and Focal Point) and the
local teams in six towns of the demonstrative projects. At the end of the visit of
each country, a discussion was made on the most important outcomes, results
and recommendations that should be implemented in consent.
Second Phase
With the results of this observation, an adjustment of the contents of the
col ective interview and identification of documents were carried out, to be
applied in the second phase.
Collective interviews: these collective interviews should be filled using a guide
with the participation of all the members of the national and local team.
Documental analysis of contents; the information given by the members of the
managerial team of the program will be supplemented with a gathering of
documents related with the answers to the interviews.
Statistical analysis: some pertinent data were gathered directly from
information systems. The data collection last almost four months (October to
January) due to the presence of hurricanes, which reduce the time to fill the
forms. At the same time, the regional coordinator and national teams reviewed
the first draft of the report.
Third Phase
With the result of self administrate collective interviews, the final report was written
and finally, reviewed by key informants for three times more.
1.4.8 ETHICAL ISSUES
The recommendation of this review report intends to have a positive effect on
the ongoing project, and therefore achieve a direct impact on people's health.
The identification of misuses, weaknesses and strengths can be used to
improve the programme implementation.
All participants were informed before or during the field visits to obtaining
informed consent to participate. The people involved in interviews were allowed
to withdraw whenever they wanted to. A tape recorder was not used when an
interviewee refused permission or appeared uncomfortable in its presence.
The observation was related to job activities, which did not affect the privacy
and psychological well being of the individual studied. Most of the documents
were public documents presented in events or obtained from open archives.
1.4.9 CONSTRAINT AND LIMITATION
The main constraint in this review for the researcher was the short time of field
visits. In order to cope with this limitation, two strategies were applied: the
collective interviews and the revision of the draft report by regional coordinator,
national and local staffs.
CHAPTER 2
PROJECT PERFORMANCE
2.1 PROJECT DEVELOPMENT
This section presents the development about the performance of the project,
specially the level of reached goals in products, process, results and the impact.
At the same time, this section is a summary of the project, which is deeply
described in the next sections.
2.1.1 Activities, products and achieved results
Officially, this project started in May of 2003. At the country level, the project
started at different time in each country. Of the evaluated countries Panama
and Costa Rica began the activities earlier (April 2004), the rest started the
project, at national level, in June of 2004 (Table 1).
The activities of institutional arrangements and the adaptation of the
mechanisms of human resources and financial management into the local and
national realities delayed for one year the implementation process of the
project. Also there was a delay in the Regional Coordinator designation (June
16th, 2004), of the National Coordinators and the designation of focal points. In
some countries as El Salvador, Guatemala and Panama there were changes at
the institutional focal points, because of the change of Governments, which also
affected the project development (RCI). It is important to remark that the delay
of redesign and the approval of the mexican project, contributed with the delay
of some activities related with the support of Mexico to other countries or it had
not had the necessary intensity (RCI).
At local level, the designation of the local coordinator and the beginning of the
base line happened in different times, with an early beginning in Costa Rica and
a late beginning in Guatemala, Panama and Mexico where it was planned to do
start during the firsts days of January. The base line had a different length of
time, 8 months in Costa Rica and 1 month in Panama.
With the exception of Costa Rica, the intervention in the communities does not
have too much time. The introductory activities of the control strategy without
persistent insecticides in all of the visited countries just started in the last 5
months in Panama, two months in Guatemala and one month in Mexico before
the evaluation, once the recollection of the data for the base line was finished.
In Mexico, the line base will ended in the firsts months of 2006.
Table 1. Schedule of the project development by countries, November 2005
DATE
COUNTRY
COSTA
GUATE-
MEXICO
PANAMA
RICA
MALA
Beginning of the Project at national April 04
June 04
June 04
April 04
level
Beginning of the Project at local June 04
November 04 August 05
January 05
level
Designation of the National
-------
June 04
May 04
April 04
Coordinator
Designation of the focal point
August 05
August 97
May 04
First disbursement
February 04
March 04
February04
Designation of the local coordinator
May 04
March 05
October 05
April 05
April 04
September 04
First disbursement into the demo June 04
March
04
February04
area
July 04
Beginning of the base line
July 04
March 05
July 05
June 05
End of the base line
February 05
August 05
February 06 June 05
Duration of base line
8 months
6 months
6 months
1 month
Beginning of the control activities in August 04
August 05
September
May 05
communities
July 04
05
Time of intervention in communities 13 months
2 months
1 month
5 months
(until september 2005)
Source: Colective interviews selfadminstrated at local and nacional level
Achievement of the general objetive.
About the achievement of the general objective, all the countries have adopted
technical alternatives of vector control at the demonstrative areas, not only
without using DDT, but also without using of persistent insecticides, that is why
it can be evaluate as highly satisfactory. Only Panama, sprayed PH 40%
Sumithion in one of the demonstrative communities (Barranco Montaña
Adentro) because of the presence of a malaria outbreak. Once that the
epidemic was controlled, the use was interrupted (LI).
About the use of insecticides control malaria at national level, Panama reported
the use of Fenthion of Baytex 2% (POP), 9910 kg of 2004 in 2003 and 40536
in 2004 and deltametrina (piretroide) 2644,8 Kg in 2001 and 3300 in 2003.
Guatemala used 114 kg of Icon (piretroid) in 2001 and deltrametrina 114kg.
During 2005, insecticides were not used at the demonstartive areas (NCI).
This important advance about the no use of persistent insecticides for the
control of malaria, is threatened for the use of this types of insecticides in
dengue outbreaks, happened in 2005. Panama, used Sumithion (insecticide
organophosforate).
Advances in component 1
After formulating in consensus the methodology of the base line, denominated
Base Line Guide, with the exception of Mexico, all the countries started the data
recollection and have finished the report. The temporary results were presented
at the last Regional Technical Committee meeting carried out in Costa Rica in
from September 12th to 14th in 2005.
The base line not only contributed to the local teams to recollect the information
but in some demonstrative localities started interventions related with the
training of the community about the characteristics of malaria, its ways of
transmission and the relation with the mosquitoes breeding sites, and in some
of the cases the beginning of the activities for the control of the breeding sites
(NI).
Although, some of the national coordinators and the interviewed focal points
have assure that the base line information has been used, from the analysis of
the reports, is shown that the culture about the use of the information to adapt
the control strategy and the IEC plans still needs to be developed (NI).
Two regional workshops about new alternatives for the control of malaria have
been carried out with the national teams from the 8 participant countries. Also,
have been made national workshops and communitarian assemblies and
meetings with leaders, promoters, volunteers and teachers to facilitate the
participation and training of the communities. During the second and third
trimester of 2005 have been carried out field interventions for the vector
control at the demonstrative localities (D:IT).
In relation with the reached products of this component, the four visited
countries have implanted the vector control strategy with the participation of the
communities. Mexico, as the proposer of the control strategy, have totally
applied the alignment of the Guide. The three remaining countries, have
followed this alignments with the appropriate modifications to the particular
conditions of each country, particularly in the application of the schemes of
treatment. For that, there was an agreement since the beginning of the project,
so each country apply the scheme that is proposed by the national normative
and recommended by the PAHO/WHO, that is why the mexican scheme
appears in the Guide as an option (RCI, PO).
The staff of the national and local teams from all the countries are training in
new approaches for malaria control without persistent pesticides. Leaders,
communitarian agents and teachers are informed and strongly motivated about
the control strategy (PO).
During field visits the evaluator confirmed that the health staff at national and
local level and community leaders are strongly involucrate at the activities about
malaria control without the use of DDT or other persistent pesticides. The
participation of the community in this activities is very high, the strategy rests at
the community work (PO).
An immediate effect shown at the evaluation visits is the fact that vector workers
are changing their role from direct inspectors to community advisers. In all
countries, the process of plans elaboration have started and activities have
been carried out to promote the public alert about health and environmental
risks because of the DDT use. For that, it has been produced educative
materials as leaflets and posters in the native language Ngöbe Buglé and in
spanish in Panama, printed brochures, videos in Costa Rica, El Salvador and
Mexico. Theater plays and puppet shows which are presented at schools in
Costa Rica and Guatemala.
In Guatemala, in coordination with the Ministry of the Environment, it is been
made a law to forbid DDT, to have a legal base and also to eliminate other
persistent insecticides from the control strategies (NI). Activity which has been
intensified in the rest of the countries, specially Nicaragua, Honduras y El
Salvador, taking advantage of the national operative committees where other
groups are linked (RCI).
Even when the systematic cost effectiveness of the new methods to control the
malaria are unsettled, some alternatives of control has been proved in the
countries with a high approval from the health workers and the communities,
which is an evidence of their viability.
Even there is not a protocol or guide and the information to evaluate the cost
effectiviness of the interventionists have not been recollected, there are non
quantified evidences about the lower cost, lower logistic needs and human
resources of this strategies compared with the insecticide spraying. They are
based in the mobilization of the community, resources from the private
enterprises and in some cases, resources of the municipalities as in Honduras.
In Honduras, after the training at the 12 demonstrative localities, the health local
teams and the Groups of Communitarian Work (GCT), proposed not to use
again any type of plagicide for the vectorial control of malaria, commiting
theirselves to do, at least once a month, an environmental intervention (cleaning
and breeding sites drainage, chaponeo de solares and others). .
Elimination of Habitat of Anophelins Breading Sites (EHCA), clean house and
clean patio are the central strategies of the vector control activities. These
strategies have as advantages: these do not pollute the water with insecticides,
the effects are immediate, these are cheap because these do not need to buy
insecticides or equipment to apply them, to make it is necessary domestic tools
as machetes, shovels, pickaxes, rakes, wheelbarrows, etc., it helps the
formation of healthy habits and it encourages social relations and the
communitarian organization (Regional Coordinator Handbook, Mexico). Also,
with the pre and post intervention evaluations with the participation of the
community it increases the perception of efficiency and credibility in the
population (PO).
Two experts from each of the eight countries has been selected and trained in
gas cromatography for the evaluation of human and environmental exposure to
DDT and persistent plaguicides newly introduced. Currently, national
laboratories relay on trained staff and necessary equipment to analyze the
insecticides in the environment and the human health.
A web page was early designed and at this time, during this evaluation, it is
used periodically updated, http://shp.paho.org/sde/ddtgef. Slowly, the national
coordinators are using this net system and they are encouraging the local
executors to optimize the use (RCI), because at the present time they are not
using it (RCI). All the documents of the project and the results of the regional
events are in the web site, but a major effort has to be done to create a culture
of consult and use of the available information. This lack has been improved
through Regional Technical Committee meetings and the phonoconferences.
In addition of the Intranet page, the regional coordination has carried out eight
phono conferences, where the ejecution of activities have been coordinated. As
well as they serve to discuss the proyect advances in each country, offered
useful technical cooperation about GIS, method for DDT inventory, elaboration
of the base line, development of laboratory nets and others. Of each event, a
summary has been elaborated and it has been published at the project's web
page and sent to each country by e mail (RCI, IT).
The two meetings of the regional technical committee and the Steering
Committee, composed by the Ministry of Health, PAHO, the CCA y CCAD
representatives, are also two privileged settings of experience exchanges and
technology transferences.
Through all of these strategies, actually exists a net between countries and
information and experiences are exchanged. The successful experiences and
good practices in a country are replied and adapted by the other countries.
Because this exchange has been restricted only to the national coordinators
and focal points, the local staholders (health staff and community) request to
increase the interships and to share the information and experiences between
the projects (LI).
One of the aspects of major development is the Georeferenced Information
System (GIS), with support of the Regional Programme of AIS/PAHO/WDC and
the Nutrition Institute of Central America and Panamá (INCAP) has been
offered technical and decentralized cooperation to six of the eight countries. For
that, in each country have been carried out traininig workshops for the national
local staff. The ICAP in coordination with AIS/WDC has offered local support to
Guatemala, Honduras, El Salvador y Panama, taking comparative advantage of
being a regional center of reference of the PAHO. In Panama, the PAHO has
also made the alliance with the Gorgas Commemorative Institute and in
Nicaragua with the Leon University.
The demonstrative areas staff was trained in GPS use and GIS tools. In all the
localities visited there are communitarian maps and in Guatemala and Costa
Rica georeferenced there are maps with information about new and repeated
cases of malaria, malarious houses and anophelines breeding sites. Mexico is
at the process of implemented GIS, but they make use of maps with information
as described previously. The country which shown a major development and
application of the GIS was Guatemala, where the workers at local level
supported by the INCAP technicians have developed new applications (PO).
As result of the fulfilment of the activities in component one and two, it is clear
that the anophelines breeding sites and refugies have been eliminated with
alternative strategies (cleaning of the breeding sites, fishes cultive, bacillus and
others) with strong communitarian participation. It is also proved the
improvement of the case management coberage for malaria cases and its
contacts.
In relation with the project monitoring and evaluation, there are reports every
three months and annually from each country; the annual reports are presented
at regional technical meetings. There are also reports of the regional
coordinator visits to the national levels of the countries, as wel as reports of the
phono conferences, which help to coordinate activities and also are used as
monitoring instruments and as a way to exchange technical cooperation.
Two regional-technical meetings have been carried out. At the last meeting in
Costa Rica, the evaluator realized that more than share experiences, the
presentation of good practices and learned lessons, advanced monitoring can
be done. Before the meeting, guides to presentations were sent and most of the
countries followed this guide, but the presentation format and the indicators
used to report advances were not homogenous. The presentation with the best
characteristics was the one from Nicaragua, so is recommended to use this
good practice in the future.
An important practice is that at the end of the technical meetings commitments
should be established and written, which was done at the field visit in the
demonstrative area of Ixcan in Guatemala.
In Mexico, communitarian agents participate systematically on the pre and post
evaluations of the EHCAs activities. In the rest of the countries, the evaluation
of the Demonstration Projects with the participation of communitarian
representatives from the local communities and the society, have not been done
because of the short length of time since the intervention. This activity has been
planned to be done in a short term time considering that with this project the
communitarian participation has been reached during the complete process of
planning and execution. The technical workers are noticing the change of
attitude for the monitoring processes and participating evaluation (RCI).
According to the local teams, they received continuous visits of monitoring,
although because of the long distances between the capital (where the regional
team is), and the demonstrative areas, the presence of the national team is not
too frequent (LI).
In all of the demonstrative projects there is monitoring system in development.
At the evaluation visit was clear that in all the communities there is monitoring of
the activities, products and reached results. Although all the countries are
documenting the experience, there is not a format to unify the information (PO).
Advances in component 2. Building Cappacity
The activities defined in this component, complement the described at
component one, so, some of the expected results are attributed to both
components.
With the participation of countries and PAHO experts the technical guide was
elaborated, 1000 copies were printed and distributed to the eight countries, in
other international events and to the strategic partners of the project. The guide
include all the aspects related to the proposed control, but it does not have the
detail so the field workers and the communities can develop the propose
activities, which is going to be another contribution of the project. However,
Mexico has specific operative handbooks which can be used by the other
countries: "Manual of the Local Promotor for the Elimination of Habitats y
Anophelines breeding sites" adressesed to community promotors and the
"Strategy for the Elimination of Habitats of Anophelines breeding sites
(EHCAS), Coordinator Manual" adressed to workers and others health workers.
Training courses and workshops have been carried out using the Guide
contents. In all of the visited demonstrative projects, have been carried out two
kind of workshops: i) with the local health teams, involving vector control staff
(where is still available) and the staff from the general services of health; ii) with
the participation of local communitarian leaders, communitarian agents of health
(volunteers) and local school teachers.
In Honduras, the institutional staff and the communitarian volunteer leaders
were trained, not only from the demonstrative areas, but to all the health unities
from the six municipalities involved in the project (RTC).
The guide suggests a surveillance and monitoring system, but the countries
have adapted the guide to the specific systems of each country. Mexico, has
developed a exhaustive monitoring and surveillance system of the interventions,
which is a complete application about the guide components.
One of the activities which are being planned and which is also a request from
the health workers and local leaders is about making exchange trips and local
meetings for the malaria control technicians where they can exchange
experiences on alternative control techniques of the malaria vector.
In all the countries, activities of institutional strengthen has been developed
through the training of the local and national staff of the Ministries of Health in
techniques about selective vector control, epidemiologic surveillance system,
monitoring and Georeferenced Information System. The deliver of computers,
printers, GPS, cameras, vehicles, have fortified the capability for data
processing and analysing in all of the visited demonstrative projects (Table 2).
Also, have been received vehicles and image projectors, especially for the
national level, but these resources are insufficient at the local level. In fact, the
non satisfied needs at the demonstrative areas are: image projectors to help the
training process, vehicles (motorcycles o bicycles) for the transportation of the
health and vector staff to the demonstrative areas (Table 2). In Ixcan,
Guatemala, to facilitate the trainings, they need to rent it in Q. 250.0 300.0
quetzales per hour. In Panama, they need asigned transportation at local level,
a multimedia projector, a camera, lawn mower and tools and educative material
The bought transportation can not be assigned to the local level of MINSA
because the laws in Panama about vehicles in IM (international mission) can be
just transferred to national institutions after two years. Even though, the vehicle
is used through the PAHO in works at local level. In Costa Rica, even when a
vehicle was bought nine months before the mid term evaluation, bureaucratic
obstacles have take the vehicle away from the demonstrative area (LCI).
Table 2. Received resources and needs for the institutional development
EQUIPMENT
COSTA RICA
GUATEMALA MEXICO PANAMÁ
Local Nat
Loc (Nat)
Loc (Nat)
Recieved
Computers
1
1 (5)
5
2
Printer
1
1 (4)
4
2
Software
1
3 (11)
11
2
GPS
1
2 (10)
10
0
Camera
1
1 (4)
4
0
Vehicles
0
1
Others: tools
Yes
Yes
Yes
Image projects
Yes
Yes (1)
1
1
Needs
Transportation Image
Projector
projector
Transportation
Transportation
Source: Colective interviews selfadminstrated at local and nacional level
The national coordinators and the focal points have received training and they
have enough experience to create refrenece national centers in order to carried
out studies of POPs environmental impact.
All the participant countries relay on equipped laboratories and with trained
personnel on the study of the impact of DDT in the environment (ground), food
(fishes) and people. In each country, different institutions have been involved to
create reference laboratories. In Costa Rica, the IRET is the reference
laboratory where people work with plaguicides with a good georeferenced
information system (RCTR).
With the participation of the University of San Luis de Potosí, it has been
improved the national capabilities on the evaluation about risks and samples
recollection techniques to make the studies about the impact of DDT.
Advances in component 3
In all the countries, the actualization of the national inventories of DDT and
other persistent plaguicides has been completed. In the presentation during the
meetings in Costa Rica, it was evident that still, in a lot of places there are
persistent insecticides badly stored and with high risk of environmental
contamination. Some countries have made activities to improve the storage of
the DDT reserves.
At the moment of the evaluation, four countries have joined to the Stocholm
Convention: Guatemala, Belize, Costa Rica and Panama. El Salvador,
Honduras, Mexico and Nicaragua have confirmed the adhesion to the
convention.
In coordination with the FAO, are contacting companies which are going to
pack, to transport and elimination of DDT. The problem is that is been a year
since the inventory and the stored DDT haven't been repacked, and less than
that, it hasn't been eliminated (LCI).
Advance in component 4
In June of 2004, a regional coordinator and seven national technical
coordinators and eight focal points were hired to lead the activities of the
demonstratives projects. Because of the governments changes there were
delays on the assignation of focal points. At the moment of the mid term
evaluation there is one regional-technical team with headquarters at the INCAP
which is linked with the eight countries and the national and local teams that are
working regularly.
In order to manage the project a Regional Sttering Committee and a Regional
Operative Committee were organized. Two meetings with the Sttering
Committee and two with the other one were done. The reports of these
meetings are published at the web page. In all countries, the national operative
committees have organized the operative local groups and the communitarian
groups. At the moment of the evaluation, they are working regularly and it's
expected the strengthen to make sure the sustainability and transference of the
model.
In the visted countries the management system of the project has been adapted
to local realities and specially to the PAHO administrative and financial systems.
Table 3. Activities, Products, Inmediate Effects and Reached Results
Component 1. Demostrative projects and disemination
ACTIVITIES
PRODUCTS
INMEDIATE EFFECTS
REACHED RESULTS
1. Planification and ejecution of the demostrative project introduction 1. Inception phase of the control strategy Partial use of the base Elimination of breeding
in the 8 countries
finished on the nine demonstrative projects.
line to adapt the control sites and refugies of
1. 1. Methodology, ejecution and script of the report of the linea de Areas maped at Demonstrative Project.
strategy and the IEC anophelines with
base and technical evaluation.
Reports of the lineas de base and technical plans.
alternative strategies
1. 2. Two regional workshops about new alternatives for the control of evaluation finished in 7 of the 8 participant
(cleaning, fishes,
malaria ejecuted with the participation of tne 8 national teams of the
participant countries.
countries.
Motivated health staff at bacillus) and with a
national and local level strong communitarian
1. 3. WorkshPAHO and communitarian assemblies and meetings Trained staff of the national teams in new and communitaries
participation.
with leaders, promoters, volunteers and teachers to help the method o control tha malaria without leaders involved with the
communitarian participation and training.
persistent pesticides. Informed and strongly control of malaria without Opening at the cover of
motivated leaders, communitarian agents and DDT use or others the diagnosis and
1. 4. Field interventions for the vector control and the analytic costs of teachers, about the control of malaria without persistent pesticidas.
treatment of the malaria
environmental and biologic samples
persistent pesticides.
cases and its contacts.
The vector workers
Review of the alternative strategies and first change their role from Elimination of the DDT
evaluations of products and results.
direct inspectors to
use or other persistent
communitarian advisers.
pesticides to control the
malaria.
ACTIVITIES
PRODUCTS
INMEDIATE EFFECTS
REACHED RESULTS
2. Formulation and application of the plan to promote the public alert 2. Formulated plans and ejecution.
Major communitarian
about the use of DDT and the participation of the 8 countries in the
participation at the
project.
Videos produced in Costa Rica, El Salvador control activities.
2. 1. Formulation of the plan
and Mexico.
2.2. Educative materials, produced or printed
Posters and leaflets produced and distributed
- Guide to develop the demonstrative projects, Spanish version 1000 in Panama.
printed copies and PDF in CD ROM.
- Macro document of the project, Spanish and English version, Teather plays and puppet shows presented in
printed and in PDF in CD ROM
schools in Costa Rica, Guatemala and El
- Promotional poster of the Project, english version.
Salvador.
- Educative poster about the control of malaria, Spanish version
"Prevent Malaria Disease", educative Trifolio about the control of
malaria "For your family and community health prevent malaria",
Spanish version, informative Trifolio of the project DDT-GEF, Spanish
and English version
3. Evaluation of costs and factibility of the new control 3. Alternative strategies to control malaria
applied in all of the demonstrative projects as
methods of malariain different countries and environments
partially ejecuted but without an explained methodology.
factibility indicator.
4. Evaluation of the environmental and human exposure to Non quantified evidences of the lower cost
and lower logistic needs and human
DDT and other pesticides.
resources.
4.1. Training experts in gas cromathography.
4. Laboratories with equipment and staff to
analyze the insecticides
4.1. Seven experts (1 per country) trained in
gas cromatography.
4.2. All the countries laboratories equipped to
analyze with gases cromotography.
ACTIVITIES
PRODUCTS
INMEDIATE EFFECTS
REACHED RESULTS
5. Implementation of the web page, Intranet page and GIS in 5. Net between countries formed, and Succesful experiences
Regional net of
development.
exchanching information and experiences
and good practices of one information and
5.1. Implemented Web Page and periodically updated.
5.1. Web page and Intranet updated and country are adapted by exchange of experiences
5.2. Intranet Page and phono conferences.
working
the other countries.
about studies,
5.3. Six nacional workshops to train the Project staff (nacional 5.2. Eight phono conferences ejecuted for
elimination of DDT and
and local) using Georeferenced Information System.
coordination
Local teams practice with application of new
Local staff training in GIS supported by INCAP and Gorgas 5.3. Trained staff at the demonstartive areas, the GIS application to control technics of vector
Institute.
trained at the GPS use and GIS tools. All the improve the analysis and
demostratives localities visited (except Mexico) the interventions.
georefenciados maps availables and with
infromation about malaria y anophelines Exchange of experiences
breeding sites.
between countries.
National and local teams
received technical support
6. Monitoring and Project evaluation
6. Reports very three months n¡and annually at the right moment.
from each country presented at the regional
6.1. Evaluation of the demonstartive projects with the technical meetings of monitoring evalution.
participation of local communities representatives and the Reports of technical regional meetings about
society.
monitoring advances and exchange of
6.2. Two Regional meetings of evaluation done
experiences and formulation of agreements
(Regional-technical committee)
and commitments.
6.3. Monitoring visits with technical support at regional level Reports of visits and help consultancy.
and from the nacional level to the locals
Component 2: Strengten of the regional-institutional to control malaria without DDT.
ACTIVITIES
PRODUCTS
INMEDIATE EFFECTS
REACHED RESULTS
1. Elaboration and distrubiton of the printed Technical 1. Technical handbook produced by consensus, Nacional and local
IDEM component 1
Handbook about methodoligies used in the project.
digital version, 1000 copies printed and distributed. technicians use the
handbook to guide and to
2. Workshops and training courses in malaria, 2. Local and national staff trained in control adapt the control
environment, entomology and ecology; integration in strategies with communitarian participation.
strategies.
control vector for malaria, field operations and technical
participation of the community.
3. Integrated nacional programs in control of
malaria, exchange information and knoledge
3. To develope a surveillance system of malaria and between countries. Exchange between
information exchange about malaria control at regional demonstrative areas will be carried out on 2006.
level
4. Technicians in control of malaria are trained to
4. Short term trips and local meetings for technicians in use integrated technics in vectors control. It started
malaria control with the purpose to exchange in the last trimester of 2005 and it will continue
experiences in alternative technics to malaria vector during 2006.
control vector.
5. Reference centers for the study of DDT residual
5. Strengh nacional reference centers with trained staff action in Mexico and Costa Rica, they observe
in risk analysis, education and communitarian international recognized standards and exchange
participation for the control of malaria without DDT or information.
other persistent pesticidas and suitable to exchange
information between laboratories and referente centres. 6. Study of needs is finished, in process equipment
purchase.
6. Strengh nacional laboratories for chemical evaluation Staff trained to evaluate environmental and human
and information exchange.
contamination with DDT and other persistent
plaguicides.
Component 3: Elimination of DDT reserves
ACTIVITIES
PRODUCTS
INMEDIATE
REACHED
EFFECTS
RESULTS
1.National inventories of DDT and other persistent Upgraded reports about DDT and other persistent Improvement at the
plaguicidas upgraded with participation of the 8 plaguicides are oficially delivered to the 8 countries storage of DDT
countries industries. 136 tons of DDT were identified
reserves.
and should be eliminated on 2006.
Component 4: Management and coordination
1. A Regional coordinator and eight national technicians 1. Regional coordinator and the seven national Commitments
and eight institucional focal points were hired to coordinators, selected and working; in Costa Rica between countries
manage the activities of the demonstrative projects.
wasn´t hired a national coordinator, the
and political support
management of the project was taken by an from the heatlh
2. Ejecution of two meetings with the Regional international consultant payed by the PAHO authorities for the
Administrative Committee and two with the Regional regional, local and national teams, constituted and project.
Operative Committee.
working.
3. Reports elaboration every three months
2. Regional and national committees and local
groups are constituted and working normally.
3. Management sytem adapted to local realities.
4. Three reports and minutes from the Regional
Administrative Committee meetings.
Source: Visits to the demonstrative areas and documents (three-month period reports)
2.1.2 . Perception of performance, changes, advances, problems and
limitations
The valuation of the local and national teams of the four evaluated countries,
about the success level of the project, averages between moderadate
satisfactory to satisfactory. Guatemala is the most successful country with this
project. In Panama, there is an important discrepancy about the perception of
the local level, with the national level: the national level goes from satisfactory to
highly satisfactory, and at the local level goes from moderate to satisfactory.
This perception not coincide with the facts observed. In fact, despite the
difficulties to work with indigenous people, there are a high level of participation
of the organized groups, traditional authorities (regional indigenous congress,
local chiefs, religious group Mamachi), local governments (majors,
corregimiento representants and corregidores). Costa Rica and Mexico have
the lowest perception averages, that contrast with the observed in the mid term
evaluation, which found a similar level as in Guatemala.
The aspects on which the success perception is the highest in all of the
countries (average by variable) is in order of the importance: objectives
relevance (means 4.4), communities empowerment and appropriation (meand
4.3), cost effectivity and impact (means 4.1 and 4.4). The lowest perception of
success is in monitoring and evaluation (means 3.1) and financial planification
(means 3.3).
Table 4. Partners valuation about the success level in the project,
November 2005
VARIABLES
Costa Rica Guate
Mexico
Panama
Medium
-mala
(SD)
Loc Nat
Loc Nat Loc Nat
Loc Nat
Total
Objectives relevance and 4
4 4
5 5
4 5
4.4 (0.53)
planned results
Achieved activities and
4
4 4
3 3
3 4
3.5 (0.53)
products
Cost efectivity
4
4 4
4 4
5 5
4.1 (0.69)
Impact
3
5 4
5 5
4 5
4.4 (0.79)
Sustainability
5
4 5
3 3
4 3
3.6 (0.79)
Partners participation
3
4 4
4 4
3 5
3.9 (0.69)
Local Team appropriation
5
4 4
4 4
3 5
4.0 (0.58)
Communities appropriation
4
4 5
4 4
4 5
4.3 (0.49)
Approach implementation
3
4 4
4 4
3 4
3.7 (0.49)
Financial planification
3
4 3
2 3
3 5
3.3 (0.95)
Replicability
3
4 4
4 5
4 4
4.0 (0.58)
Monitoring and evaluation
3
4 3
4 1
3 4
3.1 (1.1)
Average (SD) Local
3.3 (0.49)
4.1 (0.29) 3.83 (0.8) 3.6 (0.67)
National
4.0 (0.60) 3.85 (1.1) 4.5 (0.67)
Source: Colective self administrated interviews at local and national level
SCORE: 5 = Highly satisfactory; 4 = Satisfactory; 3 = Moderadate Satisfactory; 2= Unsatisfactory; 1=
Highly unsatisfactory
Loc= Local Level; Nat= National Level
.
Coinciding with the success perception, the local and national teams identify the
communitarian participation and the vectors control without insecticides as the
major advances. In Costa Rica is appreciated the appropriation of the local
team, the constituition of Volunteer Commitees, the participation of the partners
from the Local Government, Social Organizations, neighbors associations,
health boards and other state institutions, the GIS development and
Epidemiological Surveillance inter border areas at the demonstrative areas of
the project. The local level of Costa Rica specify that in relation with the cost
effectiviness of the interventions, is good because most of the dialy activities
are making without the project funds and the national staff was not hired. In
relation to the sustainability, is specified that these activities have been carried
out during the past three years, without fumigating, there is an opportune
diagnosis and treatment, that there is a total access to the health services and
thare is a coordinated work with other institutions.
In Guatemala, important advances are identified, such as: first the Commmunity
Action Groups, teachers and students training, the control of positive mosquito
breeding sites, second the actualization of the DDT and other COP´s inventory
in Guatemala, third the use and management of GPS´s and the map
elaboration by the Public Health staff and the application of systematic
strategies for vectors control in the demonstrative areas without using
chemicals (fishes, breeding sites cleaning, small engineering works, etc.), finally
the control activities carried out by the the communities with support of the
Health Ministry.
In Panama, the most important advances are: i) the constitution of the
communitarian work groups, the participation of young teams, the
communitarian works for malaria control, which includes cleaning shifts and the
participation of the University, National Authority of Enviroment, Custom Duty,
Migration, Ministry of Farming Development, iii) the constitution of the National
Operative Committee and the Demonstartive Area Group, iv) effective
incorporation of the traditional authorities (regional indigenous congress, local
chiefs), v) upgrading if the DDT inventory and other COP´s, vi) the use and
management of GPS and GIS by the local technicians. In relation to
surveillance system exists from the begginig of the project, but it have been
fortified with the project. A inter borders meeting in Changuinola, Bocas del
Toro was carried in march 2004.
In Mexico the most important advnces are: understanding of the program trough
informative meetings, the communitarian approval of the demonstrative project,
the approval by the the operative staff of the Vectors Control Program.
Table 5. Advances perception, November 2005
VARIABLES
Costa Rica Guatemala
México
Panamá
Communitarian perception and approval X
X
X
X
Training, educationand sensiblization and X X X
difusión of the project
Operative staff approval
X
Intersectorial participation
X
Geographic Information System
Vectors control without chemicals use
X
X
DDT and other COP´s inventory upgrade
X
X
Surveil ance between countries
X
Source: Colective self administrated interviews at local and national level
The development level of the model was evaluated by the level of development
of case management, prevention and vector control, comunnitarian
participation, information and surveil ance system, the descentralization level
and the adaptation of the model to the process of the Health Sector Reform. In
the total valuation as in the valuation by variables there is a discrepancy of
perception between the local and the national level. In all countries, the major
development is at the prevention and vector control, the cases management
and the communitarian participation. The minor development is in the
information and surveillance system (Table 6).
Costa Rica has the most developed model, thanks to the high level of
development of case management, prevention and vector control and the
communitarian participation. In this country, the minor development is in the
information and surveillance system, with a major score at the local level than at
the national.
In Guatemala there is a low valuation of communitarian participation, which
disagree with the field visit to the demonstrative communities. In Panama there
is a big disagreement in the total punctuation and in most of the variables, with
a low valuation at the local level.The national level disagrees this perception
from the local level "because thare is a high level of acceptanceof the model by
the national, regional and local authorities". In the same way, Panama counts
with one of the most effective systems of information and surveillance, with
weekly reports about epidemiological situation, blood smere samples diagnosis
every five days and the fulfillment of immediates anti vector interventions".
Mexico has a high valuation in vector control and cases management which
coincides with the observed during the evaluation visit. The major weakness is
in the Information System, explained by the great quantity of information that it
is expected to collect.
Table 6. Evaluation of the model of malaria control
VARIABLE
SCORE
COUNTRY
COSTA
GUATE-
MEXICO
PANAMA
RICA
MALA
Loc
Nat
Loc
Nat
Loc
Nat
Loc
Nat
Case management Sumatory
28
27
24
8
24
24
23
22
Mean (SD)
2.0
1.9
1.71
0.57
1.7
1.7
1.64
1.57
%
100
96.4
85.7
28.6
85.7
85.7
82.1
78.6
Prevention and
Sumatory
4
3
3
4
4
4
2
4
vector control
Mean (SD)
2.0
1.5
1.5
2.0
2.0
2.0
1
2
%
100
75.0
75
100
100
100
50
100
Communitarian
Sumatory
12
8 9
10
12
12
7
14
participation
Mean (SD)
1.7
1.14 1.28
1.42
1.7
1.7
1
2.0
%
85.6
50.0
56
62.5 85.6
85.6
43
87.5
Information system Sumatory
17
19 15
9
19
20
15
28
and surveillance
Mean (SD)
1.06
1.36
1.07
0.64
1.36
1.4
1.07
2
%
47.2
64.3
53.6
32.1
64.6
71.4
53
100
Descentralización
Sumatory
17
13
19
14
15
20
10
18
and Reform
Mean (SD)
1.54
1.3
1.72
1.27
1.4
1.8
0.9
1.6
%
77.0
59.1
86.0
63.6
68.2
90.9
45.4
81
Total (96)
Sumatory
78
70
70
45
74
79
57
86
(2.0)
Mean
1.6
1.46
1.46
0.94
1.5
1.6
1.2
1.79
100
%
81.1
72.9
72.9
46.9
77.1
82.2
59.3
89.5
Source: Colective self administrated interviews at local and national level
Loc= Local Level; Nat= National Level
From 48 questions (see Apendix 1) with answers "yes", "partial", "no". The answers were
changed into an ordinal scale with the follow scores: yes = 2 points; partial = 1 point; no = 0
Sumatoria = total score (highest score 96)
Mean = average score reached with a maximum of 2 points.
% Development percentage = sumatoria / highest score (96).
The local and national teams notice that the most important limitation are: delay
on the payments, the slow consolidation of the National Committee and the lack
of transportation at local level (Table 7). According to the interviewed people in
Costa Rica, the most important problems or limitations are: the slow
consolidation of the National Committee, the complex administrative
management to designate the goods for the project, the national emergencies
as floods at the demonstrative areas, the slight flexibility of the handbook to
adapt it to the local realities, the lack of knowledge on entomology and the lack
of professional staff at the demonstrative area.
In Guatemala the problems are: i) the late payments by the donator, which limits
some of the planed activities, ii) the major importance given to dengue, the non
satisfactory performance in the health areas (it is reported that even when they
are working with the project, they do not have the expected level, because of
the limitation as transportation and other prioritary diseases), iii) the 8 and 12
hour long distances between the demonstrative areas and the capital city, which
limits the technical assistance, and iv) anophelines breeding sites and refugies
hard to control (huge water compilantions, streams, rivers, the high vegetation
around the houses) (NCI)
In Panama, the problems identified are: i) the irregularity at the meetings to
coordinate activities at the beginning of the Project (because of the general
elections period in the country, may 2004 and the change of the government
authorities in september 2004), ii) the slow integration of other public institutions
and authorities, iv) the late funds disbursement, v) the lack of transportation at
local level.
In Mexico, the most important problems according to the national level are: i)
difficulties in the precise register of the imformation about the tasks of the
communitarian demonstrative project; ii) the effective coordination with the
State, National and Regional health authorities in each of the demonstrative
areas, and iii) the administrative efficiency for disbursements and the proof of
the spending according to the PAHO and the PNUMA GEF rules (NCI). In the
local level the problems are: the extense operative universe, the integration and
the coordination of the national, state and local levels for the activities
development, the efficiency and opportuneness of the payments and the proof
of the financial resources for the PAHO and the donor GEF.
Table 7. Perception of limitations
VARIABLES
Costa
Guatemala
Mexico Panama
Rica
Late payments
X
X
National Operative Committee
X
Constitution
Weak public support
Complex financial administrative
X
X
management
Other priorities: floods, epidemics
X X
(dengue)
Slight flexibility in the Handbook
X
Breeding sites hard to control
X
Long distances at the demonstrative X
areas
Lack of knowledge in entomology
X
Lack of professionals at local level
X
Inter institutional coordination
X
Transportation at local level
X
X
Information system
X
Source: Colective self administrated interviews at local and national level
For all the interviewed, the most significant learning is the importance of the
communitarian work and the fast incorporation of the communities into the
control activies against malaria (NCI, LCI).
For the regional coordinator the most important learnings are:
1. The extended period between the design phase and the phase of the
project beginning meant the alliances desactivation and the
discouragement of the principal partners of the project, which needed an
special attention and reactivation with the implications that it takes.
2. To promote, to introduce and to experiment a documented model and a
strategic thought have demanded high creativity from the principal
managers, specially because persist a classic clinical approach to control
disease.
3. It has been required an integral vision of development to movilize politic
wills and resources from other sectors for the environmental abord to
control malaria without using persistent insecticides.
4. The way to involve other expert institutions in specific topics have
determined the success of the strategic lines introduction of the project,
for example the INCAP, Universidad de León and the Gorgas Institute for
the SIG/DDT/GEF; the health risk evaluation with the Universidad de San
Luis de Potosí from Mexico and the IRET from Costa Rica.
5. Even malaria is a serious public health topic in Meso America, it is not a
problem in the public agenda, so this is not a political problem, as
dengue or AIDS can be (ER).
In Costa Rica the lessons learned are the importance of communitarian work,
the alternatives and experiences from other countries, the importance of
medical entomology against malaria.
In Guatemala the biggest lesson is the use of GISI, which involved the learning
of using GPS, the elaboration and interpretation of geo referenced maps. It is
also recognized, the project strength and performance at the health area level
and demonstrative communities, the capacity to involve the community in the
solution of the health problems and giving them technical training for prevention
and control, as the best way to assure the sustaintability of the actions. Another
lesson is the big importance to manage the project with the existent natural
organizations instead of creating parallel structures, as well as the intra and
inter sectorial work wich helped with the ejecution of the proposed tasks.
For the local team in Panama, the most important lessons are: the fast
assimilation of strategies against malaria by the community, the perception of
change by the communitarian leaders and local authorities, as well as the
understanding about the importance of the community collaboration to make
those changes, even with a few resources. The national team recognizes as
lessons: i) the asigment of the focal points in Boca del Toro y Ngöbe Buglé
which facilitated the development of the project at local level, ii) the integral
approach, that at the demonstrative areas should join the consideration of other
health problems so the community can accept, know and participate; iii) the
need of giving special attention to malaria in the native population and the
importance of the support and involvement of local authorities with the project.
According to the national and local level from Mexico, the learned lessons are:
the flexibility of the program to accomplish the several needs of the
transmission areas, of the local and national program and the millennium goals;
the development in technical capabilities and the spaces to share technical
experiences and human development. It is also valorated the fact of achieving a
feasible adjustment between the community needs and the project objectives
looking forward for a communitarian change of attitudes and sustaintable
preventive practices.
2.1.3. Training
The process to introduce the strategy involved a huge effort to train in all levels,
specially at the communitarian level (Table 8). Mexico and Guatemala are the
countries that reach the highest covers in all aspects and Panama is the lowest,
because of the shortest lapse of time to execute the project. This process has
been made from the regional level to the national, from the national to the local
and from the local level to the communitarian.
The aspect in which were expended more training in all the countries is
education about malaria, vector control and communitarian participation, as well
as the Technical Handbook contents. In Costa Rica, the coverage of malaria
education and vector control with the community and students, especially from
elementary school, through a puppet show is big. With the exception of Mexico
and Guatemala, epidemiologic surveillance is the less trained aspect. In
Guatemala, 18 technicians from the demonstrative Areas, are qualified to work
on GIS, epidemiological surveillance and alternative control methods.
In Mexico, Guatemala and Panama, specific materials for trainning were
elaborated. In Guatemala materials about treatment, epidemiologic surveil ance
and malaria transmission were elaborated, as well as they elaborated socio
dramas shown in schools in the demonstrative areas, with the purpose to teach
about control alternative strategies and risk of chemicals. In Mexico, training
materials for the introduction of control strategy have been elaborated, as well
as enthomological evaluations (EHCA´s) and the program community integral
training. In Panama, educative materials about prevention, communitarian
participation and environmental management were created.
Table 8. Number of trained people by topics
TYPE OF TRAINING
NUMBER OF TRAINED PEOPLE
COSTA RICA GUATEMALA MEXICO
PANAMÁ
Nat Loc Co Nat Loc Co Na and Lo Nat Loc
About the handbook contents
5 18 50 12 22 6
150
2 5
Education and communitarian
5 16 1300 5 22 200
30
19 10
participation
Methods for vector control
5 16 25 3 22 200 60
19 10
Epidemiologic surveillance
0 0 0 3 22 15
150
0 5
GIS
15 4 0 8 22 6
30
19 19
Risk evaluation (DDT)
2
3
30
0 1
Taking decisions
0 0 0 3 2 5
20
0 0
Projects management
0 0 0 2 2 5
20
0 0
Source: Colective self administrated interviews at local and national level
Nat= National Level; Loc= Local Level; Co= Communities
2.2. MODEL IMPLEMENTATION AND DEVELOPMENT
2.2.1 Structure and organization of the project
The Regional Coordination is located at the INCAP in Guatemala and the
National Coordinations at the PAHO´s offices . To set the regional office of the
project at the INCAP was a good choice, because it is a PAHO´s center of
regional reference management that helps to conduct with most of the countries
of the project DDT/GEF. Aspect that could be more difficult from the PAHO
headquarters in Guatemala or another country. Also, it allows the transference
of experiences and knowledge, because professionals at the INCAP can help
with technical support, as epidemiology and georeference.
It is also correct to have a hired national professional (NAP) as the national
coordinator for the project, because of the instability at the national focal points.
The coordinator has given continuity to the project and he has a major
independence, but also the coordinators have been used the PAHO´s influence
and leadership with the Public Health Ministries in the Region.
In all countries, National Committee has been constituted under the leadership
of the Health Ministries and PAHO. Delegates of the Ministries of Environment,
Agropecuary, Migration and others are participating in the committees. As a
weakness found at the previous chapter, is the slow constitution of this
committee and the lack of consolidation (NCI).
The local committees are sttafed by health, laboratory and vector personnel. In
some countires, as Costa Rica, Panama and Guatemala, the local
governments, the private companies (banana plantation) and the national
government have delegates into the commitees. The committees have a
coordinator, a sub coordinator, a secretary and members. The committee´s task
is to disseminate information about the project and to manage communitarian
and institutional meetings (LCI).
It was found the existence of communitarian committees in all the visited areas.
In Panama a health committee was constituted in Barranco Montaña Adentro
and a Malaria Committee in Bisira town. In Guatemala, Health Action Group
(HAG) was constituted with: president, vice president, secretary, treasurer and
members; who preside, coordinate, supervise, control activities and they are the
responsables of all the tools and supplies already delivered (PO).
The program orders or directions to subordinate levels are transmited by
different means: telefax, e mail, telephone and through monthly planifications
and supervisions. The used procedures to report to the superior level are the
just mentioned. The control to the subordinate levels is made trough: reports
about the activities done by all the staff and send to the central unities, through
monthly meetings with the regional, local and national technical boards.
Monitoring, via phone calls, are made to fol ow the planned activities, especially
in Guatemala (NCI, LCI).
About the autonomy level of the projects, the national level from all the
countries valuate it as medium to high, but the local levels described medium
levels of autonomy. The major autonomy is given by taking decisions; then, the
financial resources management and programing. The lower autonomy is
related to the human resources management.
Mexico has the major autonomy in all aspects, because the specialized
structure of the malaria program was not affected by the health sector reform
processes, as it happened in other countries. In Costa Rica, the Ministry of
Health (MOH) do not have an ejecution team for the project. The functionaries
have to carry out the project activities as additional task. At local level, the Area
Chief does not participate at the staff hiring process and he can not hired
people for the project. The PAHO administrates and ejecutes the resources
requested by the local point, although there is a internal process (between
MOH and PAHO) to transfer resources to make payments, this is a slow
procedure. The activities are planned and the decisions taken with the
participation of the MOH and PAHO´s coordinator team. The staff of Talamanca
has an important role inside of the Project National Committee and they are
always listened and when decisions are taken, the vision of the local level is
important (LI).
In Panama, a high level of autonomy has been achieved at the human
resources management area, because the MINSA staff and other national
institutions participate and support the project. The decisions are taken at
national level, with the regional and local levels participation, and there is an
appropriate level of communication.
Table 9. Autonomy level at the human resources management and taking
decisions
AREA
Costa Rica Guatemala Mexico
Panama
Mean (SD)
Loc Nat Loc Nat
Loc Nat
Human resources
0 2
2 3
3 3
2 3
2.3 (1.0)
management
Finanacial resources 2 3
2 2
3 3
2 3
2.5 (0.5)
management
Programing
3 2
3 2
3 3
2 2
2.5 (0.5)
Taking decisions
3 3
2 2
3 3
2 3
2.6 (0.5)
Mean (SD)
2.0 (1.4)
2.25 (0.5)
3 (0)
2 (0)
2.5 (0.6)
2.25 (0.5)
3 (0)
2.7 (0.5)
Source: Colective self administrated interviews at local and national level
High = 3; Medium =2;Low = 1; None = 0
Loc= Local Level; Nat= National Level
In relation to the structures and organization of the places where the
demonstrative areas are, the local committees have joined the Ministry of
Health structures and specially at the vector control programs, taking
adeventage of the technical experience and the structure that remain from the
vertical elimination program. In Mexico there is still a specialized semi
autonomous structure of the program, but there is a really good integration with
the general health services (PO).
In Panama, the specialized structure persist, but because of the health services
descentalization process (began in 1996), the MCP (SNEM) disappeared and
the old structure was weakened because the retired vector workers are not
replaced. With the project, the integration of the MCP to the general health
services is being reinforced. The Local Coordinator of the project in the
demonstrative area of Boca del Toro is the Regional Epidemiologist; the
Medical Director of the Health Center of Bisira is the local Coordinator of the
Ngöbe Buglé Region, who leads the interventions of malaria control in the
demonstrative areas of Kankintú and Kusapín.
An important fact is that, even with the lack of the vector staff, the Ministry of
Health have hired as promoters, people who have been carried out activities of
volunteers collaborators, who speak the native languages (PO). In fact, the
vertical model, is been redesigned for a context with a few resources, with a
native population who speaks another language. In addition, this is an
inundated area so the risks are more collective than individual and there are a
few resources.
In Guatemala, the vector control structure persists, they are not just in charge of
the malaria control but also the rest of Vector Transmited Diseases (VTD). The
control department of VTD has a head office far from the demonstrative area
office, but it is under the Regional Chief´s leadership. It can be qualified as an
integrated structure, but it´s not a horizontal structure yet.
In Costa Rica, the area chief, where the demonstrative project is, is the leader
of the project. At this area it does not exist a parallel or independent structure
for vector control, so the area chief is ,at the same time, risponsable of the
preventive activities. The area counts with multidisciplinary team, with director,
epidemiologists, teacher and also vector inspectors who work in the
communities.
At the health model in Costa Rica, the heeling acitivities and some of the
preventives are asignated to the Caja de Seguridad (Social Security), the health
area has a role of regulation, supervision and control. Even though, in the case
of malaria and in the case of the project, the area chief is the responsable of
malaria activities (LI). There is a narrow coordination between the health
general services and the health staff in the area. For example, when the health
area identifies feverish patients, they take a sample, send it to the laborartory
and when it is confirmed as positive, they notify the area and they make the
followment and the complete radical treatment. The model of the strictly
supervised malaria treatment is made by the area and the Social Security only
gives malaria drugs (PO).
Costa Rica is the country with the most descentralized intervention. The local
interviews report:
"At national level, it does not exist a properly malaria program. The
health sector reform process and the changes that have happened,
affected the former program. Today, it is necessary to modify this
situation, because the action of the epidemiologic surveillance,
belonging to the MOH functions, need to be strengthen with resourses at
a national and operative level. The review of the national normative will
help to strength the institutional risponsabilities related to malaria
management" (LCI)
The activities of the health general services and malaria control, as well as the
vector workers are totally integrated only to one office. In relation with the
descentralization process, the former MCP structure was eliminated and all the
workers at the Area are integrated. Currently, the inspectors are multipurpose
for all of the VTD (dengue, malaria, chagas, etc.). In this sense, there is a profile
change of the inspectors, in 2003 the inspectors were only for malaria, and they
were organized as squads. At this moment, when an inspector goes to a house,
look for all the information related to vectors and in some of the cases look for
other health problems (LI).
The "Caja de Seguridad" has technical assitants for primary attention who
administrate vaccines, control pregnant women and also support the
campaigns; they also make an active search of febrish patients (PO). .
In Talamanca (one of the demonstrative areas in Costa Rica), once a month,
the area director and the "Caja" manager have a meeting, and according to the
area officer, this relation works really good. Even though, it has been
commented that in other areas it depends on the protagonists will and when
there are conflicts between the area officer and the "Caja de Seguridad"
director, the coordination does not work. The normative establishes that they
have to meet every fifthteen days and the meeting must be called by the area
headquarters (LI).
One of the weaknesses of the project in Costa Rica is that part of the vector
staff is temporary and the contracts are renewed every six months. There are
ocassions when they can not be renewed the personnel trained is lost. One of
the most important advances is the staff change about the way to think, they are
more communitarian now (LI).
2.2.2 Control strategies and used technology
At section 1.1 of the Chapter 1, it was reported that 1000 copies of the
Technical Handbook were published, even though just a small quantity of
people received it: 100 in Mexico, 10 in Costa Rica, 52 in Guatemala and 5 in
Panama. The number of trained people about the contents of the handbook is
higher than the number of distributed handbooks, being Guatemala the country
with the higher number of trained people (Table 10).
In relation with the opinion about if the Handbook replied to the policy or norms
of the country and to the available resources, only the local level in Guatemala
gives a favorable opinion, in the rest of the countries it is partial y favorable. In
Costa Rica people say that: "The guide was elaborated and designed in Mexico,
where there is great experience in Anopheles pseudopuntipennis control and
there are a lot of technical and financial resources. We have Anopheles
Albimanus and we do not even have a thousandth of the advantages at the
technical and financial part" (LCI).
Table 10. Number of the people who received and were trained with the
Technical Handbook and the opinion about the handbook adaptation in
the country.
COSTA RICA GUATEMALA MEXICO
PANAMA
Loc Nat
Loc Nat
Loc Nat Loc Nat
Number of the people who 10 10
12 50
100 100 0 5
received the handbook
Number of trained people
20 20
100 100
100 100 2 5
Does the handbook reply to Partial (P)
Yes (P) Yes
Partial (P)
the polithics or norms of the
Yes
country and to the available
resources
Source: Colective self administrated interviews at local and national level
P = Partial
According to the collective interviews, it has presented some important changes
in the strategy to control malaria, especially in Guatemala. In all countries there
have been changes in the strategy of larvae control and in the training of clinical
management cases. In Guatemala, where there is a high percentage of treated
cases without a laboratory diagnosis, the improvement in this aspect at the
demonstrative area is sustainable. With the exception of Costa Rica where
there was already a great coverage and quality of diagnosis and treatment. In
Guatemala and Panama there is an important change, which also affects the
improvement of the accurate detection of outbreaks and epidemics.
In the ejecution of the projects, the Handbook has been adapted to every local
reality and to the national normatives. Because of that, the control strategy,
even it has common elements (the stratification process, the EHCA activities,
the clean house and clean patio activities and the improvement in personal and
family´s hygiene), there are important differences in: the clinical case
management and the elimination of human breeding sites of plasmodium. The
similatities and differences in the application of the control strategy are identified
in Table 11, and how the strategy is applied in each one of its components is
described in the rest of this section.
Table 11. Characteristics of the control strategy by components and
countries
Component
Strategy description
1. Estratificación
All the countries:
Two phases
First phase: identificatiom of localities with higher APIs every
three or five years period.
Second phase: identification of malarious houses and repeated
cases .
2.Clinical
Mexico: TDU 3x3x3 years. First dosage include primaquina in
management of
the blood smear taking of time, if is positive recive 3x3x3
the cases.
squeme.
Costa Rica: Supresive treatment in the blood smear taking of
time, following by radical trearment for comfirmed cases y TDU
3x3 for one year
Guatemala and Panama: Supresive treatment in the blood
smear taking of time, following by radical trearment for
comfirmed cases.
3. Case
Mexico: active and passive search.
Identification
Guatemala: passive search.
Strategy
Panama: active and passive search.
Costa Rica: pasive searching (notification post) and active
searching of cases in babana plantatiomn workers thorugh the
malaria card.
4. Infection
Mexico: TDU 3x3x3 in positive cases and fammily contacts.
sources
Costa Rica: TDU 3x3x1 for positive cases and family contats.
elimination
Panama: Radical treatment to every fammily contact and
neighborhood positive cases.
5. EHCA
All the countries.
Mexico: Community work to cleans every 15 days or monthly
and evaluation od f results pre and post intervention.
Panama, Costa Rica and Guatemala: Community work every
month and results pre and post intervention.
6. Home
All the countries: clean house, clean yard
Improvements
Mexico and Costa Rica: encalamiento de viviendas.
Panama: green cars for clean house and patio, and read for
dirty house and patio
7. Familiar hygiene All the countries
improvement
8. Biological
All the countries: larvivorous fishes and breeding sites cleaning
techniques and
Mexico: bacillus and alcohol etoxilado.
physical control of
Panama: bacillus
adult larvae
9. Adult Control of
Mexico and Costa Rica: hpuses painted with lime
adult anophelines
Panama: insecticide spraying in outbreaks
and barriers
Guatemala: repelent trees
Source: Participant observation, local interviews and polls.
In relation with the control strategy, in Mexico, which is the country which
proposed model, the only change in the project is the training of health staff in
cases management and to improve the coverage and quality diagnosis; an
operative investigation abour rapid test for malaria diagnosis was done.
According to the interviewed people from the three remaining evaluated
countries, the project has caused important changes in the malaria control
strategy, specially in Guatemala (Table 12). In these three countries there are
changes in strategy of larvae control and training in the case management. In
Guatemala, where there is a high percentage of cases treated without a
laboratory diagnosis, the improvement at the demonstrative area is sustainable.
In Costa Rica and Mexico where there was already a good covererage, there
were no important changes in diagnosis and treatment quality. In Guatemala
and Panama there is an important change, which also influences the
improvement of outbreaks and epidemics detection
Table 12. Changes caused by the project in control strategy and in the
model of services
DIAGNOSIS AND TREATMENT
Costa
Guate-
Mexico
Panama
Rica
mala
Loc Nat Loc Nat Loc Nat
Loc Nat
Diagnosis procedure
No No
Yes Yes No No
No
Startegy to improve the coverage and No Yes Yes Yes No No
Yes
quality of the diagnosis and the
treatment
Health staff training about the
Yes Yes Yes No Yes Yes Yes
management of the cases
Strategy and mechanisms to provide No No
Yes Yes No No
Yes
medicines and supplies
PREVENTION
Changes in the strategy of vector larvae Yes Yes Yes Yes No No
Yes
control
Reduction of vector- persons contact No Yes Yes No No No
No
Epidemics and outbreaks control
No Yes Yes Yes No No
Yes
Source: Colective self administrated interviews at local and national level
Nat= National Level; Loc= Local Level
Related to the problems that the project has experimented during the
introduction of the strategy, Mexico does not report problems and the rest of the
countries most are minor problems. The interviewed people identified the next
problems:
In Guatemala, the problem wich affects the diagnosis and treatment activities is
the large time between the sample takes and the reading of blood smear (LCI).
Another problem is "the financial part, because there were activities planed to
strengthen this component in this three months, but with the lack of resources, it
has to be delayed until we have the funds" (NCI). In Costa Rica, the existence
of a lot of imported cases interferes in the control and fol owment of them.
In relation with the strategy to improve the coverage and quality of diagnosis
and treatment, the problem in Guatemala is the difficulty to contact local people
to take samples from localities to the laboratory and the health staff training
about cases management. In Costa Rica there is a limitation of the operative
staff.
In the strategy of drug and supplies provision, in Guatemala the budget was not
enough to obtain the necessary, and the ejecution of funds are too slow at local
level. In Costa Rica there is a national regulations handled by the Social
Security (Caja Costarricense del Seguro Social, CCSS) which is in revision
(NCI).
Estratificación Strategy
The estratification strategy suggested by the Handbook and used by the 8
countries can be qualified as a biethapic methodology. At the first phase,
localities are identified with collected APIs during the past 3 or 5 higher years,
which helps to identify the localities with the major persistence of malaria (stable
malaria). At the level of each locality with persistent malaria, activities as physic
and biological vector control are focalized; especially the elimination of habitats
of anophelines breeding sites (EHCA) (PO).
At the second phase, malarious houses are identified (houses with two or more
cases or repeatd cases) from the prioritary localities. The malarious houses are
focalized places where the intervention are implemented: elimination of the
breeding sites of plasmodium, home improvement, promotion of personal
hygiene and in some places impregnated bednets (used as a strategy to reduce
the vector-person contact).
All the visited countries have used this stratifacation criteria; first, to select the
demonstrative localities and then as part of the base line and to focalize the
interventions.
Clinical management of malaria
In all the countries, blood smear is used for the diagnosis of malaria applied on
feverish patients. In Guatemala is also used a clinical definition because of the
lack of laboratories. Each country has adopted a different plan of treatment to
adapt them to the national norms. In fact, not all the countries have adopted the
strategy of treatment 3x3x3, used in Mexico.
In the demonstrative area of Talamanca (Costa Rica), the treatment squeme
was modified, mixing the radical cure (seven days of primaquina in double
doses) and after that, a treatment with modified TDU, which can be called
3x3x1: cloroquina and primaquina in just one monthly giving for three months,
three months of rest, other three months with TDU, and other three months of
rest until a year of treatment can be completed. In this country, the correction of
Primaquina dosis is being revised; currently, one daily primaquina pill for 5 days
for an average adult or one daily Primaquina for 14 days is normed; the new
normative will be a double dose of Primaquina for 7 days or one dose 1 for 14
days (Interinstitutional Malaria Committee meeting is on hold).
Guatemala and Panama use a presuntive treatment at the same time when the
the thick blood smear is taken, following by a radical cure of 7 or 14 days when
it has been confirmed by the laboratories. In Guatemala, they give primaquina
doses from the half of the recommended doses by PAHO. In Panama, when the
treatments are for seven days, the quantity of primaquina is 180 mg, in the 14
days treatments the doses is complete (210 mg).
With the exception of Panama where the general health services are being
integrated in diagnosis and treatment, in all the visited countries the volunteers
have been recuperated to take samples and to distribute treatments. In Mexico
where the specialized structure still persists, the general health services are
considered notifying centers (PO).
In Mexico, in the Regional Hospital, there is a clinical detection of feverish.
When a feverish patient is found and malaria is suspected, they take a thick
blood smear sample and they notified to the vector service, which makes the
control and if the sample is positive it goes to the 3x3x3 program. A similar
procedure is used in Costa Rica: the clinic staff of the Caja de Seguridad takes
samples when they find suspicious cases, they send the blood smear to the
regional laboratory, and if the result is positive they notified to the area office for
the radical treatment and following with TDU 3x3x1 (PO).
In Mexico, Guatemala and Panama there are specific laboratories for malaria,
separated from the laboratories of general services. In Costa Rica they are
integrated to the general services, even there is a specific malaria laboratory at
the headquarters in the Talamanca Area.
In Costa Rica, where the workers from Panama cross to the Costa Rica border
to work during the day, one of the most important practices to improve malaria
control at the border area, is that the workers who legal y live and work at the
banana plantations have to do a thick blood smear sample, in order to obtain an
obligatory ID card (malaria card). To be able to go and work at the Talamanca
area (Costa Rica) workers must present this ID after they take (LI, PO).
This strategy works really well at the legal banana plantations, because there is
an agreement with the owners so they do not hire people who does not have
the malaria ID. This strategy at small or independent ranchs is not working well
so there has beeen an agreement, during the evaluation visit, to reinforce this
strategy in Panama (LI). To reach a high coverage, stations to the take the
samples have been set in small business or restaurants next to the river.
It has been discussed with the national team the fact that, this strategy could
transform in a discriminatory mechanism against workers from Panama. And
also that as a consecuence, business man can hire people without ID but
offering them low salaries. The answer to that was no. Eventhough, there is an
agreement to make an evaluation at communities in Panama to know their
opinion.
Every country has a different strategy to evaluate the impact of the treatment in
positives cases. In Costa Rica there is monthly control with thick blood smear
with the purpose to evaluate the TDU 3x3x1 strategy and the failing indicator is
the relapse of feber event. In Guatemala all the positive cases have to give a
control sample after the radical treatment. Mexico has an information system
which allows identifying the repeated cases and evaluating the impact of the
therapy scheme. In Panama, the guide establish that a control has to be made
fifteen days after the beginning of the treatment and, if it is P. Vivax, it has to be
taken a monthly thick blood smear for eight months (PO).
In the case of Guatemala, at the national level, the diagnosis coverage
problems are obvious, only the 15% has been confirmed by laboratory. In
Panama there are problems too, because of the lack of human resources to
pick up the blood smear taken by volunteers. In both countries there is an over
delay in the delivery of the results of the blood smear, that can be for more than
five days.
In the demonstrative areas of Guatemala the laboratory diagnosis coberage and
the results delivery have been improved. At the moment of the evaluation, the
85 % of the treated cases have a parasitologic diagnosis. The use of quick test
has been planned, specially at the Mexico border areas.
In Mexico, there is an active search of the cases at the communities where
malaria cases were confirmed. In Panama, the malaria program normative
stablishes a permanent active search in all the country endemic zones; but the
vector workers in Panama say that an active surveillance is made periodically,
only when the vector staff visits the communities. In Guatemala happens the
same.
In Mexico, there are not cases with a exclusive clinical criteria diagnosis, all the
cases are diagnosed by laboratories. In Guatemala and Costa Rica there is an
increase of the diagnosis made by clinical criteria and there is a decrease in of
the diagnosis made at laboratories and the total number of taken samples,
between 2003 and 2005. In Guatemala it is shown that there is an increase
during 2001 to 2003 (see Table 13) but there is a decrease from 2003 to 2005,
because the 2005 data is partial (until october). In Panama there is an increase
in the diagnosis cases by clinical criteria and in the number of observed blood
smears, which reflects the improvement in the service offers, but between 2003
and 2005 there is a decrease of: cases diagnosed by laboratories, of treated
cases and of people who finished the treatment. This is explained because the
2005 data is partial (until October).
In Mexico from 2003 to 2005, there is a reduction in all of the evaluated
indicators. Due to this country has applied the strategy for four years, this
reduction can be attributed to the transmission reduction at the demonstrative
areas.
In Mexico and Guatemala, there is a reduction in the average time between
taking smear blood samples and the begginig of the treatment, but in
Guatemala persists really high averages.
Costa Rica did not present the 2005 data, but there is an increase of diagnosed
cases by laboratory and a slight reduction of observed blood smears during
2001 to 2004, which can be explined because in this area, since 2002 an
improvement strategy for diagnosis and treatment started. They did not present
information about the number of people who began the treatment, confirmed
treated cases, cases with a complete scheme in 2001. In this criterias there is
decrease between 2003 and 2005.
Table 13. Changes at the coverage in clinical services of malaria in clinics
2001, 2003, 2005
COVERAGE
Years
COSTA
GUATE-
MEXICO PANAMA
RICA
MALA
No RI
No RI
No RI
No RI
Number of cases diagnosis by 2001
15430
0
287
clinical criteria without
2003
1210 0,07 0
1373 4,7
laboratory
2005
79172 7,5
0
1544 1,2
Number of cases diagnosis by 2001
1363
4097
4,996
287
laboratory
2003
718 0,5 1932 0,47 3,663 0,7 2373 8,2
2005
1289* 1,8 1494 0,77 3,406 0,9 1544 0,7
Number of observed blood 2001 43123
15756
1052723
smear
2003 9622 0,2 12010 0,8
166807 1,1
2005
9204* 0,9 9172 0,8 898,275* 188191 1,1
Number of people who started 2001
ND 4,996
287
treatment
2003
1623
3,663 0,7 2373 8,2
2005
1311 0,8 3,406 0,9 1544 0,7
Number of confirmed treated 2001
ND 4,996
287
cases
2003
1623
3,663 0,7 2373 8,2
2005
1311 0,8
3,406 0,9 1544 0,7
Number of cases with a 2001
ND ND
287
complete scheme
2003
1623
ND
2373 8,2
2005
1311 0,8
ND
1544 0,7
% of repeated treated cases
2001
100
2003
30*
100 1,0
2005
25 0,8 100 1,0
Mean time from blood smear 2001
ND ND
5
taking and beginning of
2003
38
7*
5 1,0
treatment
2005
23 0,6
5 0,7 5 1,0
Source: Colective self administrated interviews at local and national level
Data 2004
Another weackness indentified in Guatemala and Panama is the samples
quality control. Eventhough all the positive blood smear and the 10% of the
negative ones are sent to the laboratory of national reference, by the local
teams, this activity is not being accomplished and theres is no feed back of the
results to the evaluated laboratory workers.
En el área demostrativa de Costa Rica existe un laboratorio en la clínica de
Talamanca y dos microscopistas. El programa de control de calidad se realiza
en los laboratorios centrales del país, el seguimiento de los pacientes se hace
con placas seriadas.
At demonstrative area of Costa Rica there is a laboratory and two microcopists
at the Talamanca clinic. The control of the quality of the program is made at the
country central laboratories; the track treatment results is made with serials
blood smear.
In three of the countries that sent the information, there are no changes in the
number of microscopists and still, there is not a properly blood smears quality
control system.
Table 14. Changes at the quality control of the laboratories
Years
GUATE- MEXICO
PANAMA
COVERAGE
MALA
No RI
No RI
No RI
Number of trained and microscopists
2001 3
12
13
licensed
2003 3 1,0 12
13 1,0
2005 3 1,0 12
13 1,0
Number of the microscopists evaluated
2001 3
12
13
2003 3 1,0 12
13 1,0
2005 3 1,0 12
13 1,0
Number of evaluated blood smears
2001
ND
2003
ND
2005 7988
ND
Number of fake positives
2001 ND
0
2003
ND
0
2005
ND
0
Concordancy by specie
2001 ND
100%
2003
ND
100%
2005
ND
100%
Source: Colective self administrated interviews at local and national level
Elimination of human infection sources
Based in empirical evidences and in some non published studies, Mexico has
formulated as a hypothesis that the malarious houses and repeated cases are
the cause of persistence of malaria at the localities. To eliminate the hostess
when a case appears, they make an active search of feverish patients in the
community and they treat the patients and their families with the TDU 3x3x3
scheme (PO, LI). This scheme,consists in giving a treatment with just one
doses of cloroquina, primaquina for three months, then three months of resting
and then the repetition of this cycles during three years.
Based on the natural history of the plasmodium vivax, the mexican technicians,
affirm that most of the relapses (feverish repeated events in confirmed cases)
happened at the first two months, at sixth and ninth month; because of that, the
patients should be treated in this months to avoid the development of
plasmodium and the transmission is also eliminated. The Mexican technicians
affirm that the human hostess should be eliminated, including the family
members even when there are no symptoms (NI).
In Costa Rica demonstrative area, in adition to the radical treatment a
modification has been made to the TDU 3x3x3. TDU cycles are applied, for
three months and three month of resting, until one year is completed (TDU
3x3x1). This scheme is used only to steady residents, because there is floating
population that lives in Panama but goes to work at the banana plantations in
Costa Rica (OP, EL). The TDU 3x3x3 or its modification 3x3x1, is hard to
applied in areas with a high temporary migration, that is why in Mexico and
Costa Rica is used specially for residents and permanent workers.
Guatemala do not use any strategy to reduce the plasmodium hostess. In
Panama, the case is followed with thick blood smear controls during eight
months for P. vivax and 5 months for P. falciparum. The fact that Panama give
the treatment to all of the family members and neighbors of a positive case,
without making the thick blood smear tests, means that this is the strategy to
reduce the human hostess (LI).
In Guatemala and Panama the TDU 3x3x1 have not been adopted because
they argue that there are no scientific evidences to adopt the strategy, which
coincides with the PAHO experts. In adition PAHO (Dr. Marquiño and Carter)
support that the doses of primaquina are small and there is a risk to create
resistence. To avoid this problem, Costa Rica decided to give first a treatment
of radical cure and then begin the TDU 3x3x1 (LI).
2.2.3 Vector control
EHCA and biological techniques for larvae control
The application of the physic elimination of habitats of anophelines breeding
places (EHCA), has been adopted by all of the visited countries and the
members participate actively at demonstrative areas. In the Handbook, two
patterns for the application of EHCA have been definied, related with the
prevalent anopleline specie, so the strategy can be defined as a selective vector
control. In Guatemala there are other prevalent anophelines, so the national
team agrees that is neccesary to develop other EHCAS patterns (NI).
The Mexican technicians say that one of the essential requirements of the
EHCA strategy is the pre and post evaluation. In fact, in Mexico, this
requirement is strictly accomplished with the EHCA promoter participation in the
community (NI). One of the weaknesses in the work, in Panama, Costa Rica
and Guatemala is that in the EHCAS activities theres is no pre and post
evaluation. In the case of the first two countries, the population have not been
trained to evaluate, in a simple way, the result of the acitivities of vector control
(PO).
In Panama, motivation methods as the competition between communities are
used. They make cleaning activities every week, covering one hundred meters
from the community; where they cannot clean, they filling in. They make area
divitions for the cleaning at each one of the sectors (streets) in the community,
the city major gives a prize to the cleanest streets and the ones that do not have
red cards (see next section). In the fol owing holidays the "cleaning queen" will
be elected. People do not ask for money for them, only for some incentives as
a throphy (LI).
In Guatemala the project gave hand tools to the communities, but in Panama
the communities are complaining about the delivered quantity (four
wheelbarrows, shovels, etc,.) (LI).
The use of larvivorous fishes (gambusia puntata) is the biological technic of
larvae control used for all of the countries. The use of endemics species from
the same area, which are carried from a breeding places with low larvae
positivity to another one with high density, guarrante that depredator species ca
not be introduced to change the local fauna. In Guatemala and Mexico, there
are pre and post evaluations of the control larvae activities.
.In Central America and Mexico are previous experiences about the use of other
biological technics for larvae control, as the use of bacillus spherical, the same
which is used in some countries. The studies about the impact of using
nematodes concluded that this technics is not applied in big scale and that´s
why it has been rejected as an alternative (Galindo, 2005).
Home improvement and promotion of personal and family hygiene
The strategy of clean house and clean patio is also adopted by all the countries.
The "white washing", which consist on painting the house wal s with lime
(especially in the malarious houses), has been adopted by Mexico and Costa
Rica. Panama and Guatemala are planning the introduction of this method (PO,
NI). Honduras also reports the implementation of this strategy in the malarious
houses and houses next to breeding sites.
A strategy to reinforce the intervention of clean house, clean yard, drainage and
breeding sites cleaning has been created in Panama. Because of the presence
of epidemic outbreaks of dengue, the Ministry of Health and the Presidency,
agreed to give green and red cards after the house controls. The green cards
are for clean houses, clean patios and for houses with drainages or breeding
sites cleaning.This measure has been applied in demonstrative areas (Bisira
and Barranco Montaña Adentro) by the the vector staff and the general medical.
In the other case, when the houses are not clean, the Ministry of Health (MOH)
can give fines and sometimes, by the medical version and the present
inhabitants, they have to go to the police (PO, NI).
This strategy, which was a success in Bisira, became a discriminatory rule at
the native area of Barranco Montaña Adentro. According to some of the young
leaders of the Malaria Committee, the red cards were just delivered at the
houses, without the community had recived trained about this methodology.
That action was received as an aggression, because the health workers told
that malaria was produced because of dirtiness and carelessness. And also
because of the discrimination that exists in health services. This casuse a
reaction from young people to organize the community to keep the houses and
yards clean, but more as a reaction to that negative intervention. So the
difference between Basira and Barranco Montaña Adentro was that in the first
one, the health staff visited house by house educating the population about
malaria and dengue during the base line study, and also they set a legal
framework for the fines while in Barranco Montaña Adentro that did not happen
(PO).
Reduction of the contact vector-person
Even in the whole area there is experience about mosquito nets impregnanted
with insecticides, only in Honduras there are mosquito nets at the malarious
houses at the demonstrative areas. In Guatemala there was a project to use
mosquito nets, which is used at the nearest areas of the demonstrative
localities. The projects of the Global Fund, which are being ejectuted in
Honduras and Guatemala, have as one of the central strategies the use of pre
impregnted bednets, which reduce the need to implement a structure for the
periodical impregnation.
In Honduras and Guatemala repellent trees as "nin", cedar and eucalyptus were
sown to work as barriers that decrease the contact between vector and people.
Eventhough, there are no impact evaluations about this strategy, in Honduras
the sown of repel ent tress (Nin, Cedar, Mahogany), have been supported by
the Secretary of Agriculture and Ganadería and the banana enterprise
Standard F Company, that during years have used these repellent trees at their
plantations. Currently, some demonstrative municipalities in Hondura are
developing seedbeds and viveros, with communitarian participation to plant in
the malarious localities with a major incidence.
Elimination of adult anophelines
Mexico and Costa Rica stopped the insecticides use to control malaria since
three years ago. As it was described, with the exception of Panama that made a
Sumithion spraying, insecticides for malaria were not used before and since the
beginning of the project at the demonstrative areas (NI, LI).
According to the interviewed people "at the beginning it was a little bit hard to
change the vector staff mind about the chemical control to the ecologic control.
In Guatemala, we do not use persistent chemicals, eventhough we are
decreasing the quantity of organ phosphorated chemicals and used piretroides"
(LCI). In Guatemala, has been used at national level Fenthión 2%, Propoxur
40% and Deltametrina (wetter powder). In Panama Fenitrithión PH 40% is used
to control malaria, but not at the demostrative areas.
At national level, there is still an extense use of insecticides to control dengue
and chagas at national level. As there are no cases of dengue at the
demonstrative areas insecticides have not been used to control them. In Costa
Rica, Themefos (abate) and Ciflutryn is used; in Panama, Deltametrina for
Chagas and dengue, and in Guatemala, Deltametrina al 5% wetter powder and
liquid (2.7 gr/lt) to control changas and dengue vectors, as well granulated
themefos at 1% to control dengue (NCI).
In relation with the problems to introduce the preventive activities, specially the
strategy of vector larvae control (ie. selective control or the use of new control
technics), in Guatemala there was no problem because the volunteers agreed
to make larvae control (LCI), the communities are actively participating (NCI). In
Costa Rica the staff has a lack of training and unknowlegde of enthomology
(LCI), and in Panama is difficult to continue because there is no technical
qualified staff, basically in entomology.
In relation with the reduction of vector-people contact, the limed house is a
previliged strategy in all the countries, Only in Guatemala the use of bednets
without insecticide is promoted. In Costa Rica there are problems in products
availability because of the cost to white wash houses, the local government has
donated lime.
Changes at the vector control coverage
While in Guatemala there is a decrease of the coverage in fumigated
communities and sprayed houses; in Panama there is an increament explained
by the presence of a malaria epidemic at the demonstrative area. Mexico
presented intramural residual treatment and space treatment data on 2004, but
during the observation the informants said that insecticides were not used
during 2005, but there is a high number of communitarian cleaning activities
(4643) in 2004. In Guatemala there is not an increase in the number of
meetings carried out with the communities and there is a slight decrease at the
sanitation activities from 2003 to 2005. In Panama the increament in both
aspects is also slight. Again, the reason is that the 2005 information is only until
octuber (Table 15).
The major progress, in both countries, is the number of localities with updated
maps, which is requirement to plan the activities of vector control. Mexico does
not report this information, but during the observation it was shown that there
are maps in both of the visited communities. Costa Rica did not send this
information.
From the four countries evaluated, only Guatemala and México has the
information of physic control of breeding sites, clean houses, clean patios, and
limed houses activities. Mexico has a high coverage of these activities (Table
16).
Table 15. Changes in the coverage of vector control activities
ACTIVITIES
Years GUATEMALA MEXICO
PANAMA
No RI
No RI
No RI
Number of fumigated localities
2001 ND
260
2003 46
206*
206 0,79
2005 14 0,3
270 1,3
Number of sprayed houses 2001 ND
2175
2003 4801
40,903*
2756 1,2
2005 841 0,17
9500 3,4
Protected population
2001 ND
ND
21750
2003 22980
ND
22570 1,03
2005 3748 0,16
ND
95000 4,2
Number of meetings with the
2001 ND
ND
ND
community
2003 175
ND
ND
2005 165 0,94
ND
ND
Number of communitarian sanitation 2001 ND
35
activities
2003 26
4643*3
37 1,05
2005 28 1,07
41 1,11
Distributed Impregnated mosquito nets 2001 7050
ND
0
2003 1166 0,16
ND
0
2005 0
ND
0
Localities with updated maps
2001 ND
ND
ND
2003 ND
ND
ND
2005 175
ND
6
Source: Colective self administrated interviews at local and national level
* 2004 Data (First Semester)
Table 16. Activities of breeding sites, clean houses, clean yards, and limed
houses control. Mexico and Guatemala 2005
ACTIVITIES OF PHYSICAL AND BIOLOGICAL Mexico
Guatemala
CONTROL OF BREEDING SITES
Lineal meters of river chanel cleaned
107.900
200
Lineal meters of breeding sites veenered
78.767
800
Square meters of breeding sites intervened with biological
0
measures
Number of clean houses
6.000 (69%)
186
Number of clean yards
6.000 (69%)
186
Number of white washed houses (lime)
870
0
Source: Colective self administrated interviews at local and national level
2.2.4 Management and Resources
In relation with the improvement of management at the national and local levels,
there is a perception of a major improvement at the national level than at the
local level in Costa Rica, Guatemala and Panama. In Mexico there is
agreement between both levels.
Guatemala and Mexico report improvement in both aspects. The only aspect,
that do not present changes in Mexico is in the monitoring of the staff
performance. In Guatemala, the valuated changes are: capability in
management and investigation and in the management system. In the local
level there is an improvement in equity, efficiency and quality. In this last aspect
the local level in Panama and in the national of Costa Rica reported
improvement (Table 17). In Costa Rica there is a minor perception of
improvement than in Guatemala, because their management and capacity
system was possibly major before the begginig of the project.
In Panama, the national level reports that with the beginning of the project
DDT/GEF, the management of the malaria program is stronger, registering an
improvement at the local and national levels, with the formation of intersectorial
and local committees, coordination with different levels in health services,
application of new control strategies, and monitoring and surveillance.
Table 17. Changes in management, equity, efficiency and quality
COSTA
GUATE-
MEXICO PANAMA
CHANGES
RICA
MALA
Loc Nat
Loc Nat
Loc Nat Loc Nat
MANAGEMENT AND INVESTIGATION
CAPACITY
Improvement at the operative
No Yes Yes Yes Yes Yes Yes Yes
investigation capacity
Training and development mechanisms Yes Yes
Yes No
Yes Yes No
to improve the management and
direction.
Information management system
No Yes Yes Yes Yes Yes Yes
GESTION SYSTEM
Resources planfication and distribution
No Yes Yes Yes Yes Yes Yes Yes
Financial system and financial
No No
Yes Yes Yes Yes No
management
Staff developement monitoring or
No No
Yes Yes No No No Yes
evaluation system.
Polithics of intersectorial coordiantion
Yes No
Yes Yes No ND Yes Yes
EQUITY, EFFICIENCY AND QUALITY
Budget amount changes
Yes No
Yes No Yes Yes No
Budget, human resources and equipment Yes No
Yes Yes Yes Yes No
distribution changes
Administrative outcomes decrease
No No
Yes No
Yes Yes No
Spraying costs, diagnosis and treatment No No
Yes No
Yes Yes Yes
changes
Workers development changes
No No
Yes No
Yes Yes Yes Yes
Medicines and insecticides availability No No
Yes Yes
Yes Yes Yes Yes
changes
Quality changes (improvement or
No Yes
Yes Yes
Yes Yes Yes Yes
deteriorartion) of services
Source: Collective self administrated interviews at local and national level
All the countries have an specific plan and a written declaration of the national
and local control strategy. With the exception at the local level in Panama, all
the countries have a strategic plan. In all the countries and at all the levels,
there is an annual plan, three month term plans and a purchase plan (LCI, NCI).
All the interviewed say that the current annual plan reflex the national policies to
malaria control. In relation with annual plan contents the opinion of the
interviewed is that they present all the elements: objectives, activities, logical
frame, resources (budget), financial sources, schedule, risponsables and
indicators (of process, products, result and impact) (LCI, NCI).
In relation with the performance level of the annual plan during 2004, Costa
Rica and Mexico report a total performance at the local level and partial at the
national level, the rest of the countries report a parcial performance in both
levels. In relation with 2005, Mexico reports a total performance in the national
and local level; the rest of the countries report a partial performance in both
levels.
.
About the non performed aspects, the reasons of no achiviement were: the
delay on the NAPs hiring process, the late beginning at the local level and the
delay in the disbursements. In Costa Rica the reasons are de lack of staff and
the long procedures; in Guatemala the lack of finanacial resources because of a
delay in the payments and in Panama the change of government and the
floods. About the late payments in Guatemala, the national staff say: "As I
mentioned before, currently we are in a crisis with the funds which have not
been delivered by the donator (by the moment there is an ejecution of the 97%)"
(NCI). Other reasons can be reviewed in Table 18.
Table 18. None performed ascpects and the reasons of non performance
COUNTRY NON PERFORMED
REASON OF NON PERFORMANCE
ASPECTS
Costa Rica
Comunication plan
Lack of staff
GIS Consolidation
Long procedures
Biologic control
Institucional development
Laboratories Equipment
Mexico Implementation of
1. Delay of the payments of the GEF resources;
demonstrative areas
2. Delay in the payments for the operation; 3.
Progressive coordination with the local, state and
national level; 4. Adjustment in spending codes
(PNUMA, PAHO) for the operative needs; 5. lack
of specific local staff; 6. Extense demonstrative
areas, far communities and difficult access
Guatemala
Volunteers training
Lack of staff, motivation and communication
Short term training and Funding
experience exchanges
Surveillance and vector Funding
control
Basic equipments for Funding
monitoring
Panama Environmental
Floods, change of president
interventions
Source: Collective self administrated interviewes at local and national level
All the interviewed think that the malaria control policy agrees with the
epidemiologic situation. About if the financial resources are enough, only
Mexico reports that these resources are enough in both levels, but they
emphasized the need of and adjustment of materials and equipment
programmed. Costa Rica reports that the human resources are partial in both
levels, Guatemala reports partial at local level and enough at national level, and
Panama insufficient (Table 19).
In Panama, the lack of health officials for the accurate follow up of the work
activities at the demostartive areas is emphasized. In Panama, the health staff
is small, although there is a followment of the activities and evaluations at the
demonstrative areas. In Costa Rica the is also emphasized the lack of trained
staff to reinforce the GIS subject and the lack of health officials for the accurate
follow up of the work activities at the demonstrative areas, because the involved
staff can not make a full time work:
"The staff do not work excusively in Malaria, not even exclusively in
vector control, they are not wel paid, there are difficulties with the
transportation and the access to most of the areas. The area is too big,
2809.51 km2 for only 16 health inspectors who does not work exclusively
in Malaria" (NCI).
Only, the local level in Costa Rica reports that the material resources are
enough, the rest think that they are partilly enough. In Guatemala, the opinion
is:
"According to the programed (the resources) are enough eventhough the
third payment have not been delivered, currently we have a financial
deficit and scarcity of material to continue the project" (LCI).
About the supporting systems functioning, Costa Rica has the best perception
(good, at national and local level) and Panama at the national level. There are
disagreements between Guatemala and Panama about the national and local
level, but those differences are not higher in a category (Table 19).
Table 19. Opinion about the adecuation of malaria control policy, the
resources adequacy and the supporting systems functioning
ITEMS
COSTA RICA GUATEMALA MEXICO
PANAMA
Loc Nat
Loc Nat
Loc Nat
Loc Nat
Policy in accordance of Yes (Yes) Yes
Yes Yes
Yes
epidemiological situation
Resources are enough:
Human
Partial (P) Partial (Yes) Partial (P)
ND
Financial
Partial (P) Partial (P) Yes Yes
Partial
Material
Good (P) Partial (P) Partial Yes
Partial
Opinion about the systems
functioning:
Logistic
Good (G) Regular (G) Good (G) Regular (G)
Acquisitions
Good (G) Bad (Re) Good (G) Regular (G)
Transportation
Good (G) Regular (B) Regular (Re) Good (G)
Mantenance
Good (G) Bad (Re) Regular (Re) Good (G)
Staff management
Regular (Re) Regular (G) Good (G) Good (G)
Priority definitions
Yes
Yes
Yes
Yes
Source: Collective self administrated interviews at local and national level
P = Partial; G = Good; Re = Regular; B = Bad
In Costa Rica the staff management system is the lowest valuated. In
Guatemala there is the lowest perception about all the supporting systems,
specially the acquisitions and the staff management, in Mexico the
transportation and maintenance and in Panama the logistical system and
acquisitions system are the lowest valuated.
The funds of all countries are administrated and the project ejecution are
controlled by the PAHO´s national offices. Guatemala and Panama do not
receive the funds on time. The explanation on the delay is the fact that there are
countries that have delayed the ejecution, specially Mexico, so there is extra
money at the PAHO in Washington, which determines that the donator do not
send the funds. With the exception of Costa Rica, where the National
Coordinator (NAP) was not hired, the rest of the countries spend the funds
according with the budget (NCI, LCI).
In general, there are not big problems that can affect, in a significant way, the
management of the project. A common fact that affects the management in all
the countries is the lack of support by the superior levels. In relation with other
problems, they are different for each country: in Costa Rica the lack of
intersectorial and interinstitutional coordination, in Guatemala the lack of
supplies and the support of the superior level and in Panama the lack of
equipment and supplies and, in the beginning, the lack of support by the
superior level, but at the moment of the evaluation it already improves. (Table
20).
Table 20. The most important problems of the management of the project:
PROBLEMS
COSTA
GUATEMALA
MEXICO PANAMÁ
RICA
a. Lack of planification or No No
No
No
programming
b. Lack of leadership
No
No
No
No
c. Lack of coordination in the No No
No
No
team and with the other levels
d. Lack of intersectorial and Yes No
Yes No
interinstitutional coordination
(Sometimes)
e. Lack teams or supplies
No
Yes
No
Yes
f. Lack of the superior level Yes Yes
No
Yes
support
g. Lack of training in gerencia
No
No (Yes)
No
No
Source: Collective self administrated interviews at local and national level
Supervision and follow up
Because of the staff limitations, transportation and the long distances between
localities and the demonstrative areas, the number of recieved supervision visits
by the local levels are just a few. Eventhough, the local and the national level
teams have made an important effort to visit the localities.
Only Panama has a supervision guide at national level. All the local teams say
that there is not a supervision guide and report, but at national level three of the
four countries made a supervision report. Both levels in Mexico received written
feed back of the supervisions and only the local level in Guatemala and the
national in Panama, gave and received a written feed back.
The transportation and the supervision budget are the project fortresses, the
regular fol ow up meetings, the agreements and their follow up. The follow up
meetings are made monthly in all the countries.
Table 21. Supervision and follow up of the project activities
COSTA
GUATE-
MEXICO
PANAMÁ
RICA
MALA
Loc Nat
Loc Nat
Loc Nat
Loc Nat
Number of units visited
6 3
2 6
2 2
3 15
Number of visits to localities
12 8
2 6
6 6
3 15
Number of visits received
3 0
4 1
2 2
2 15
Supervision guide
No No
No No
No No
No Yes
Supervision report
No Yes
No Yes
No No
No Yes
Writting feed back:
Giving to supervised
No No
Yes No
No No
No Yes
Recibed by supervisors
No No
Yes Yes
Yes Yes
No Yes
Existence of the budget and Yes Yes Yes Yes
No No
No Yes
transportation
Regular follow up meetings
Yes Yes
Yes Yes
Yes Yes Yes Yes
Agreements in reunions
Yes Yes
Yes Yes
Yes Yes Yes Yes
Agreements follow up
Yes Yes
Yes Yes
Yes Yes Yes ND
Source: Collective self administrated interviews at local and national level
Technical Assistance
In general, the perception of technical assistance is good, with the lowest
average for the local level in Guatemala and both levels in Mexico (Table 22). In
Costa Rica, the local level, did not report the opinion about this aspect, but at
the national level they qualified as good the technical assistance received by
the regional level. In Guatemala the local level perception is regular, because "it
has not given in a continous way" (LCI), but the national level says that the
technical assistance is good. Mexico reports that the opportunity of the technical
assistance in both levels is regular. In Panama, the national and the local level
qualified the technical assistance as good in all aspects.
Table 22. Opinion about the technical attendance quality, received by the
local and national level
ASPECT
COSTA
GUATE-
MEXICO
PANAMÁ
RICA
MALA
Loc Nat Loc Nat
Loc Nat
Loc Nat
Relevance
ND 2
1 3
2 2
2 2
Oportunity
ND 2
1 2
1 1
2 2
Utility
ND 2
1 2
2 2
2 2
Quality
ND 2
1 2
2 2
2 2
Mean (SD)
2 1 2.25
1,75 1,75 2 2
Source: Collective self administrated interviews at local and national level
Very good = 3; Good = 2; Regular = 1; Bad = 0
Comunication and Coordination
There is an accurate internal coordination in the projects. There is at least one
technical meeting per month and in month before the evaluation, a meeting was
carried out in all the countries. In Costa Rica there are two monthly thecnical
meetings at local level. With the exception of the local level in Costa Rica, all of
them inform to the superior level, pick up doubts and control agreements (Table
23).
The coordination between projects is not as satisfactory as the internal one.
With the exception of Mexico that reports that they did not exchanged
information between projects in both levels, the rest of the countries report that
they have done it. All levels and national level in Mexico do not visit the web
page, intranet, the data base or reports. With the exception of Mexico, all the
national levels participates in the phono conferences, but only the local level in
Costa Rica participates in it. All of them know the other countries experiences,
and in exception of the local level in Guatemala, everybody has adapted the
experiences from the other places and countries in the project (Table 23).
The Regional Operative Committee meetings and the technical visits to
Honduras, Guatemala and Panama are the mechanisms used to know the other
experiences. The team from Guatemala remarks the experience with "nin" trees
(Honduras and Nicaragua), the seed fish, the communitarian participation
(Honduras and Mexico), the epidemiologic surveillance sytem in Nicaragua, the
work with small and big engineering environmental modification to control
breeding sites in El Salvador and the puppet shows in Costa Rica. Mexico
valuates the experience in Honduras, with the majors participation in the actions
with the demonstrative community.
The replied aspects are: the organization and communitarian participation
strategy, the puppets use, the larvae control of breeding sites (NCI, LCI), the
municipality vinculation through the sensibilization, meetings or workshops to
promote the project and to establish the pro-active col aboration links (Table
23).
Table 23. Evaluation of the internal and interprojects coordination
Internal
COSTA
GUATE-
MEXICO
PANAMÁ
RICA
MALA
Loc Nat
Loc Nat
Loc Nat
Loc Nat
Number of technical meetings per 2 1
1 1
2 2
1 1
month
Number of meetings during the 2 1
1 2
2 2
1 1
last month
Report to the superior level
No Yes Yes Yes
Yes Yes
Yes Yes
To Pick up doubts
No Yes
Yes Yes
Yes Yes
Yes Yes
Control of agreements
Yes Yes Yes Yes
Yes Yes
Yes ND
Interprojects
Information exchange with other Yes Yes
Yes Yes
No No
Yes Yes
projects
Access to the project´s web site
No Yes No Yes
No No
No Yes
Contributions to web site
No No
No Yes
No No
No Yes
Access to the project´s Intranet
No Yes No Yes
No No
No Yes
Access to the data base
No No
Yes No
No No
No Yes
Access to reports
No Yes Yes Yes
No No
No Yes
Fono conferences participation
Yes Yes No Yes
No No
No Yes
Know about the other countries Yes ND No Yes
Yes Yes
Yes Yes
experiences
The experience information from Yes ND No Yes
Yes No
Yes Yes
other countries has been used
Source: Collective self administrated interviews at local and national level, 2005
The coordination with some institutions from other sectors at the demonstrative
areas is very ample. They coordinate activities of cases clinical management,
prevention, training, information and communication. It is reported a medium
high level of coordination and prevails the relation in the technical aspect. The
integration mechanisms are also vary, but the meetings prevail. In the Table 24
the most important institutions are presented.
The mechanisms that have used to formalize the relations are the letters of
agreement, committees and agreements (Table 25).
Table 24. Activities, coordination level, type of relation and integration
mechanisms from othe institutions that work at the influence area of the
project.
INSTITUTION
ACTIVITY
COORDI-
TYPE OF
INTEGRATION
NATION
RELATION MECHANISMS
LEVEL
GUATEMALA
Cuban Brigade
Diagnosis and treatment Medium
Technical,
Committees,
ONG´s
chats
Medium
Training
meeting,
communitarian
Health in Action Promotion, prevention,
level coordination
Proyect, ASDI
diagnosis and treatment
High
Technical
Meetings
and Global
Fund
PANAMA
CSS, private
Epidemiological
High Technical
Coordination
health facilities
Surveillance and
treatment suministro
COSTA RICA
Caja Seguro
People attention and
Medium
All
All
Social
epidemiological
surveil ance
Municipy of
Diffusion and
Low
Logistic and
All
Salamanca
comunication; didatic
technical
materials; Supplies for
operators and some
resources
MEXICO
State Secretary Operation and
High Logistic
and
Coordination to
of Health
coordinated participation
technical
superior level
Source: Collective self administrated interviews at local and national level
Type of relation: financial support, technical, logistic, training, none, others
Table 25. Created mechanisms to formalized the relation with other
institutions
INSTITUTIÓN
MECHANISM OF FORMALIZATION
GUATEMALA
Health Action
Agreement letters
Global Fund, Médicos en Acción, ASDI y Have not been formalized (activities
NGO´s.
invitation cards)
INCAP
Commitment letters
Plaguicides technical commitee.
Commitment letters
PANAMA
ANAM, MIDA, ADUANAS, MIGRACION
Comités
COSTA RICA
UNA/IRET
Intention letters
MINAE (Envoronmental Min.)
Agreements
MEXICO
State Secretary of Health
Agreement letters
Universidad Autónoma de San Luis Potosí Agreements
Nacional Institute of Public Health
Agreements
Source: Collective self administrated interviews at local and national level
Resources
In relation with the number of the health staff at the visited demonstrative areas,
only in Costa Rica there is an increase in the volunteers and microcopists. But
in the same country, there is discrease in the vector workers, during the five
year period. In the rest of the countries, there are no changes. In Mexico there
is an important increase of enthomologists and in Guatemala, even it does not
present a number in the self administrated interview, during the observation visit
it was shown the presence or this resource; in the rest of the countries one of
the lacks at the demonstrative areas is the absence of this kind of staff.
Table 26. Health Staff changes at the demonstrative areas
Years
COSTA
GUATEMALA
MEXICO PANAMA
RICA
No Rl
No RI
No Rl No Rl
Number of volunteers
2001 3
2
349
0
2003 3 1,0
2 1,0
349 1,0 0
2005 10 3,3
2 1,0
349 1,0 0
Number of
2001 0
4
1
microscopists
2003 1 1,3
4 1,0 1 1,0
2005 2 1,5
4 1,0 1 1,0
Number of
2001 0
9
0
entomologys
2003 0
12 1,3 0
2005 0
25 2,1 0
Number of vector 2001 25
1
control workers
2003 18 0,72
1 1,0
2005 16 0,88
1 1,0
Source: Collective self administrated interviews at local and national level
In general, during the last five years there are no important increases at the
health demonstrative areas of the project. In Costa Rica has been created a
clinic and in Panama, a laboratory in a hospital during the ejecution of the
project. It´s important to notice that there are just few hospitals or ambulatories
facilities with laboratories.
Table 27. Changes in the number of health services at the demonstrative
areas
Services
Years
COSTA
GUATEMALA MEXICO PANAMA
RICA
No Rl
No Rl
No Rl No Rl
Number of clinics,
2001 2
1
ND
4 1
hospitals or "A" Health 2003 2 1
1 1
ND
4 1
Centers
2005 3 1,5
1 1
ND
4 1
Number of hospital beds
2001
30
ND
2003
30 1
ND
2005
30 1
ND
Number of clinics with 2001 1 1
1
ND
3
laboratories
2003 1 1
1 1
ND
3 1
2005 1 1
1 1
ND
4 1,3
Number of ambulatory 2001 8
0
ND
16
services
2003 11
0
ND
16 1
2005 11 1
0
ND
16 1
Number of ambulatorio 2001 0
0
ND
1
services with laboratory
2003 0
0
ND
1 1
2005 0
0
ND
1 1
Source: Collective self administrated interviews at local and national level
Increase reason(Rl): 2003= 2003/2001; 2005= 2005/2003
1= no variation; < 1 = reduction; > 1 = increase
2.2.5 Intersectorial coordination policy and conection with other
projects
The presence of the Commission of Environmental Cooperation for America of
the North (CCA) in the Steering Commitee and the Comisssion for the
Environmental Cooperation for Development (CCAD), give multi sectorial
presence, but there is a recommendation to integrate an environmental
representant for this Committee, which is going to help to link this sector with
the project. The Steering Committee and the Operative Committee are ruled by
the agreement with PNUMA/GEF, eventhough it is recommended to extend the
participation of other actors, specially agriculture and environmental actors, to
make alliances and guarantee the sustainability (RCI).
The National Operative Committees have a much more multisectorial
constitution, with the participation of the Ministry of Environment and Agriculture
delegates, and also the delegates from different departments of the Ministry of
Health. Eventhough in all the countries is recognized that the presence of other
sectors, especially the environmental, is weak (NCI, LCI). Panama and Belize
said that one of the problems is that there is no participation of the
environmental national authority in the project, especially in the focal points of
the Stochholm Convention (RCI).
At the demonstrative areas level, the local operative team, is constituted by
health and vector staff, but in all the visited countries there is an effort to
improve the coordination and participation of the municipalities, universities and
other institutions related to environment and agriculture (PO).
Nicaragua has integrated the research centers of Leon University, (focal groups
of Stocholm Convention) and Mexico integrated the Universidad Autónoma de
San Luis de Potosí, the National Institute of Public Health, the Institute of Health
and Demography and the Universidad Nacional Autonóma de Mexico (UNAM).
To these efforts, is necessary to establish the roles of the different partners in
the project.
The Major of Talamanca (demonstrative area in Costa Rica) was invited to the
Regional Operative Committee meeting. The Major said how important is the
community and municipalities participation as community representants; he
affirmed that is necessary to support the malaria control strategy. He also said
that the municipality can support the malaria and dengue control campaign. The
major also offered to create a commission for malaria and dengue at the
municipal level, and to introduce the development plan against malaria in the
area, with topics as: land use regulation, legislation for the control of breeding
sites which is one of the weak points identified in Mexico and also the
infraestructure to allow the elimination of the breeding sites in a long time term
(RCI, PO).
In Guatemala, the municipality participates in the project through the
Development Municipal Council (COMUDE) meetings, the Health Municipal
Comision and through the health meetings.
"These health meetings are integrated by the local representants of all
the communities which form the municipality. It is chaired by a member of
the municipal corporation and priority health problems are disscused; the
communitarian leaders are incorporated at the project activities at this
forum. At the local level, this project is lead by the local power, which is in
charge of the prevention and vector control activities" (LCI).
In Panama, the municipality participates in technical and operative meetings. In
Costa Rica, the municipality gives the logistic support and also the educative
material and some of the supplies to manage malaria at the demonstrative
areas. The participation "was small at the beginning, currently the Major is
sensible with the project and with the problem of vector illnesses and we create
the Council Comition Againts Malaria and Dengue" (LCI).
In Costa Rica, the municipality have not given money, the MOH and community
resources have been used; the municipality just gave money to the health fair.
In Guatemala and Panama, the municipality and specially the auxiliary majors
or the corregimiento representantes (RCI) are involved in the project. In Mexico,
they support the prevention activities (limed, tools for communitarian work) and
promotion of the participation in surveillance (they use the volunteers net to take
samples), treatment (fulfillment of the treatment schemes), communitarian
preventive work and in the family hygiene and house cleaning. In Honduras, the
Majors have signed agreement letters to be able to transfer funds in the local
level and to make environmental interventions; the funds are manage by a
tripartite commission (the Major, a Representative of the Civil Society and a
Representative of the Health Secretary of the local level).
One of the most important difficulties to apply the control strategy in the area
and specially in Costa Rica, is that there are a high immigration flows, that
according to the interviewed, it requires a coordination between the risponsable
entities for agricultural development, Caja de Seguro and municipalities. With
Panama is important to homoginise the treatment schemes. Honduras, at the
Regional Operative Committee meeting report, says that inter programmes
meetings, community meetings and agreement letters between municiaplities
have been made.
In general, the participation of the private sector, specially the private
companies, is minimal. Mexico says that the private sector participates at the
community participation promotion (to encourage the participation in the
communitarian work for the family and house transmission control). In Costa
Rica there is a good participation specially of the banana business men, who
are integrated to the health committees at the affected areas
"the banana plantations of the area make environmetal actions to control
breeding sites at their water chanels and they cooperate with the Malaria
Card obligatiory law" (LCI)
"they will cooperate with resources (financial) and they also pay the
availability of some staff to support the programs at the health areas"
(NCI).
Guatemala and Mexico, Panama and Costa Rica have border demonstrative
areas. There have been made inter border meetings in Guatemala and Mexico,
but they did not agreed joined activities. Between Panama and Costa Rica,
exists the Technical Cooperation Proyect (TCC), agreements between health
ministries of both countries, there have been made technical operative meetings
and joined activities for integral control. They also give treatment supplies loans,
and attention to patients in both borders without caring abouth the nationality.
From the four visited countries, only Guatemala has a Global Fund Project to
control malaria, but the demonstrative area of Oaxaca is not included in the
project, but Alta Verapaz is. This project began two months before the
evaluation visit. The NAP is part of the technical group and part of the MCP by
the PAHO. The PAHO just invited the Global Fund participate in the regional
meeting made in Costa Rica.
In relation with the intersectorial coordination achievements, Costa Rica is the
country wich reports more achievements. It is common for all the countries the
joined programming, the consultancy and the technical and political support.
(Table 28)
The most important problem about the interinstitutional coordination in Costa
Rica is the lack of interest of the Ministry of Environment. In Guatemala the lack
of interest of the health administrative service, the lack of leadership or
iniciative, the lack of support by the superior levels and a lot of leader levels at
the Ministry of Health. Mexico and Panama do not report problems (NCI, LCI).
Table 28. Achievements with intersectorial coordination
ACHIEVEMENTS
COSTA
GUATE-
MEXICO*
PANAMÁ
RICA
MALA
Joined programming
CCSS,
COMUD
CENAVECE
ANAM, Costoms,
PAHO,
E
CCAAN
Migration, MIDA
Municipio
(Yes)
UASLP
Financial support
CCSS,
CENAVECE
PAHO
SSE
Municipio
Consultancy and technical support
PAHO,
(Yes) CENAVECE
ANAM
CCSS
SSE
Supply and material help
PAHO,
Municipalities
CCSS
Political support
Municipio
(Yes)
SSE
Municipality and
corregimiento
represenatives
Malaria Epidemiological Surveillance
CCSS
ND
MINSA and CSS
Source: Collective self administrated interviews at local and national level
* Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades (CENAVECE),
Comisión para la Cooperación Ambiental de América del Norte (CCAAN), Univ Aut. San Luis
Potosí (UASLP), Secretarias de Salud Estatales (SSE)
2.2.6 Community and Social Participation Policy
All the interviewed report that there have been changes at communitarian and
social participation policy and at the volunteers, health promoters and the
community training (Table 29).
Table 29. Changes the politic of communitarian and social participation
SOCIAL OR COMMUNITARIAN
COSTA
GUATE-
MEXICO PANAM
PARTICIPATION
RICA
MALA
A
Loc Nat
Loc Nat
Loc Nat Loc Nat
Polithic and strategy of
Yes Yes Yes
Yes Yes Yes
communitarian and social cooperation
and participation.
Volunteer, health promoters and Yes Yes Yes
Yes ND Yes
community training.
Source: Collective self administrated interviews at local and national level
In fact, in all the visited demonstrative areas there is an important involvement
and movilization of the community in the project and an active participation in
the control activities, especially at EHCA activities. The visited leaders, the
teachers and the community members, say that the project has made them
realized about the relation between malaria cases with the presence of breeding
sites, the clean houses and patios and the cleaning habits. They are also
capable to identify the malaria symptoms (LI).
As the project advances, in Panama, for example, the leaders recognize how is
the malaria transmission, which are the signs and symptoms and "they have
realized how to avoid malaria and they hope to have a free malaria community
without using insecticides". This perception has been created because of the
quick results, reached with the developed activities (LI, PO).
In all the countries, women have a principal role at the EHCA activities. In
Talamanca, Costa Rica, there was just one man participating in the cleaning of
one stream (PO). In each country, the communitarian teams for malaria control
have a different origin and insertion. In Panama, where the localities are mainly
indigenous, the government created the Indigenous Comarca, with their own
government. At the comarca, a meeting was carried out with the Regional
Congress Ngöbe Buglé from the Bocas de Toro region (june 2004), all the
communities attended the meeting and they made a big assembly, where a
person to lead the Antimalaria Committee was designated (PO).
At the native communities there is a big quantity of committees: for education,
water, the comuna president, corregimiento representants, the native congress,
the health committees, the local assemblies, the environment coordinators,
family representatives, etc. Most of these committees are leaded by adults.
Eventhough, the malaria control committee in Barranco Montaña Adentro, is
constituted by young people and leaded by a young woman (PO).
At the communities in Panama, there are also authorities with the capacity to
give fines, as the "Corregiduría" which is a legal communitarian institution linked
to the local government (Municipality). According to the antimalaria committee
members, sometimes they do not give the fines so they are not going to create
enemies. Another institution is the corregimiento representatives, who are in
charge of the funds distribution to support communitarian activities (PO).
In Panama, the local point of the Comarca Ngöbe Buglé and also the present
leaders at the evaluation meeting, say that they are proud because the project
is always made without resources. They agree that the used strategies not only
help to discrease the presence of mosquitos, the strategy also helps with the
hygiene (LI). One of the problems that the communitarian leaders in Panama
remark, is that because that is a community without farmers, there is a lack of:
resources, health staff and communication media that difficult the job of the
malaria inspectors (LI). An important aspect is the fact that communitarian
leaders, even when they work in malaria control, they should support other
health problems. Some of them think that there are more important problems,
as lack of food and work, to solve (Panama) (LI).
The communitarian organitazation in Guatemala is strong. After the armed
conflict, the demonstrative areas were strengthen with a strong legal base,
which was saw during the field visit. The communitarian participation is big.
There are elected auxiliar majors in each community, elected by direct vote.
These majors have funds to support the most important activities in the
community. The vector staff gives technical support, training and works together
with the communities in the vector control activities (PO).
In Mexico, the EHCA activities are developed by the families which receive a
scholarship for their children, as a part of the government program
"Oportunities". When the beneficiaries receive this scholarship, they must make
communitarian work. Because of the wrong information, given by a project
coordinator, about that the families did not have to work at the activities to
control malaria, the communitarian participation was weak. A lot of people
denied their participation at the EHCA activities because they have not received
the scholarship, so they do not have the obligation to do it (PO).
There are a lot of information, education and comunication experiences (IEC)
developed at the demonstrative areas. Theater plays, puppet shows, posters,
brochures, t shirts with the no insecticides use promotion have been elaborated
(Guatemala). Training courses and workshops have been made, too. The IEC
activities have been linked to the communitarian holidays, as an example in
Panama, at the Bisira locality, the "Cleaning Queen" is elected (LI).
Although there is a great creativity and enthusiasm by the sanitation workers,
the health staff have not been trained at the IEC activities, to evaluate and to
systematize the experiences.
In relation with the schools participation, in all the demonstrative areas and
specially in Guatemala and Costa Rica there is a good participation of teachers
and students. Puppet shows (Costa Rica) and theater plays have been made at
the schools and also some health fairs for the children. In Panama, teachers
and students heve been trained at the demonstrative area of Bisira (PO).
Tecahers and students have been trained about the malaria transmission,
which are the symptoms and signs and about how to control the transmission
with the houses, patio and streams cleaning at the nearest places. Until this
moment, the community, teachers and students know about the relation
between mosquito and malaria breeding sites, the malaria characteristics and
its treatment. The result is "even the children know that when they have fever
and shiverings they should be taken to the health centers" (LI: Communitarian
leader of Guatemala)
In relation with the use of insecticides to control malaria, some communitarian
leaders in Guatemala, say that they do not like the application because
sometimes they have dermatologic reactions as itching. In all the visited
countries, the communitarian leaders realize that the DDT and persistent
insecticides use can have advers effects, so they agree with the control
strategies of the project.
In all the visited localities, they have maps with information about new and
repeated cases, malarious houses and positive breeding sites. The vector
workers in Mexico and Panama use them at the communitarian situation rooms.
It is important to remark that, thanks to the experimented development in
Guatemala made by the GIS, it has been used to make a communitarian
situation room. One of the communitarian leaders was capable to analyze a geo
referenced map of his community.
All the interviewed (in both levels) says that there is a policy and a strategy of
social and communitarian partipication. In Guatemala "there is a strategy which
involves the COCODES, COMUDES, CODEDES. That means communitarian
councils from the local level to the central level, these are government policies".
The documents are available at http://www.ops.org.gt/ADS/San/san.htm (NI). In
Mexico there is the Official Mexican Normative for the Vector Transmited
Disseases Program.
In all countries, volunteers and communitarian leaders support the opportune
diagnosis and treatment. For two of the countries, is common the organization
of the Health Committees, but in Guatemala there is an important participation
of the Development Community Councils (COCODE), which gives and strategic
advantage, that allows to introduce the malaria policy in the communitarian
development plans. There are disagreements between the national and the
local level, because the local level reports that there are no volunteers and
health promoters (Table 30).
In relation with the strategies to know and to answer the claims of the users
involvement, the local level of Guatemala reports that it does not exist, while the
national level says that it does exist. Costa Rica did not aswer these questions;
Mexico and Panama had a positive answer in both levels.
In Guatemala, Mexico and Panama, both levels answer that there are strategies
to evaluate the quality and to increase the community sensibility. To evaluate
the quality of the services, there are indicators at the monitoring and supervision
system. In Guatemala it is made every week when the situation room is
updated, through the health table meetings and the social auditorium which use
the user interviews to determine if the health services are qualified (Table 30).
In Mexico, the training is strength (communitarian informative and educative
worshops, common assemblies), increase of the field visits with support for
communitarian activities, link of the teachers and other local health institutions.
The used mechanisms to know and to answer the user and patient claims of the
program are: the CAP study and the SWOT analisys in the base line, in Mexico
there are also polls and interviews of the services acceptance by the users. To
involve the users to the program activities, there has been used the existent
organizative strucutures, meetings and capacitations (Table 30).
At the national level in Costa Rica and both levels in Guatemala answer that
there are mechanisms for the communitarian participation: "When the
community is concentrated to participate in the health mesa, transportation and
alimentation costs are given, and sometimes lodging" (LCI). Just the local level
in Guatemala reports that they have a communitarian financial strategy:".
To increase the population sensibility toward the program, the training meetings
are used. In Guatemala, Mexico and Costa Rica there has been sensibilization
meetings with the population and socio dramas and puppet shows at the
schools, but also at the periodical visits to the communities.
In relation with the perception of the communitarian participation level, Costa
Rica and Guatemala qualified it as medium, Mexico as inter medium and
Panama as high. In relation with the activities with the communitarian
participation, all the interviewed answer about the participation in planification,
acitivities ejecution and in the home improvement and breeding sites control.
The participation in diagnosis and treatment, evaluation activities and in the
guide's creation is the weakest in all the countries. A positive aspect is that
because of the free services in all the countries, the communities do not support
with materials, transportation or economic contributions.
Table 30. Politics, strategies and activities for social and communitarian
participation
SOCIAL AND COMMUNITARIAN COSTA
GUATE-
MÉXICO
PANAMÁ
PARTICIPATION
RICA
MALA
Loc Nat
Loc Nat
Loc Nat
Loc Nat
Politic written definition politic and
Yes Yes
Yes
Yes Yes
Yes Yes
strategy
Mechanism/organization
Volunteers
Yes Yes
Yes (302)
360
No Yes
Communitarian agents
Yes Yes
0
49
No Yes
Health promoters
No Yes
0
409
Yes Yes
Health Committee
Yes Yes
0
49
Yes Yes
Notification teams
Yes
Communitarian councils of
Yes
development.
Strategies:
To know/answer claims
NR
No Yes
Yes Yes
Yes Yes
To involve users
NR
No Yes
Yes Yes
Yes Yes
To evaluate the quality
NR
Yes Yes
Yes Yes
Yes Yes
To increase the sensibility
NR
Yes Yes
Yes Yes
Yes Yes
Mechanisms to promote the
No Yes
Yes Yes
Yes Yes
No No
participation
Communitarian Funding
No No
Yes No
No No
No No
Level of communitarian participation
Medium (M) Medium (M)
Inter. (In)
High High
Activities
Guides creation
No No
No No
No No
No No
Priorities identification
No Yes
Yes Yes
Yes Yes Yes Yes
Solution identification
No Yes
Yes ND
Yes Yes Yes Yes
Activities programming
Yes Yes
Yes Yes
No No
Yes Yes
Activities ejecution
Yes Yes
Yes Yes
Yes Yes Yes Yes
Diagnoss, treatment
Yes No
No Yes
No No
No No
Materials and transportation support No No
No No
No No
Yes Yes
Economic contributions
No No
No No
No No
No No
Home improvement
Yes Yes
Yes Yes
Yes Yes No No
Breeding sites control work
Yes Yes
Yes Yes
Yes Yes Yes Yes
Communitarian education Program
Yes Yes
No Yes
Yes Yes Yes Yes
activities evaluation
No No
No Yes
No No
ND Yes
Source: Collective self administrated interviews at local and national level
The demonstrative areas of the four visited countries, have indigenous grups: in
Guatemala the Q'eqchi, Uspanteco and Achí; in Costa Rica the Bribrí and
Cabécar; in Mexico, at the southeast region: Mayas Lacandona, Tzotzil, Tzental
in Chiapas, Zapoteco and Mixtecos in transition in Oaxaca, in the northwest
region: Coras, Tarahumara in Chihuahua. In Panama, the Gnöbe Buglé. In
Costa Rica, at the demonstrative area there are indigenous groups at the high
region of Talamanca, "they are not directly affected; but the problem is the
native groups of Panama because they come to work at the banana plantation
area of Sixaola" (LCI).
The services are not designed, created or modified to adapt them to each
ethnical group yet. With that purpose there is going to be a workshop in Bisira,
at the Panama side, on December 7 of 2005. In all the sites, the health staff
speak the native languages, but just in Panama and Mexico have adapted the
information, communication and educative materials to the native culture and
langagues (LCI).
Although in the base line there have been included variables to identify the
knowledge, actitudes and practices of the population about malaria, it does not
include questions about the perception or acceptance about the insecticides
use, specially the persistents insecticides (LCI).
According to the interviewed people, the most important achievements by the
communitarian participation are:
In Guatemala "They have made the project as their project and contribute
to adress in the impact of decrease malaria without chemical use" (NCI)
and "A high level of community participation have been reached to
prevent and control malaria. The population knows better the
transmission ways and vector behaviour. The population begins to know
the most important risk factors", "... the communitarians have learned to
defend theirselves against the vector by the cleaning of breeding sites
and the vegetation around the houses" (LCI).
In Panama, the "Creation of the Communitarian Committee of work and
the environmenatl interventions with the participation of the community"
(LCI).
In Costa Rica "the sensibilization achieved about that Malaria is a
community problem" and "The response to organize volunteer groups"
(LCI).
In Mexico "the recognition of a wealthy and diverse culture at the rural
communities deserves understanding and repect in order to achieve a
shared responsibility program-community, for surveillance and prevention
of the malaria transmission in Mexico" (LCI).
The principal problems of the communitarian participation, by the interviewed,
are:
In Guatemala "they have participated but they feel that they are loosing
time of work so their economy can be affected" (LCI) and "the credibility,
because of there have been a lot of proposed projects that never were
achieved. The indifference, we have some groups which are not involved
yet" (NCI).
In Panama, "by the moment there are not important problems about
communitarian participation, they only ask for the company of the health
staff" (ECL y ECN).
In Costa Rica, "the lack of resources and the follow up and coordination
because of the lack of qualified staff. The human group at the health
demonstrative area is small" . (NCI) And "the perseverance and
continuity of the participants" (LCI).
In Mexico "Decrease in the disease transmission, diversity, culture,
language, vertical dependence that the program keeps and the lack of a
communication model suitable to the behaviours or local culture" (NCI).
2.2.7 Base Line, Information system and Indicators
Base Line
The creation of the guide allows to standarize the base linea procedures and
also to obtain information for the final evaluation of the project.
In Guatemala, the base line was made with the community representatives
colaboration, and the discoveries were discussed by them. In the advance
reports, the countries declared that they have used the results of the base line
to guide the intervetion and the adaptation to the local reality. Eventhough,
Guatemala´s and Panama´s reports do not present a discussion, a conclusion
and recommendations that allows to realized how they used the base line
information.
Surveillance and information system
Both levels in Mexico and the local level in Guatemala and Costa Rica, report
the existence of monitoring and evalution sytems, supervision, epidemiologic
surveil ance and updated situation room. Mexico does not have a computer
program to process data, but Costa Rica and Guatemala have it. The national
levels of both countries say that they do not have the updated situation room
(Costa Rica) and the surveillance system (Guatemala). In Panama, while the
national level answer that they have all the elements just described, the local
level says that they do not have the monitoring and evalution system and the
situation room updated (Table 31).
In relation with the the computer programs, Costa Rica uses FOX base, GISEpi
and Excel; Guatemala uses EpiInfo y GISEPI and Panama uses Epi-Info and
GIS-Epi. In Panama and Costa Rica, data bases have been elaborated in
EpiInfo or Excel, but they do not have an specific computer program to process
and analyse data (NCI, LCI).
In relation with the information use, the national and local level in Costa Rica
and Guatemala, the local level in Mexico and the national level in Panama
report the use of it in all the investigated variables. But the local level in Panama
and the national in Mexico say that they do not use the information in none of
the aspects (Table 31).
All countries, in both levels, have: a methodology to divide and to identify
epidemiologic risk areas, a geographic information system and they exchange
the information and experiences. Only the Costa Rica national level says that
they do not have the methods to indentify and to predict outbreaks or epidemics
yet; at the local level, this country, does not prepare with a systematic way
plans of contingency; the rest of the interviewed countries have a positive
answer.
Table 31. Information and Surveillance system
VARIABLES
COSTA
GUATE-
MEXICO
PANAMÁ
RICA
MALA
Loc Nat
Loc Nat
Loc Nat Loc Nat
EXISTENCE
Monitoring and evaluation
Yes Yes Yes Yes Yes Yes No Yes
Program supervision
Yes Yes Yes Yes Yes Yes Yes Yes
Epidemiologic Surveil ance
Yes Yes Yes No Yes Yes Yes Yes
Situation room updated
Yes No
Yes Yes Yes Yes No Yes
Program of procedure
Yes Yes Yes Yes No No
Yes No
USE OF THE INFORMATION
Identification of risky families or groups Yes Yes Yes Yes Yes No No Yes
Mapeo de Riesgo
Yes Yes Yes Yes Yes No No Yes
Caracterización de nivel endémico
Yes Yes Yes Yes Yes No No Yes
Selección medidas de control vector
Yes Yes Yes Yes Yes No No Yes
METHODOLOGY AND
COMPONENTS
Methodology to divide/identify risky Yes Yes Yes Yes Yes Yes Yes Yes
areas
Methodology toidentify and to predict Yes No Yes Yes
Yes Yes
outbreaks or epidemics
Geographical information system
Yes Yes Yes Yes
Yes Yes
Systematic preparation for contingence No Yes Yes Yes
Yes Yes
plan
Information and experiences exchange Yes Yes Yes Yes
Yes Yes
Source: Collective self administrated interviews at local and national level
2.2.8 Indicators
The Handbook defined the basic indicators of reference at Anex 12. The list of
indicators is exhaustive and it covers procedures, products, results and the
impact. Only Mexico has developed a monitoring and surveillance system,
which includes all the basic indicators of reference. In the rest of the visited
countries, they are developing the monitoring and surveillance sytems, but it
does not includes all the suggested indicators. It is evident, that in all the
countries, because of the lack of human resources, it is not possible to col ect
all the suggested information. With the exception of Mexico, all the countries
have not unified the formats to col ect the information, specially the ones
recommended at the Anex 7 of the Handbook.
Of the proposed indicators of the guide, the ones which are being used by the
visited countries are: malarious houses, repeated cases (more than one febril
event in a person), positive breeding sites, controlled breeding sites, Annual
Parasite Rate (API). In Mexico and Guatemala, the larvae index by larvae stage
is reported before and after the intervention (PO).
One of the most important indicators which are used by the communitarian
promoters of the EHCA in Mexico, are the evaluated positive breeding sites by
the number of positive takings, where it is not necessary to difference between
the stage and type of larvae (anopheline, aedes o culex). This indicator is used
in the before and after evaluation of the EHCA activities carried out every two
weeks or monthly (PO).
The larvaria density as a predictive indicator (API) was ratified by Nicaragua in
a study which reports a strong association between density and incidence
(OR=3.5; p value < 0.05). This is an easy indicator, which in Mexico is made by
the community members, but mechanisms to identify the realation between
larvaria density and malaria cases have not been created yet (PO). Another
easy indicator, used by Mexico, is the percentage of localities and families
participating at the EHCA activities, which can be associated with the before
and after evaluations results and the presence of new cases.
All the base line reports the API before 2004, and in the advance reports the
2005 API is also reported. This is an important impact indicator, available in all
the countries, but it is not wel used, because it compares an annual API (2004),
with a 7 or 8 months partial API.
In Mexico, where the strategy has been introduced since four years ago, there
are free transmission communities in the last years, that is why they are
working to identify indicators in order to certify free transmission areas. It has
been discussed the kind of use that this indicator can have in these areas,
because it is a predictive indicator, which al ows to introduce the prevention
concept in the communities.
Impact Indicators
Because the project began just in the last 6 months its activities at community
level, it is not possible to measure the impact. Eventhough, there are some of
the indicators which can be used to measure the impact and it is made by the
analysis of its behavior at the demonstrative areas in Panama and Guatemala,
to illustrate its importance.
In Guatemala there is a trend to decrease the non standardized API between
2001 to 2003 and 2005 (Increase reason 0,4 to 0,8). But when the standarized
API is analyzed by the screening effort there is a decrease from 2001 to 2003,
but there is a slight increase from 2003 to 2005. But in Panama there is an
important increase of APIs from 2001 and 2003 and a slight decrease from
2003 to 2005, which is significant if hurricanes are counted during the five year
period. Mexico reports an API decrease from 2001 and 2004, but analizing the
standarized API there is a significant increase from 2001 to 2003 and then a
slight increase from 2003 and 2004. None of them report API in children less
five years old, which is important to decide the convenience of the impregnated
bednets use. This increase can be explained by a remarkable rediction of the
transmission reduction, but also because of an incease in the positive blood
smear Index and as a result of the focalization of interventions at the
communities with persistent malaria and malarious houses. It is expected a
remarkable reduction of crude and standarized APIs at the end of the project
(Table 32).
None of the three countries report minor API in five years, which is important to
decide the convinience of using mosquito nets pre impregnated with
insecticides (Table 32). From the three countries that sent the information, ther
is only one dead person in 2001 and 3 in 2003 in Panama, but none in 2005,
even when the P. falciparum increased. An important impact indicator is the
absence of deaths during 2005 in the three countries. This last fact is also
important, because the death and severe cases risk are increasing in Central
America, as well as the possibility of resistence to cloroquina, as it happened in
South America. Mexico reports a few malaria cases by P. Falciparum in
immigrants.
Table 32. Malariometric Indicators
ACTIVITIES
Years
GUATEMALA MEXICO
PANAMA
No RI
No RI
No RI
Non Standarized Annual Parasite 2001 66,2
1,05
2,98
Rate (API)
2003 28,2 0,4
0,51 0,48 14,3 4,8
2005
21,5 0,8
0,91 1,78 10,4 0,7
Annual Parasite Rate (API)
2001 66,2
1,05
6,0
Standarized
2003 37,1 0,6
24,87 23,6 13,2 2,2
2005
39,5 1,1
46,67 1,8* 8,9 0,7
Annual Index of IAES
2001
23,2
3,3
4,9
2003
17,5 0,8
0,7 0,21
5,3 1,1
2005
12,6 0,7
0,6 0,85* 5,7 1,1
Positive láminas Index (ILP)
2001
26,5
3,16
0,6
2003
16,1 0,6
7,46 2,36
2,7 4,5
2005
17,1 1,1
14,0 1,87* 1,8 0,7
% Falciparum
2001
2,4
0,07
4,2
2003
5,4 2,4
1,9 26,6
13,9 3,3
2005
52,9 5,4
0,3 0,19* 56,2 4,0
Pluviosidad annual average at 2001
600 800
152
demonstarive areas
2003
600 800
165 1,1
2005
300
600 800
165 1,1
Floods or hurricanes in demo areas 2001
No
0
2003
No
2
2005
Yes
3
Source: Collective self administrated interviews at local and national level, * 2004 Data
Another available indicator, from two of the four countries, is the percentage of
positive localities and the high risks localities (more that 10 cases). In
Guatemala, the high percentage of positive localities contrast with the low
percentage in Mexico. In Guatemala, the percentage of positive localities in high
rik is also high, compared to Panama and Mexico, which is not higher than
10%. In Guatemala, even when there is not a decrease of the positive localities
percentage, there is a slight decrease in the percentage of the high risk
localities (Table 33).
Table 33. Number and percentage of positive and high risk localities of
malaria transmission.
ACTIVITIES
Years
GUATEMALA MEXICO
PANAMA
No RI
No RI
No RI
Total of positive localities
2001 159
ND
7
2003 169 1,1
12,247*
7 1,0
2005
181 1,1
ND
7 1,0
Total localities
2001
184
ND
76
2003
182 1,06
199,391*
76 1,0
2005
181 1,07
ND
76 1,0
% of positive localities
2001 86,4
ND
100 1,0
2003 92,8 1,07
6,1*
100 1,0
2005
100 1,07
ND
100 1,0
% of high risk localities and total of
2001 94,3
ND
9,2 1,0
positive positive localities
2003 85,2 0,9
2,6*
9,2 1,0
2005
65,2 0,7
ND
9,2 1,0
Source: Collective self administrated interviews at local and national level
High risk locality = more than ten cases per year. * 2004 Data
Cost Effectiveness Indicators
With the exception of Mexico, there is not a col ection of information at the
demonstrative areas to get cost effectiveness of the interventions. The
information sent by Guatemala have mistakes about the number of the
necessary hours per square meter of cleaning borders at breeding sites.
Based on the following basic components presented by Mexico there is a cost
estimated to protect 1000 houses, comparing EHCA with indoor spraying. The
established parameters are the number of hours needed to clean or to modify a
linear meter of river-basin, a square meter of breeding sites and a clean house
and patio. Taking in mind that the salary for a 8 hours working day in the study
area is USD 4.5, the estimate cost is 0.56 per hour. This cost was multiplied by
the number of meters and houses. For each house it was estimated 10 meters
of linear river-beds and 10 square meters of breeding sites. To be able to
protect 1000 housesit´s required USD 6900, without taking in mind the cost of
human resources and transportation.
Although is necessary the study of cost effectiveness, it is evident that the
investment in EHCA is much lower than the spending of intramural residual
treatment and space treatment.
Table 34. Estimated cost of activities for physical and bilogical control of
the breeding sites
EHCA
Hours Cost
Supplies
Reached Total
meter
hour
by meter Coverage Cost
man
or
(meters or
house
houses)
Clearing or modification of river-
0.1
0.56
0.056
10000
560
beds (linear m.)
Chapeo of breeding sites
0.3
0.56
0.17
10000
1700
borders (m3)
Clean houses and clean patios
4
0.56
2.24
1000
2240
Total
4500
INTRAMURAL RESIDUAL
Kg x Cost x Cost x Coverage Total
TREATMENT
house Kg
house
(houses)
cost
Houses 0.125
55
6.9
1000
6900
Geographic information System
In all the visited countries, the communities have been maped and
georeferenced, with malarious houses and cases of the last two years, special y
houses with repeated cases. Mexico, at the moment of the evaluation visit, was
beginning the process of GIS implementation at community level, but the field
workers and the communitarian promoters have elaborated maps with the
information before mentioned (PO).
The most important advances of the information system have been given at the
GIS development. In Guatemala, with the INCAP support, the local staff have
achieved useful applications to take decisions and to make inferences in the
relation between breeding sites and malarial houses (PO). Costa Rica and
Panama have also developed important applications. Panama counts with the
support of a geographer from the Conmemorative Gorgas Institute that
col aborates technically with the health staff at regional and local level.
These applications let see the power that the GIS has for the monitoring and
evaluation. In this sense, it is evident the capability that the vector and the
epidemiologic staff have reached to make epidemiologic analysis and helped by
the maps made in GIS at the demonstarive areas. In Guatemala, the important
advance in the GIS use has been favored by the presence of the INCAP
technicians (PO).
There have not been developed the GIS applications to make the monitoring
interventions (dynamic applications), but skills to introduce its use have been
developed (PO).
2.2.9 Sustainability and replicability: reached sinergies
Costa Rica, Guatemala and Mexico report the existence of sustainability and
replication plans in other areas. In Panama the sustainability and replicability
plan is in development (ECL, ECN).
Sustainability
Budget and own resources
In Mexico, the vector control program has its own budget and even the budget
has been reduced in the last years, the adoption of the strategy, which requires
small investments, guarrantee its sustainabilty. There is not a reduction in the
vector workers, because when a worker is retired, is replaced by a new worker,
which is used to redistribute the staff according to the needs. The opposite
happens in Panama and Guatemala, each year the vector staff is reduced
because of the workers retirement without a replacement. In Panama
volunteers have been hired in order to reduce the deficit at the demonstrative
areas, but this personnel can be fired at the end of the project (PO).
In Talamanca, Costa Rica, from two of the vector workers, one has a definitive
designation and the other one is hired. According to Health Area Chief, these
contracts are not renewed, which can affect the continuity of the actions (LCI).
Something important is that in Costa Rica there is an universal insurance and
there are cross subsidies so all the services are free, that does not happen in
Panama, where there are charges in the services, wich represents an outcome
for the population and it becomes a barrier of access for most of the population.
In Mexico and Guatemala, all the malaria control services are free.
The biggest menace for the project sostenibility is the deflection of the funds to
dengue control and the mitigation of storms and hurricanes impact (OP, ECL).
During the period from 2003 and july 2005 the national and regional counterpart
contribution was USD 1´445.617, the PAHO-WHO gave USD 317800 and the
countries 1´118.017. This high contribution is also a sustainability indicator.
Political support and institutional and communitarian empowerment
The four countries report that malaria is one of the three health problems or
illnesses that receive more financial and political support at the demonstrative
areas of the project. In Costa Rica occupy the second place next to dengue, in
Guatemala the third place and in Panama the first place (LCI).
In Costa Rica there is a National Emergency Law for malaria and dengue
Control that formalize the political support, but in Guatemala and Panama there
is not a formalization mechanism (ECL, ECN). According to the opinion of the
interviewed people at the visited demonstrative areas, because of the quick and
successful results reached and the communitarian involvement there is an
important institutional support of the local and national headquarters, specially
in the focal points (PO).
The relation between municipalities and their involvenment in the malaria
control is still incipient, but all the majors have said that they are interested to
participate actively at the project introduction (LCI).
Effort and structural limitations
According to the population and the communitarian leaders, the first intervention
to clean the breeding sites, required a big effort, but not at the maintenance
activities, that required a smaller effort, so these activities can be kept. The
problem are the extense breeding sites, which are difficult to control, because it
requires machines or infraestructura investments for chanels or permanent
drenage (LI).
At the demonstrative projects in Panama and Costa Rica, the problem to control
malaria is more important because of the floods, tropical storms or hurricanes,
that create huge breeding sites which are difficult for a communitarian
resolution. Another problem that can affect the sustainability, according with the
interviewed, is the temporary immigration, because of the introduction of new
cases and the difficulty to apply strategies to eliminate the human reservory of
plasmodium (TDU 3x3) (NCI, LCI).
According to the interviewed in Panama and Guatemala, an element which is
affecting the project sustainability and replicability, is the fact that in some of the
Central American countries there are haemorrhagic dengue epidemics that
deflect the attention and provoke financial and political support to this problem
and malaria is disregarded. For example, in Panama, the human resources that
can work in malaria, even at the demonstrative areas, ca not work regularly as
they should in a demonstrative project (NCI, LCI).
Risk and impact perception
By the fact of chosing communities with persistent malaria during the past 5 or
10 years, there is a high perception of risk about malaria and its effects in the
community life quality, the families and the people. In relation with the impact
perception, all the project partners said that the efectivity cost of the used
control strategies are better than the insecticide spraying (ECL, ECN).
Training and capability to integrate new technologies
The sanitation workers at the districts, the vector workers and the community
members have been able to absorb and to integrate new technologies for
control and information as the GISEPI.
Replicability
One of the mechanisms that the teams identify to reaply the strategy, is the
regional support and empowerment, so it has been established the need of a
regional council to define the regional guidelines and strategies, fol owed by the
national and local councils, where the regional guides can be implemented (LI).
In the case of Mexico, the project DDT-GEF is going to reinforce the
introduction of the strategy in the areas that have not been able to reduce the
malaria transmission, so the replicability of the project is proved in this country.
In Guatemala, the vector workers are spontaneously aplying part of the strategy
in the nearest areas of the demonstrative, specially the EHCA strategy (PO).
In Guatemala and Honduras is being ejecuted theGlobal Fund Proyec to control
malaria and in El Salvador was made a proposal for the five round. In
Guatemala there are efforts to coordinate activities at national level, eventhough
the Area Director of Alta Verapaz suspects that the Global Fund project
ejecution, focused in vector control strategies, can affect the ejecution of the
DDT-GEF project, and the other areas can lose the opportunity, that represent
the Global Fund Project, to replicate the strategy (LI).
CHAPTER 3
DISCUSSION, CONCLUSIONS AND
RECOMMENDATIONS
There was an initial delay because of the preparatory activities which were not
considered in the project design, these last approximately from six to eight
months. Effectively, the adaptation of the project to the financial processes and
mechanisms, of purchase and hiring to the realities of each country and
specifically to the purchase logic and the financial management of the PAHO,
took more time than the expected. For this reason, the most important
recommendation to the donors is to approve the extension of the project, not to
do it will make to loose the opportunity of having a model highly cost
effectiveness and replicable.
In the next sections the principal findings, the conclusions and the specific
recommendations are discussed.
3.1. PROJECT APPROACH
The project uses an echo system approach, with five elements that characterize
to this approach (Level, 2003):
1. A control and prevention strategy based in an epidemiological model of
health fields (Dever, 1991), that covers interventions on four fields: i) the
biological, with the clinical management of cases and the elimination of the
plasmodium human hostess, ii) the modification of lifestyles such as the clean
house, clean patio and improvement of the personal hygiene, iii) environmental
modification, through the EHCA interventions and the elimination of the use of
persistent insecticides, iv) the improvement of the provision of diagnostic and
treatment services, as wel as the integration of the general services in this
activity.
2. Multidisciplinary approach with the integration of several professionals from
different disciplines (doctors, biologists, nurses, educators, etc). Although, there
are weaknesses, there is also a multi sectorial approach in the intervention. The
projects in four of the evaluated countries, coordinate with the municipalities in
the demonstrative areas and carrying out inter sector works. However, the
"transdisciplinary" concept (Level, 2003) is still weakly adopted because very
few countries have integrated universities and investigation institutes in the
project. In Nicaragua, the Universidad de León has been integrated to the
investigation activities, in Panama the Gorgas Institute and at regional level the
San Luis Potosí University.from Mexico There are initiatives in Guatemala and
Mexico to incorporate the universities in the investigation activities, but these
are not formalized.
3. Community participation. In the project the community participation is
privileged as central axis of the vector control activities, but its participation in
monitoring activities, evaluation and accountability is still weak.
4. Equity. Due to the areas chosen as demonstrative are the ones with
persistence of malaria and most of them are rural areas with native population
highly vulnerable (critical poverty), the concept of social equity is accomplished.
Aditionally, the focalization of interventions at the malarious houses, allows that
most need people receives major interventions. However there are no
definitions, or policies of gender equity.
5. Environment protection, through the integral strategy for malaria control
without using persistent toxic substances.
RECOMMENDATION
It is necessary to strength the transdisciplinary approach:
1. Integrating Universities and investigation institutes to the operative studies;
2. Designing strategies, scenarios and instruments that allow the community to
participate in monitoring and evaluation of the interventions, particularly in the
pre and post evaluation of EHCA, clean house and clean patio;
3. Strengthening the participation of the municipalities, to insert the fight
against malaria in local development plans in the context of the Millennium
Goals.
It is necessary to integrate the community in the formulation of trimester plans,
monitoring and evaluation of the interventions.
3.2 STRATEGY AND CONTROL METHODS
The project uses a combination of control methods that cover al the necessary
effects to control malaria, surpassing the practices of the elimination period
centered in the insecticides use for the control of adult mosquitoes; in the
project it has been an accurate use of this method, limiting it to control of
outbreaks or epidemics. Even more, in Mexico and Costa Rica it has been
introduced a method to eliminate the human hostess of plasmodium, which is
an interesting innovation of the project, absent in the recommendations and
international bibliography, as it is the TDU 3x3x3 or 3x3x1. Another innovation
is the houses heating and the sowing of repellent trees as methods to reduce
the vector person contact. It is important to remark the low use of impregnated
materials in the project. Another aspect that should be develop, specially in
extensive breeding sites is the evaluation and regulation of the development
projects. In the next table it is summed up the used methods and some that
should be:
Table 35. Malaria Control Measures
CONTROL MEASURE
EFFECT
1. Early diagnosis and prompt treatment, Destruction of adult parasites
chemoprophylaxis.
2. TDU 3x3x3 o 3x3x1
Elimination
of
the
human
hostess
2. Insecticide spraying: house spraying and Destruction of adult mosquitoes
space spraying
3. Limed houses, repellent trees and Reduction of man mosquito
impregnated materials: bed nets, curtains and contact
screening of houses
4. Environmental management and
Destruction of mosquito larvae
environmental modification: mosquitoes
and source reduction
breeding sites control.
5. Assessment and regulation for developing Destruction of mosquito larvae
projects
and source reduction
Source: Adapted from Najera et al (1992:14)
The countries have made adaptations to the control strategies, in such way that
in each country it is applied the control strategy for malaria adapting it to the
conditions, resources and national capabilities. It could give more wealth to the
project, because there will be several control models with a common strategy,
that is going to help the replication in diverse scenarios. The difficulty is in
control a high number of interaction and confounding variables to explain the
results and reached differential impact, so it is important to strongly document
the differences between countries and demonstrative areas.
The characteristics of the used control strategy, coincides with the technical
elements of the Global Malaria Control Strategy (WHO, 1993) and the Roll Back
Malaria initiative. These can be summarized in the following aspects:
1. Risk approach and focalization of the interventions
Through the used methodology of stratification, it was selected houses or
individuals, which concentrated the major number of interventions and the
interventions with the major cost effectiveness. The first stage of the
stratification allowed to identify the towns with bigger index of historical
transmission and persistent malaria (that were prioritized as demonstrative
areas of the project). The used indicators were the API, accumulated average,
of the last year and the cases repeated in the last ones 5 or 10 years. In a
second step it was identified to the malarious houses (defined as houses with
the presence of one or more cases or repeated cases) and the repeated cases.
The interventions directed to improve hygiene houses (clean house, clean patio,
and painting houses with lime) and to the personal hygiene, have been focused
on malarious houses. The treatment of cases and family contacts with TDU
were also concentrated in the malarious houses. In this way a more cost-
effective intervention is achieved.
This strategy of stratification is used to focalize the interventions, even it has a
risk approach, it improves the efficiency and the efficacy of the control strategy.
This approach is applying in all demonstrative areas, but in some sites
modifications have been made, such as making massive interventions in all the
houses of the community, particularly massive treatments and sprayings, as in
"Barranco Montaña Adentro" town in Panama.
RECOMMENDATION
To implement a field diary or note forms in which are documented: all the
executed interventions, not planned interventions (particularly those that break
the risk approach and the focalization of the interventions) and the reasons of
their implementation.
To homogenize the interventions and if this is not possible, to document the
interventions, in order to compare the results and impact in the different areas.
2. Selective control of vectors
Selective vector control is defined as the selection and application of vector
control methodologies that are: the most effective, the safest, those that have
the smallest impact in the environment, the cheapest and those that are better
adapting to the local situation (OPS, 1999).
As it was described in the previous chapter, the interventions applied in the
project are safe, they have a low environment impact and they have been
adopted by the communities. In relation to the cost effectiveness, according to
the information of Mexico and the opinion of the interviewed, these are low cost
and more cost effectiveness. Additionally, the interventions of clean house,
clean patio and limed houses are multi purpose, because they contribute to
dengue and chagas control.
RECOMMENDATION
It has not been carried out evaluations of cost effectiveness, so it is necessary
to formulate an evaluation protocol of the interventions cost effectiveness to be
applied in all the demonstrative areas and to compare them with the traditional
methods of vector control.
In relation to the adaptation to the local reality, in the Handbook (Technical
Guide) two control models has been defined for two more important types of
vectors. However, there are demonstrative areas in which other vectors exist,
as Guatemala and in areas where the strategies have not been adapted, neither
discussed.
RECOMMENDATION
According to the opinion of the national team of Guatemala it is necessary to
develop control strategies for another type of vectors and for other ecosystems.
.
Although, in this inception phase of the control strategy, there is a high
acceptability of the communities, the presence of persistent and larges breeding
mosquito sites can reduce the motivation of community people or to make the
intervention ineffective. In Panama, the cleaning activities generated, as
necessity, having places and technology for garbage disposal.
RECOMMENDATION
It is necessary to study engineering alternatives to encase rivers and gulches
with accessible methods that have bigger sustainability than the cleaning made
by the residents. The municipalities should participate actively and to introduce,
as part of the development plans, the necessary infrastructure works. For that,
the experience in El Salvador should be shared with the rest of the countries.
In very extensive mosquito breading sites, the endowment of light machinery
(clear machion, motosaw) can facilitate the control activities. This component,
should be included in a new project or to be negotiated as a contribution from
the local and national governments.
To integrate in the vector control activities mechanisms and strategies to
dispose and the use of garbage and waste by the communities. For example, it
can be trained how to produce "compost" using the organic waste. To
determine the extension of this intervention, it is necessary to evaluate how the
garbage disposal and brashest is making in other demonstrative towns.
In Guatemala and Mexico there is a great strength in the evaluation activities
and entomological surveillance. Guatemala has built a national net of auxiliaries
of entomology. In the other hand, in Panama and Costa Rica this activity is
weak, because there is not field staff in the demonstrative areas trained in
practical entomology.
RECOMMENDATION
Using the experience of Mexico and Guatemala is necessary to elaborate a
specific guide of entomology and to develop teaching materials to train
auxiliary of entomology. It can be organized a regional course that besides
approaching practical entomology, be also good to train in selective vector
control.
To facilitate the visits of the workers from Guatemala and Mexico, in order to
carry out training in Panama, Costa Rica, and other countries that have a need
in this field.
The strategy of "Red and Green Card", formulated to stimulate the cleaning of
houses and patios that it worked wel in a town of Panama, it became a
stigmatizing activity. On the other hand, it has not established criteria to qualify
cleaning of houses or patios, so this strategy can become a subjective
evaluation that does not contribute to the control of Vector Born Desease
(VBD). The interesting of the strategy is the fact that was emitted by an
obligatory ministerial ordinance from the authorities of Panama and it has been
transformed in a compulsory strategy.
RECOMMENDATION
The strategy of "red or green card" can be a practice to be adopted in other
countries, but it requires a sensitization and previous training of the families. In
order to eliminate the stigmatization, in the first evaluation, it should be
managed confidentially between the appraisers and the families. It could
accompanied from prizes to the towns and clean houses, as the gratuitous
delivery of lime to paint the houses or T shirts.
Another alternative is to use a more positive concept, to deliver diplomas of
recognition in replace of the green card and confidential cards of invitation to
keep the houses and patios cleaned (red card). The recommendation should
be to use the red, yellow and green card in such a way that people have a
perception of improvement, passing from the red card to yellow and green
card.
There should be defined standards to qualify when they should give a red card
or synonymous and when green; for that, the criteria of Mexico can be used as
reference to evaluate the intervened houses.
The percentage of red, yellow and green cards of each community, can
become indicators of improvement, because this is an easy concept to
understand for the communities. It is necessary to incorporate these indicators
to the situational communitarian rooms, to look the improvements through the
monitoring. An example as how it can be make, is the health ladder, that is
used in the Comunnity Epidemiology Guidelines (Tognoni, 1997).
3. Rapid diagnostic and opportune treatment
There is not uniformity in the treatment outlines used among the countries for
the treatment of P. Vivax, particularly in the doses and days of primaquina
prescription. This is one of the most important weaknesses in the inception
model, which has been discussion reason and it debates with PAHO and CDC
and it has impeded to reach an agreement that allows homogenizing the used
guidelines.
In Mexico the TDU 3x3x3 is used, for this reason the radical treatment is not
carried out. In Panama and Guatemala are using lower primaquina doses than
is recommended and only for five days. PAHO recommends a treatment with
primaquina with a double doses for seven days (Marquiño).
The treatment outline used by Costa Rica of radical cure and later on the TDU
3x3x1, it is an alternative that integrates both the recommendations of PAHO
and the one that Mexico uses, but that it is necessary to validate the efficacy of
this outline.
RECOMMENDATION
It is urgent to standardize and to update the treatment guidelines used by the
countries based on the current scientific evidences and to diminish the current
schemes.
According to Wilmer Marquiño from PAHO, studies of effectiveness of the
primaquina application for 5 and 7 days will be carried out. The DDT-GEF
Project should participate in these investigations, but also to evaluate the
impact of the outline used by Mexico and Costa Rica (TDU 3x3x3 and 3x3x1).
There is an important progress in the rapid diagnosis and opportune treatment,
especially in Guatemala where only 15% of treated cases has laboratory
diagnostic of thick blood smear, at national level. In Mexico and Costa Rica the
time among the taking of samples and the delivery of results is minor as in
Guatemala and Panama, in all the countries should be implemented strategies
that allow to treat the cases in the first 24 hours before the symptoms begin,
which is part of the goals of the Rol Back Malaria Initiative (Alnwick, 2001:1).
In Panama and in some demonstrative areas of Guatemala, the access and
opportunity is very critical for the communities, particularly the natives. In
Panama, in the laboratory of the demonstrative area, there is not capacity to
differentiate P. Vivax of P. Falciparum. In these two countries, it can conclude
that it has been given more importance to the activities of vector control than to
the improvement of the diagnostic and treatment coverage and quality. In the
next interventions is necessary to surpass this misbalance.
RECOMMENDATION
To train vector workers and laboratory staff of general health services of the
demonstrative areas as microscopists and to increase the number of
laboratories available.
In the demonstrative area of Panama it is necessary to train microscopists in
order to they can distinguish between P.vivax and P.falciparum and to
introduce the use of rapid test.
In Panama and Guatemala is also important to strength the net of diagnostic
through involving new voluntary collaborators, the vector workers (former
sprayers) and to introduce the use of rapid test.
The strategy of Costa Rica of to take samples to all banana plantation workers
(from Panama and Costa Rica) and to give the "malaria card" that enables them
to work, as well as the installation of positions of taking blood smears samples
and notification in the frontier steps, are not just strategies to improve the
opportunity of rapid diagnosis and opportune treatment, but also for the
opportune detection of outbreaks and epidemics, in a context of increase of the
number of cases by P. falciparum. However, the impact of this strategy cannot
have effectiveness and to become an exclusion mechanism, discrimination and
stigmatization if it is not consulted or validated with the Panamanian
communities and Panama does not participate in its execution.
RECOMMENDATION
To strength and to make official the cooperation between the border
demonstrative areas of Costa Rica and Panama, in the framework of the
binational relationships. Two are the high-priority agreements:
1. In order to improve the access and opportunity of diagnostic and treatment
of the indigenous communities of Panama, it is recommended to establish an
explicit agreement so that the blood smear taken in Panama should be
deliverd in Talamanca (border notification places) for the Panamanian
voluntary col aborators. For that it is necessary to establish a mechanism so
that Panama returns the supplies and drugs used.
2. The malaria card should become an integral health card and it should also
be emitted by the Panamanian authorities. So it should be implemented in
Panama the strategy that is used by Costa Rica of taking samples to the
workers who cross the frontiers to detect feverish and asymptomatic cases.
3. To evaluate if the malaria card has not become mechanism of exclusion
discrimination and stigma with the rural communities.
The use of rapid tests is another alternative for Panama, Guatemala and the
frontier zones of Mexico, but its cost would be bigger than the blood smear.
This alternative can be implanted when the number of cases diminishes, not
only in these three countries but in all the projects, especially to detect cases
introduced by migration or temporary work and in the areas where malaria
cases and outbreaks by P. Falciparum appear.
In the Guide, there is not a normative about follow of treated people, so each
country has its own policy. In the measure that the repeated cases are under
surveil ance, it can have an indicator of relapses or reinfections, that should be
used by all countries.
In relation to the procedure of search of feverish cases, neither there is
uniformity among the countries, Mexico and Costa Rica carry out active search
when the vector workers visit the areas. This is a central aspect of the strategy
to improve the opportunity and coverage of diagnostic and treatment. The active
search and the follow of treated people and the TDU 3x3x3 or 3x3x1 are
important activities in the strategy, but they are of difficult maintenance,
especially in places of restriction of human resources and of mobilization, so it
is necessary to find alternatives adapted to each reality.
RECOMMENDATION
In scenarios of restriction of human resources and mobilization, it is necessary
to give a more active role, in diagnostic and treatment, patient surveillance and
active search of cases to the community organizations, particularly to the
voluntary collaborators.
4. Elimination of the plasmodium human host
Another important element of the model is the strategy to eliminate the
plasmodium human host, particularly of the P. Vivax. Of the four evaluated
countries only Mexico and Costa Rica have adopted an explicit strategy, 3x3x3
and 3x3x1, respectively. Additionally, in these two countries, this treatment is
administrated to all contacts of an identified case, under the supposition that
where a case appears, there will be asymptomatic people, for the predilection of
the mosquito with certain houses (malarious houses). The malarious houses will
be potential infection sources.
In the practice, the conception of the malaria has changed, of being considered
an acute illness to a chronic infection with acute feverish accesses (illness). The
hypothesis is that in the absence of treatment, the feverish events can repeat
until for three years because of the persistence in hepatic forms. According to
the defenders of this strategy, the primaquina would not have 100% of
effectiveness to eliminate the parasite of the liver, determining frequent relapses
(repeated cases). Giving TDU once a week for three months, with three months
of rest by three or one year, it would prevent new febrile events, and
eliminating the transmissible forms and the mature parasites, would be
prevented the transmission and the appearance of repeated cases. For this
reason, the repeated cases would be indicators for the elimination of the human
host of Plasmodium.
It is very probable that the combination of EHCAs and the TDU are the
determinants that explain the success reached in Mexico and that it has allowed
that several areas are in a phase of certification of transmission interruption.
Unfortunately, there are no studies about the effectiveness of this outline of
elimination of the human hosts, particularly of the hepatic forms of plasmodium
because there are no laboratory tests to identify the persistence of hepatic
forms.
The negative of countries as Panama and Guatemala to use this strategy, is
based in the fact that there is no studies about the application of this strategy
with scientific validity (randomized clinical trials) and also the PAHO
recommendation of no using low and incomplete doses of primaquina (one pil
for one day) for the risk of drug resistance. Additionally, in places with deficit of
human resources and mobilization constraints, it is difficult to give treatment to
all the confirmed cases and their contacts with this alternative strategy, because
the health workers who visit the communities only can go every fifteen or
twenty days.
Because of the difficulty of identifying the persistence in hepatic forms, it is very
hard to carry out experimental studies. For that, as it has been made in other
interventions, with results of operative evaluations the interventions can be
adopted. For that due to Mexico has an information system and documentation
of cases (in the areas where the transmission has been eliminated) and
particularly of repeated cases before, during and after beginning the application
of the strategy, an appropriate statistical analysis (multivariate), could offer
evidences of more statistical validity and generalization capacity.
RECOMMENDATIONS
To design an study to evaluate the effectiveness of the TDU 3x3x3 and to
strongly document the application of the TDU 3x3x3 outline of Mexico and
radical treatment plus 3x3x1 of Costa Rica, to compare them with the results
obtained in the other countries that do not adopt these strategies. The impact
indicator would be the persistence of malarious houses and repeated cases.
To carry out studies of resistance of the plasmodium vivax to the primaquina in
Mexico.
The countries that have not adopted the strategy 3x3x3 or 3x3x1, should
discuss which is the alternative to eliminate the plasmodium human host. An
alternative is to carry out universal active search of current and recent fiber
cases (in the whole community) and to treat all the cases and family contacts
with radical treatment.
5. Reinforcement of basic information and investigation local capacity
Another of the four elements of the global malaria control strategy is the
enforcement of basic and applied investigation, to facilitate and to promote the
regular analysis of the malaria situation. The absence of computer programs for
processing and analysis, difficult this activity. The advances in the application of
the GISEPI, with the support of PAHO and INCAP, is one of the promising
elements to reach this objective. In Guatemala there is a very good example of
its application with the participation of local personnel and community agents.
RECOMMENDATION
To promote internships of local personnel responsible for GISEPI in
demonstrative areas and the INCAP of Guatemala.
To design a computer program to process and analyze the information, that
can be modified or adapted to each local reality. Another alternative is to train
the local personnel in the use of EpiInfo, so they can design in this package
processing programs.
To train the local operative personnel in interpretation and application of the
information and surveillance system to take decisions or about the operative
investigations.
Operative studies have been carried out and in function of the evidences,
hypothesis and interventions have been defined and applied, however, this it is
one of model's weaker aspects. In all the demonstrative projects there are
efforts to take decisions based on information or studies (administration based
on evidences), but this development is still incipient and it is necessary to
reinforce it.
In Mexico a study about risk transmission and another of malarious houses
were carried out and they were used to support the applied strategy. The results
of these studies should be replied in the other countries to better sustain the
strategy of vector control and the TDU 3x3x 3 strategies. Although these studies
have been presented in several events, they have not been still published in
scientific journals. The authors of the study agree that it is necessary to make
an effort and allocate financial resources in order to write scientific papers. A
study to differentiate re infection from relapses is carrying out as part of a PhD.
About painting houses with lime, it is certain that it is an intervention very
accepted by the community, because contributes to the perception of cleaning
and house holding and to the good image of the community in general. There is
also a traditional use applying it to the base of the trees like repellent to avoid
ants or insects. But there are no recent scientific evidences of their impact in
malaria control.
Although all the countries have implemented the strategy of selective vector
control and they have made adaptations to the proposed Guide, all the actors
coincide in the necessity of evaluating the impacts and also to systematize
more the experience.
RECOMMENDATIONS
It is necessary to carry out a specific workshop to formulate multi countries
study protocols. Mexico could be the axis of the work, but it should also be who
finances these workshops, because they have more funds from the DDT/GEF
project .
It is necessary to make alliances with the universities and investigation
institutes to formulate the protocols and to drive the multi countries studies.
Some of the topics to study are:
1. It is important to discuss the primaquina doses and also to carry out
resistance studies to the primaquina.
.
2. It is necessary to make a protocol of indicators assesment, particularly
predictive indicators. An example is the study carried out in Nicaragua about
the relationship between larval density and API.
3. To evaluate in a more systematic way the strategy TDU 3x3x3 or TDU
3x3x1, in the reduction of repeated cases (taking this as proxi indicator in the
absence of tests of diagnostic of the presence in hepatic forms).
4. It is important to evaluate and to validate the concept of malarious houses
and the risk factors or the reasons about the preference of the mosquito for
these houses. The study carried out by Mexico can be replied, in other
demonstrative areas.
5. To introduce evaluations pre and post intervention of all the implemented
strategies, particularly of EHCAS, clean houses and patios, and whitewashed
houses.
6. To allocate resources to promote the writing of scientific articles with the
results of the studies and about the systemation of the experience, to gain
position in academic environments.
There are efforts in the countries to incorporate to the Universities and
Investigation Institutes, but there is not a clear definition of the responsibilities
that they should assume. Also in the project there is not a specific objective.
RECOMMENDATION
To involve Universities settled in the places where the demonstrative areas are
and defining their roles in investigation, training, insert malaria subject in
regular curriculum of medicine, biology, agronomy, environment , etc..
3.3 HEALTH SYSTEM REINFORCEMENT
Roll Back Malaria (RBM) was defined as a social movement with the objective
of reducing the global charge of malaria, adapting the interventions to the local
needs and through to reinforce the health sector (PAHO/WHO 2000: 365). The
RBM goals includes: to support the endemic countries to develop their health
systems as the major strategy to control malaria (WHO/RBM, 1999:1). So, one
of the most important requirements is to guarantee the sustainability of
development of the health services and to act as a way to other programs of
illnesses control, as well to guarantee a new model of association (World Bank,
2001) and development and to keep the needed inter sectorial collaboration
between the health sector and other sectors.
Actually, the project has developed the elements of the Global Strategy of
Malaria Control, and also has developed the next elements according RBM:
Institutional strength
In all the visited countries, there is a team constituted by professionals with a
high technical level and in the field workers there is a continuous improvement
in the abilities for: the strategy application, the communitarian work, the GIS
information and the analysis capability. The project has dotted the
infrastructure and basic supplies to develop the institutional capability,
particularly the Information and Surveillance System through computers, GPS,
digital cameras, vehicles, etc.
A weak aspect is still the fol ow and supervision of the project. There are no
supervision guides and the feedback in some is not systematic.
RECOMMENDATION
It is necessary to formulate supervision guides and feedback formats.
Integration to the health general services
In each one of the demonstrative projects, the control strategy has been
adapted to the health system and to the specific model of attention. For
example in the case of Mexico where still persists the semi vertical structure
from the old MCP, a good adaptation was made and an accurate use of that
control strategy was developed.
In Panama, the specialized SNEM structure was used to adapt into the new
necessities, even though with a lower development than in Mexico. In relation
with the decentralization model, it is evident that the health personnel of general
services still see the vector workers as an independent institution. Although, this
has been used so the regions (general services) do not take the resources
away, specially the financial, it constitutes an obstacle to be able to integrate
the health personnel of general services to the activities for malaria control. In
this sense, the active participation of the project focal point in the Ngöbe Buglé
Comarca and the hiring of communitarian agents to integrate them to the
control activities is an experience that should be extended to other
communities.
In Costa Rica, this adaptation has been interesting because the specific vector
workers were entirely integrated to the health areas, under the leadership of the
area director, who is in charge of the entire municipality area.
In Guatemala, the remaining SNEM structure has been integrated to the health
areas, even there is still a leadership and a specific structure of vector control,
this has a great integration and coordination with the area leadership, which is
the one that defines, in last term, the work policies at the demonstrative areas.
In conclusion, there are three models to organize the health services and
attention where the strategy to control malaria has been inserted:
1. A semi vertical model in Mexico and Panama, with leaderships
independent from the health general services and with a very good
coordination with the health general services. Mexico with enough
resources and Panama with lack of resources.
2. An integrated model in Guatemala, with the presence of a specialized
team in vector control, but under the direction of the regional
headquarters.
3. A horizontal model, in Costa Rica.
One of the most important debates in the last years, have been the influence
that the elimination of the Malaria Elimination Services and the decentralization
have in the weakening of the countries response to malaria control (WHO,
2000, Schimunis and Dias 1999). The project presents the opportunity to study
the effecgt of three different models of services organization with a common
control strategy.
RECOMMENDATION
To characterize the services organization and care models in the rest of the
non evaluated countries, to be able to include as one of the variables that can
influence in the differential impacts of the strategy and in the sustainability and
replication capability of the model.
One of the project weaknesses in all the countries is the transportation of the
vector workers. It is important to solve this problem to improve the personnel
work efficiency.
RECOMMENDATION
An alternative to improve the transportation can be the purchase of bicycles and
motorcycles. This will increase the performance of the malaria workers and the
continuity of the communitarian actions.
Due to the project does not contemplate the financing of transportation for the
operative personnel, it is necessary to advocate funds from the Ministries of
Health or to formulate an additional project, as one of the requirements to
secure the continuity of the project.
3.4 SUSTAINABILITY AND REPLICATION CAPABILITY
It is evident that there is a great advance in the implantation of the control
strategy, that it responds to an increasing diminution of the resources and it is
well adapted to these scenarios. But it is necessary to give a qualitative jump
reviewing the model in each of the scenarios. For example, at demonstrative
towns with resource limitations or continuous decreasing, especially in vector
workers as in Panama, is important to review the model so it can respond to
these limitations. With the actual resources is not possible to accomplish the
activities as: the active search of cases, the samples transportation, etc.
The use of persistent insecticides to control outbreaks or epidemics and for the
agriculture in some countries, represents a weakness of the project, because of
economic reasons, there can be a fal back in the use of COPs to control
malaria, especially at the presence of malaria epidemics by P. Falciparum.
RECOMMENDATION
The model has to be redesigned in the scenes with resources limitations under
the fol owing guidelines:
To strength the community participation in the samples transportation, in the
active search of cases, in the epidemiological surveil ance and in the pre and
post evaluation of the interventions for vector controls.
In Panama, taking as a reference the experience of Bisira, to integrate the
health general services (doctors, communitarian nurses, educators, etc.) in the
control activities and communitarian education.
With the national teams of the four visited countries has been discussed the
problem that the success of the project can have, reducing the concerning from
the health authorities, the institutional support and the reduction in the
communitarian participation. So alternatives to maintain the attention of the
community have been discussed, as the implementation of predictive indicators
of failure as: new and repeated cases and new non controlled breeding
mosquito sites. The currently discussion in Mexico about to certificate the
elimination of transmission is another issue to discuss in the future.
Another positive factor, but it can affect the sustainability and replication
capability of the project is the fact that the required inversions are small, it does
not include important purchases of insecticides, and neither machinery nor
equipments, which in a scenario of diminution of the pressure of the insecticides
companies can generate lack of interest by the politicians and the authorities in
the problem and to reduce the financial contributions. The presence of
organized communities and the Municipalities can reduce this risk.
The use of insecticides for outbreaks or epidemics can generate the temptation
to use insecticides when outbreaks or epidemics appear because the
introduction of imported cases, especially if in the dengue control the strategy of
vector control without the use of insecticides it is not applied.
The municipal contribution in the funding of activities to control malaria is still
weak and the funding for development infrastructure to control big breeding
mosquito sites have not been identify as a priority. Which, together with the fact
that malaria is concentrated in poor rural areas, with a low power of demand, it
can determine that once that the project is finished; the municipalities are not
going to support the control activities anymore.
The presence of dengue epidemics, floods, and tropical storms create a
deflection of human resources and materials to mitigate its impact.
RECOMMENDATION:
In each area, is necessary to discuss a plan to secure the project sustainability
that includes strategies to secure the human and financial resources, as well as
to redesign the strategy with a high communitarian and municipal participation.
An opportunity to reply the control strategy are the Global Fund Projects (GF),
but is necessary to make advocacy and coordination with the GF mangers of
and principal receptors to integrate the developed control strategy into the
intervention areas of the project.
In the FG projects, the improvement of the coverage, rapid diagnostic and
opportune treatment have been prioritized, but also the use of pre impregnated
mosquito nets. If the mosquito nets are massively use without proper
evaluations of its effectiveness as a unique intervention, it will go back to the
same paradigm of control as the one used in the application of insecticides and
will loose the opportunity to train the health personnel in selective vector control.
It is not possible to reply the strategy if there is not a budget for: i) the training in
the model of control to the vector workers, the personnel of health general
services and the community and ii) resorurces for mobilization, supervition and
support the communities.
Additionally, is necessary to redesign educative materials for the health
personnel and communitarian agents and to insert in the educative plans for
elementary and high schools information to prevent and control malaria. It can
be taken as a reference the material developed for the vector workers by
Mancheno, Kroeger y Alvarez, entitled: "Manual Técnico para el control de
Malaria, Dengue, Leishmaniosis y Oncocercosis" (Mancheno, 1998). Recently
PAHO produced educative materials in english to control malaria, that can be
useful in Guyana.
RECOMMENDATIONS:
To carry out meetings at the regional level in each country where there are
projects with the cartera managers of the Global Fund and the principal
receptors of the projects of malaria control, to insert the control strategy in these
projects.
To begin a process of regional politic incidence with the PAHO and PNUMA
support, to achieve the specific budget of the state to reply the project in other
primordial areas.
To design a regional project to present it to the Global Fund to reply the model
in another areas of the countries.
To design educative materials for the training of the health personnel, vector
workers, communitarian agents and educators. It would be important to design
material adapted to schools curriculums so the children can support these
activities.
3.5 MONITORING, EVALUATION AND SYSTEMATIZATION OF
THE EXPERIENCE
The Guide presents a chapter of "Demonstrative Projects Evaluation", in which
four evaluation aspects are described: the impact, the process, the
effectiveness, and of efficacy. (pg. 91). Even though, the fol owing section (pg
92-93) presents proxi indicators for the project evaluation, just the process,
result and impact; efficacy and effectiveness indicators are not described.
Even is stipulated that every three months the National Coordinators prepare
technical and financial reports, in the reviewed reports all the recommended
indicators are not used because the agreed format in the convention does not
al ow this level of detail. Clearly, the implantation of the monitoring and
evaluation system has an important delay.
In the annex 12th of the Guide many indicators are listed, that are used in
Mexico because this country disposes enough human resources. The rest of
the evaluated countries are using a few indicators. Because of the fast advance
of the interventions and the obtained results, to monitor a small group of key
indicators will simplify the monitoring and surveillance system and will increase
the acceptability.
Some of the key interventions do not have monitoring indicators, as the
coverage and TDU 3x3x3 compliance. There are some listed indicators that
should be redefined so they can be measurable and comparable; for example,
in the positive mosquito breeding sites, it has to be obtained the average of
positive breeding sites and the percentage of the localities where an pre and
post EHCA evaluation have been made.
Next, it is presented an attribution map to identify and to formulate,
appropriately, the information and surveillance system:
Table 36. Attribution map of the strategy to control malaria of the DDT/GEF Project
PROCESSES/
PRODUCTS
EXPECTED
RESULTS
IMPACT
ACTIVITIES
1. DIAGNOSTIC AND
TREATMENT
Identified feverish with blood tests
Increase of IAES
Identification of feverish
Feverish with presumptive treatment.
Increase of treated febrile cases
Treatment of feverish
Positive feverish with radical treatment
Increase of positive febrile cases treated
Radical treatment
Visited notification posts
Reduction of ILP
Communitarian and
Visited voluntary collaborators
Active notification posts
notification posts visits
Volunteers actives
2. HOSTESS
Reduction of IPA
ELIMINATION
Positive and collateral cases treated with
Reduction of repeated cases
TDU 3x3x3 o 3x3x1
TDU 3x3x3 o 3x3x1
Reduction of malarious houses
Reduction of grave and
Treatment of collaterals
Identified cases by active search
Reduction of positive localities
complicated cases
Active search of cases
Reduction of mortality
Reduction of letalidad
3.HOME IMPROVEMENT
House and patios cleaning
Clean houses and patios
and per domicile veneered
Per domicile veneered
Houses painted with lime
Whitewashed houses
Pre impregnated mosquito
Houses with impregnated mosquito nets
nets
4. EHCA AND BILOGICAL
LARVAE CONTROL
Reduction of positive breeding sites
Breeding mosquito sites
Identified and treated breeding mosquito
Reduction of the mean of positive capture
identification and treatment
sites by method
Reduction of larvae density by breeding place
Refuges identification and
Identified and treated refuges
Reduction of positive refuges
treatment
Breeding mosquito sites evaluated before
Increment of breeding sites intervened
Pre y post evaluation of
and alter the intervention
EHCA activities
Intervened localities
Communitarian visits
The monitoring system suggested in the guide is incomplete, because it is not
defined the periodicity, the information sources, the minimal parameters
accepted and the actions to take if these parameters are not enough.
RECOMMENDATIONS
To formulate effectiveness and efficiency indicators to include them in the
Guide.
For each one of the selected indicators should be defined the periodicity of
report and the parameters of the minimal performance to reach. If these
parameters are not reached, they should be defined which corrections should
be make. The corrective activities should include a definition of what detailed
information should be gathered to identify the cause of the problems. The
definition of minimal parameters should be made in consensus, with the base of
the reached experience until now.
Information activities have been carried out with marionette and theater plays,
etc. All this initiatives have to be systematized and improved in terms of
participation of experts and to identify methodology and indicators for the
evaluation of the training activities, education and communication. In that sense,
the experience presented in the regional conference of identification not only
about knowledge, attitudes and practices, but the perception of the menace or
risk compared with the perception of the intervention efficacy. An evaluation
indicator is to see the decrease of the percentage of people who present a low
perception of risk and a low perception of efficacy about the interventions.
Due to the areas have differences in the access to a laboratory diagnostic
(number of notification points by 1000 inhabitants) and in the coverage of active
search, to use the crude IPA to compare the impact between areas before and
after is not an accurate indicator. This is because crude API is influenced by the
rates of cases detection (ABER). For example, it is not the same an IPA from a
demonstrative town in Mexico or Costa Rica with a high blood smear access
and active search than in Panama or Guatemala.
Definitions and basic variables have to be unified, it is important to make these
definitions with the demonstrative project of Costa Rica. Next, it is presented a
suggestion of indicators which can be used, the periodicity and suggestion of
minimum parameters, but they should be validated.
Table 37. Information and surveillance system
LEVEL INDICATOR
DATA
PERIODICITY PARAMETER CORRECTIVE ACTIONS
SOURCE
From process Surveillance
and product
% of visited localities from the total of eligible localities
Month
80%
Measure of blood tests by active search by evaluator day
Month
20%
% of the visited notification points from the total of eligible
Month
20
Average of treated collaterals by case
% of localities with CV
Month
80%
Communitarian Participation
Month
4
% of worked localities for larvae control from the total of
visited
Month
90%
% of treated breeding mosquito sites from the total of the
Month
80%
identified
Operatives
Month
90%
% of localities with updated geo indexed maps from the
total of the visited
100%
% of intervened localities with EHCA with before and after
evaluation
% of localities with CV or PN from the total of localities
From results Surveillance
Annual or trimester index of blood tests (IAES)
Year
Index of positive laminas (ILP)
Month
% of positive localities
Year
Rate of identify feverish by 100 inhabitants
Month
% de malarious houses of the total houses
Month
% of repeated cases from the total of the confirmed cases
Month
Treatment and elimination of human hosts
% of treated cases from the total of the confirmed
Month
% of col aterals (family members) of confirmed and
Month
treated cases from the total of existent family members
% of the cases with complete treatments (radical cure x 7
Month
days)
% of the cases that begin TDU from the total of cases
Month
Adherence to TDU 3x3x3: Mean of the percents of times
Annual
of taking of, from the total of taking of programmed in
persons who start TDU.
Month
Average of days between the date of the day that the
sample was taken and the beginning of the treatment
Month
Communitarian participation
Month
% of veneering houses from the total of eligible houses
Month
% of painted houses (whitewashed)
% of houses with red, yellow or green cards (clean
Month
houses and patios)
Month
Entomological
Month
% of positive refuges
% of positive breeding mosquito sites
Average of the percentage of positive whitewashed by
breeding mosquito sites
From impact Surveillance
Number and rate of crude mortality for malaria
Year
Malaria Lethality
Year
% of severe, complicated and hospitalized cases
Month
API e IPA standardized by screening effort
Year
The project is still in an insertion phase of the control strategy and there is an
advance in the activities of training to the health and vector workers and the
members of the community. Activities of vector control, home improvements,
diagnostic and treatment of the cases and the elimination of human hosts of
plasmodium have been carried out. The base line was completed just in the last
months. Because of the delay of the implementation of activities as hiring and
administrative arrangements, most of the communitarian activities do not have
more than two or three months, so it is not possible to evaluate the impact that
this intervention can have.
Although in the Guide there is an evaluation chapter, the methodology that will
be use to evaluate the impact of the project is not clearly defined. In the
evaluation design is important to take in mind that not all the countries are
applying the same interventions. Currently, there are similar models about
activities of larvae control, home improvement and the personal and familiar
hygiene, but unlike in the aspect of treatment and elimination of the human
hosts; there are localities with TDU 3x3x3 in Mexico, communities with TDU
3x3x1 and communities without TDU but treatment with radical cure for 5, 7 or
days.
RECOMENDATIONS
To identify which is the contribution of the different used interventions and the
influence of the social, economical and cultural facts and the organization of
services in the differential impact between demonstrative towns, the fol owing
alternatives are proposed:
1. Study design: pre and post evaluation without control group
Only the demonstrative areas are taken. The base line is the pre evaluation and
the final evaluation the post evaluation. To control the cofactors and
confounding variables and to identify the weight and the interaction of each
independent variable should use multivariate analysis.
The problem of this design is that at the time not all countries use the same
control strategies and that they have different models of attention and
decentralization, it would be hard to know which was the specific intervention
that had a major impact or how the interventions interact. This is important to
improve the final evaluation and to valid the model.
2. Study design: pre and post evaluation with control group
To compare the demonstrative localities taking them as an experimental group
with other communities of similar characteristics where the old control strategy
has been maintained (control group), specially where insecticides have been
applied. At the time that the base line of the control communities is not
available, the design would be a post evaluation without control group.
Unfortunately, the control localities in some countries (Guatemala, Mexico) ca
not be close communities, with similar characteristics as the demonstratives,
because the vector workers have the same areas of influence, so they cannot
be taken as control localities. The selection of control communities can be
constituted in a difficulty because they have to compare heterogeneous
localities.
As line base has been gathered useful data to evaluate the impact before 2004,
so it can be compared a period before (2001 to 2004) with a period during and
after (2005 to 2007). The most important indicators to measure the impact are:
the number of cases, the standardized IPA, but also the number of repeated
cases. A variable that is not defined in the Guide and it is important to evaluate
the impact is the rainfall rates and the presence of floods.
RECOMMENDATION
To use of standardized API by screening effort to evaluate the impact, as well
as the annual index of rainfall.
Standardized API by screening effort
API was standardized using the case detection effort (ABER) for the year 2003
o 2004 (previous years for the intervention) by applying the following formula
(Roberts, 1997):
APIs = (EMPSx / Population x) per 1000
APIs = Annual Parasite Rate standardized by sampling effort
x= year
EMPS= Estimate of Malaria Positive Slides
The calculations were as fol ows:
1. Calculate ABER for each year
ABER = (number of slides examined/total population) per 100
2. Calculate the Slide positive rate (SPR) for each year (x).
SPRx = (number of positive slides / number of slides examined) per 100
3. Select the year of comparison. In the present thesis, year 2000 was
chosen as the comparison year, because in that year the ABER had the
peak during the study period.
4. Calculate the revised estimate of the total number of slides examined for
each year multiplied by the ABER of 2000 (standard year) for the
population of each year (RESE)
RESEx = (ABER2000/100) (Population x)
5. Calculate the estimated malaria positive slides (EMPSx) by multiplying
the original proportion of positive slides for each year (SPRx) by the
revised estimate of the total number of slides examined (RESEx):
EMPSx = (SPRx) x (RESEx)
6. Then divide the estimate of malaria positive slides (EMPS) by the total
population of Ecuador for each year in the series. These quotients,
multiplied by 1,000 produced APIs standardized for sampling effort
(ABER). Calculate the APIs for each year.
APIsx = (EMPSx / Population x) per 1,000
Annual Index of Rainfall
The rainfall average will be calculated using the annual meteorological records,
provided by nationals Institute of Meteorology as follows:
1. Calculate the annual rainfall of each post summing up the monthly average
of rainfall of each post.
2. Calculate the total annual rainfall summed the annual rainfalls of each post.
3. Then divided the annual rainfall for the number of meteorological post.
In relation with the development of GISEPI, from the four visited countries,
Guatemala and Costa Rica are the countries with a higher experimented
development. In Mexico the GISEPI is in development. In Panama is required
technical help to develop faster the GIS system.
The most important application of GISEPI in Costa Rica and Guatemala is the
representation of the situation of malaria and the breeding mosquito sites
identified in the line base, but the monitoring applications have not been
developed yet. Also, each country use different indicators, data bases, and
ways of representation.
The indicators used in the geo referenced maps are: new cases, repeated
cases, malarious houses, breeding mosquito sites, influence radius of the
hatchery and positive breeding mosquito sites.
RECOMMENDATION
To develop applications for the interventions monitoring.
To support Panama to accelerate the GISEPI development.
To unify the indicators, data base and the GIS representation ways.
In the second Regional Technical Committee were presented the results and
the advances of the project, with a guide sent by the Regional Coordination.
How ever, each country chose different indicators, so there was not
homogeneous. These presentations are systematic instruments of the
experience, but is necessary to homogenize them.
There is a diversity of experiences but is necessary to document them, for that
is require to design a methodology of documentation and systematization.
RECOMMENDATION
The presentation model of the results and advances of Nicaragua can be used
as a model to uniform the structure of the presentation for other countries.
It is necessary to develop a model, instruments or tools to systematized the
experiences of each country and to be able to compare them. The
systematization of experiences can be develop as an descriptive study of
multiple cases (Yin, 1997).
3.6 DEVELOPMENT OF THE MULTI COUNTRIES NET AND
EXPERIENCES EXCHANGE
The regional technical meetings have been constituted in the most important
scenario to exchange experiences. Each country have develop experiences and
good practices, but in all the regional technical meetings there is not enough
time to present them.
.
The phone conferences are a strategy of privileged communication, but it has
been used more to coordinate activities than to exchange experiences. The web
page and the Intranet, even they are updated with the trimester reports and with
other documents, don't have a section to present the experiences and the good
practices.
Exchanges about observation or transference of experiences or good practices
between functionaries, workers or communitarian agents haven't been carried
out yet. This is one of the requests of the local workers from all the visited
countries.
RECOMMENDATIONS
To use the phone conferences as strategy of experiences exchange. To
visualize the experiences can be used the Intranet so the expositors can make
power point and video expositions.
To incorporate the local workers and communitarian agents in the phone
conferences.
To intensify the exchanges between countries and communities, it has been
suggested that the local workers and the demonstrative towns make visits or
internships to see the experiences in the fields.
To assign the development of one topic to each country. For example,
communitarian training or promoters training to Mexico, entomologists training
to Guatemala, training in GISEPI INCAP, information system and operative
studies to Mexico.
To incorporate the focal points to the Ministries of Environment, Agriculture and
to local actors, special y to majors, to the meetings of the regional, local,
national and malaria workers committees.
3.7 INTER SECTORIAL AND PARTNERSHIP POLICY
In all the visited demonstrative towns there is a good collaboration of the
municipalities and majors. The majors have manifested their interest to
participate more actively in the project, but there is not a clear definition about
the responsibilities that the municipalities should have in the strategy to control
malaria. Until now, they have collaborated with food or other small supplies to
support the communitarian work of EHCA or to provide lime to paint the houses.
It is interesting to confirm that a high percentage of the malaria control activities
can be made by the community and the municipality, with the technical help of
the malaria experts.
The presence of epidemics dengue haemorrhagic in the region, have
determined that the municipalities put more attention to this problem than in
malaria, because there are low proportions of malaria falciparum and fatalities.
RECOMMENDATIONS
To integrate the responsible of the municipalities in the control strategies to
design the plans of municipal development,according to the millennium golas
strategies, They could plan engineering projects in order to give more
sustainability to the project, because the communities can get tired of making
monthly cleanings of the big and hard to control breeding mosquito sites.
It is important to sensibilize the municipalities about the effects of malaria in the
social development and the obstacle that it is to reduce the poverty, because it
causes great financial and laboral lost. In this sense, the major of Talamanca
suggested three aspects that should be also suggested in all the municipalities
of the demonstrative towns.
1. To integrate the malaria control in the local development plans.
2. To constitute the municipal commission to follow malaria.
3. To integrate malaria control and prevention measures in the restriction of
land use. For example, to regulate the permissions to build and execute
public development plans, particularly at the flooding towns, where the
communitarian work is not too effective.
4. To formulate municipal ordinances (laws) about the sanitarian, patents
and companies permissions for their functioning, to improve the access
of the workers to the health services and the protection measures.
As the time that some interventions to control malaria, as clean house and
clean patio, work also to control dengue and chagas, it should be integrated the
municipalities to the VBD control. It was discussed with the Regional
Coordination the convenience of carrying out a workshop with the majors to
discuss about which is going to be the role that the municipalities should take to
control malaria and dengue.
The public infrastructure plans for development and the small public plans that
are carried out in the countries can have a big environmental impact and to help
the spread of malaria transmission. The Municipality as the responsible of the
local development should have the capability to regulate and to evaluate the
potential effects of these public plans.
RECOMMENDATION
It should be, as a complementary objective of the project, to train the
responsible of public plans about the environmental impact of the development
plans as highways, dams, channels, etc. that can increase the breeding
mosquito sites.
An important mechanism to formalize the local government's participation in
Honduras, is to sign agreements with the municipalities and also with the
communitarian associations, specially with native organizations.
RECOMMENDATION
The signing of agreements to formally involve the municipalities and the
communitarian organizations is a mechanism that should be taken as a good
practice by the rest of the municipalities.
Important advances have been carried out to integrate the Ministries of
Environment, Agriculture in the project, but in some countries there is not an
accurate answer and is evident that there is not a clear definition of the
institutional roles yet. For example, in Guatemala even that the Ministry of
Environment have the funds to execute the Stockholm Convention, the activities
have not been executed and the representative of the Ministry of Environment
say that does not know how to insert it in the project. Anyway, the advance in
the objectives to eliminate the DDT stocks and the studies of environmental
impact, are a favorable scenario to improve the coordination with these
institutions.
Although at the local level there is good participation of teachers in the project
activities, at national level there is not a representation of the Ministry of
Education in the Committee. This should facilitate to insert in the educational
plans the risk of the persistent insecticides use in the agriculture and the
alternatives of organic cultivation. This is also important to work with the
Ministries of Agriculture.
RESULTS
It should be important to carry out a workshop of strategic planning where can
be defined a much more inter sectorial intervention, to clearly defined the roles
and the activities that each one of the institutions related with development,
environment and malaria control coul asume. PNUD has developed a
methodology to operate the multi sectorial approach in the strategic plans of
HIV AIDS that can be adapted to the malaria control without DDT and to the
reduction in the use of persistent insecticides in the agriculture.
It is necessary to link the project more with the executors of the compromises of
the Stockholm Convention and to make a better pursuit of its advances. It is
necessary to give a major visibility to the project and to develop a major
leadership in the project to be able to make a more intense convocatory to the
civil servants in charge of the Stockholm Convention.
The relation with the Ministries of Agriculture and Education has to be strength
and to sign specific agreements that can clearly define their roles in the efforts
to reduce the use of persistent insecticides in the agriculture.
The Global Fund malaria control projects, can be transformed in an opportunity
to potentialized the project, particularly in the improvement of the coverage,
opportunity and quality of diagnostic and treatment. But, if there is not an
accurate coordination, can retreat the advance reached at the demonstrative
towns in the vector control with the communitarian participation when the
impregnated mosquito nets be introduced as the central strategy of control.
RECOMMENDATION
In relation with the Global Fund projects it is recommended to search a higher
coordination with the manager officials and the principal receptors, so they can
define an accurate intervention and discuss how to potentialized the projects. It
would be convenient that the Regional Coordination, with the PAHO support,
make a workshop at regional level with the Global Fund.
The strategy of impregnated bednets with insecticides should be introduced
with a previous evaluation of the epidemiological and entomological
characteristics, taking as reference the recommendations of the selective vector
control.
Mexico with Guatemala and Panama with Costa Rica, have demonstrative
localities in their common borders. However, there are differences in the
intervention strategies particularly in the case management and the elimination
of human hostess of plasmodium. In the Costa Rica border there is a higher
institutional strengthen and a higher socio economic development, which
determine a laboral migration from Panama to Costa Rica.
Without the Panama participation, the malaria card strategy, issued by Costa
Rica, could be turn in a discrimination tool. Because of the deficiency of human
resources and the mobilization, the improvement of the access and the
opportunity of an early diagnostic in the native communities of Panama, it is not
possible without the support of Costa Rica.
RECOMMENDATIONS
Costa Rica should give support to Panama to improve the opportunity and the
access to diagnostic and treatment. It is suggested that should be carried out a
meeting to treat the topic of malaria in the framework of the TCC agreements
and should be formulated a binational plan, with the involvement of consular
authorities.
In relation to the malaria card, the idea is that the people from Panama evaluate
if this strategy is not a discrimination tool. To avoid that, the people from
Panama should be able to issue malaria cards with binational validity and
transform it into a health card.
It is necessary to unify with Panama the diagnostic, the work of the volunteer
collaborators and the card.
.
In the Regional Technical Committee meeting in Costa Rica it was suggested
the necessity to insert the malaria control in the PAHO projects of healthy
municipalities and healthy schools.
3.8 COMMUNITY PARTICIPATION
There is an important advance in the community empowerment and
participation in the project and particularly in the activities of malaria control
(EHCA). Even though, the approach of predominant participation in the health
and vector workers is still the community collaboration.
In Guatemala, thanks to the presence of auxiliary majors, elected by direct
voting, there is a permanent presence of the communities in the municipalities.
This, which can be an ideal model in the relationship community-municipality
can not be replied in other countries, because there are different legal frames.
In Mexico, there is a limitation in the community participation, because the
presence of the "Opportunities project", dependent of the state government, has
distort the community participation. The program "Opportunities" that could be
an advantage have been transformed in a weakness, because is taken by the
population as an obligation for families who receives. The presence of the
municipalities can surpass this problem.
RECOMMENDATION
It is necessary to advance in an approach of social mobilization (REF) and
communitarian co gestion, which it does not mean to abandon the
communities. The inclusion of the communitarian leaders in the discussion of
the Local Operative Committee, particularly in the project monitoring and
evaluation, is a practice that should be invigorated.
In each demonstrative town should be discuss strategies to guaranteed the
presence of communitarian leaders in the local governments.
It is necessary that the municipalities provide regulations for communitarian
participation in the EHCA activities and in the public works of environmental
management. The strategy of red and green cards for the houses and localities
can be legislated at a municipal level as an alternative to involve all the
community members.
In all the visited countries, the communitarian leaders said that even they
received the training they would like to receive formal training courses about the
control strategy. At the evaluation visit they could not find educative materials
and explicative strategies for communitarian training.
Además, los trabajadores de campo, no han recibido de manera sistemática
capacitación para el trabajo comunitario, lo que ha l evado a que el enfoque de
participación comunitario predominante, sea el de colaboración y no de
empoderamiento y movilización social.
Also, the field workers have not received training for communitarian work in a
systematic way, which cause that health workers adopt a collaboration
approach and not the one of empowerment or social mobilization.
The diffusion and the activities of information, education and communication are
still weak and slightly systematized at communitarian level.
RECOMMENDATION
It is necessary for each country, to design and to validate methodologies and
educative materials for communitarian training and field workers training about
communitarian work. This is an essential requirement to extend the experience
at national level.
The pre and post evaluation of the EHCA activities with community participation
is another of the good practices that should be extended to all the
demonstrative towns. This practice should be extended to other interventions,
particularly to the evaluation of the active search of cases, treatment and
elimination of human hostess of plasmodium.
RECOMMENDATION
To introduce, as an obligatory character, the pre and post evaluation of the
control activities with communitarian participation: EHCA, biological control
clean house and clean patio, impregnated mosquito nets in all the
demonstrative projects.
The training of the communitarian leaders and agents about basic entomology
is a requirement that needs the elaboration of training materials.
To involve the communities in activities as the active search of feverish and
radical treatment and for the elimination of plasmodium hostess (TDU 3x3x3 or
3x3x1). In these activities the evaluation pre and post intervention should be
also introduced.
The introduction of rapid tests would facilitate the communitarian participation
in diagnostic and treatment. PAHO should promote the purchase of rapid tests
and the inclusion of the norms in the countries, particularly in far areas.
To improve the knowledge of the community and to maintain the enthusiasm
with the activities, should be developed a communitarian surveillance system.
During the visit to the communities it was clear that there were some indicators
that are easily understood by the communitarian leaders and members, as:
· Positive breeding mosquito sites
· Positive breeding sites in the pre and post evaluations
· Presence of new cases
· Malarious
houses
· People and families who do not want to participate in the control activities
and that do not want to take the antimalarial drugs.
In Guatemala, using the geo referenced maps, where is shown the presence of
positive breeding mosquito sites, the radius of the mosquitoes fly, the malarious
houses and the new cases, is easy for the population to relate the presence of
malaria cases with the presence of breeding mosquito sites.
In the communitarian situation rooms are being used indicators, ways of
graphical presentation or maps to represent the data of the line base, but it has
not been validated if these indicators are understood by the community. Also,
there are not systematized experiences in surveillance, monitoring and
evaluation of the interventions with the communitarian participation, which is an
important requirement to achieve a project sustainability.
In some communities have been documented the development of the
experience with pictures, but it is not a systematic practice. Neither is a
systematic practice to have a field diary, which would facilitate the
systematization of the experiences. There is not a format to systematize the
communitarian experiences.
RECOMMENDATIONS
To use the Communitarian Epidemiology approach to develop: scenarios of
dialogue between the health workers and the community, indicators, ways of
graphical representation and maps that can be easily understood by the
population and the health workers.
In relation with the communitarian instruments for monitoring and evaluation is
recommended the use of:
· The change in the number and percentage of houses with red or green
cards or the clean houses by locality.
· A dynamic mapping that identify malarious houses, repeated cases,
positive breeding mosquito sites, differencing with colors the new cases
(last evaluation) from the old cases. The number of repited cases per
family (malarious houses), with different colors by years would allow to
easily monitoring the houses that keep the transmission.
· To graphic the reduction of the percentage of positive breeding sites
before and after the interventions.
· To graphic the number of houses resistant to interventions and the
people who doesn't want to take the medicines and in Mexico and
Guatemala the cases that abandon the TDU 3x3x3 or 3x3x1. These are
predictive indicators that the community can easily understand.
It is important to document the communitarian work trough: i) the consignment
of the results before and alter the interventions with pictures, ii) to have a field
daybook iii) to design a matrix of experience systematization. For this last
aspect is recommended a format used in Communitarian Epidemiology
(Tognoni, 1999).
In Panama was found that even the communities value the work to control
malaria, there are another health and social problems (access to the services,
job, alimentation) that require a solution. Because the intervention is in an
introductory phase, it has not been discussed how to insert the fight against
malaria in the projects of communitarian development. In the future, if the
intervention is successful, this experience should help to make development
projects with the communities and to support them to solve the most important
problems.
3.9 PERFORMANCE VALUATION
According to the self administrated interviews, the pertinence of the objectives
of the project are near to highly satisfactory, although in the formulated logical
frame, there are products that are activities. Immediate effects have not been
defined to be able to monitor the advances of the project. There are several
results, that really are products, do not define the executors or beneficiaries
performance.
As it was already explained, the period of beginning of the project lasted more
that it was expected, as also the design and execution of the base line, because
of this reason the evaluation of executed activities are qualified as medium
satisfactory. However, because of the short time of execution of the
communitarian control activities, the reached products are highly satisfactory.
The major delay is in the communication component, which have different
advances. This component requires a major support.
Studies about the costs effectiveness have not been made, although according
to the estimation of costs is evident that the costs of integral vector control are
much lower than the indoor spraying. Also, it was verified that the activities to
control breeding mosquito sites (EHCAS) have been executed with the
community own resources and in some countries as Guatemala, with small
investments to buy the tools. The cleaning activities in houses and patios do
not present an additional cost, just the whitewashing houses requires small
investments that in some cases as Mexico and Costa Rica have been
subsidized by the Municipalities or the State. In the first communitarian
interventions it was required extend working hours to execute the activities, but
in the subsequent cleanings the worked hours decreased remarkably.
Es importante recalcar que la inserción de la estrategia de control, requirió una
presencia mayor de los trabajadores de vectores, lo que aunque incrementa los
costos, por la reducción de los casos de malaria que ya se observa en algunas
localidades requerirá en el futuro menor permanencia. Por todo lo
anteriormente explicado la valoración del costo efectividad es satisfactoria.
It is important to remark that the introduction of the control strategy, required a
major presence of vector workers, which increase of the initial costs; but when
the reduction of malaria cases will happen (which is observed in this evaluation
in some of the localities) the cost and workers presence will be reduced.
Because of all the explained, the cost effectiveness valuation of the project is
satisfactory.
The interviewed people qualified the impact as near highly satisfactory, but
because of the short time of the local intervention is not possible to evaluate the
impact. It is possible the high evaluation from the interviewed is because they
assume that the good performance of the reached results as impact.
Until the moment of the evaluation, the project sustainability is qualified as
satisfactory, because: there is a great empowerment of the control activities in
the visited communities. The risk and efficacy perception in the interventions in
the community and the health workers is high; the costs and efforts are lower
than the lost in the working days that malaria represents. The activities of vector
control (EHCAS) and the home and personal hygiene improvement, if it is
supervised, can have a high possibility of insertion in the people's culture and to
become a daily activity.
At local level, the partner's participation, particularly the communitarian leaders
and teachers, is highly satisfactory. The increasing involvement of the Majors
and other municipal and governmental authorities at local level is satisfactory.
There is not an involvement of ONGs in the local projects because they do not
work in specific topics of vector control.
At national level, the coordination between National Coordinators (PAHO) and
the focal point of the Ministry of Health is also highly satisfactory. But the
involvement of other institutions is not like that, especially of the Ministries of
Environment and Agropecuary that in two of the visited countries (Panama and
Guatemala) is weak. With the exception of Nicaragua and Mexico, the
participation of the universities is incipient. In general, the partner's participation
can be evaluated as satisfactory.
The opinion of the communitarian leaders, the local health workers (of general
services and vectors) and of the national civil servants about the project is
highly positive. Because of the advance status of the project, the valuation
about the country empowerment can be qualified as satisfactory.
The Guide defined a methodology of implementation of the project, all the
countries applied in general terms these guidelines and have adapt them to
time of the communities and resources of the country, the local and
communitarian services. The evaluation of the implementation approach is
satisfactory.
The delay of the disbursement to the countries, create uncertainty and they do
not allow to compromise money, so the evaluation of the financial planning is
moderately satisfactory.
The reliability of the project is qualified also as satisfactory. But the monitoring
and evaluation in one of the weaker aspects, so its qualification is moderately
satisfactory.
Table 38. Performance valuation of the project DDT-GEF
PERFORMANCE SATISFACTION
LEVEL
HS S MD US HI
Score
5 4 3 2 1
No % No % No % No % No %
Pertinence of planed objectives and
X
results
Reached activities and products
X
Cost
effectiveness
X
Impact (non applicable)
Sustainability
X
Partners participation
X
Country
empowerment
X
Implementation approach
X
Financial planning
X
Reliability
X
Monitoring and evaluation
X
HS= Highly satisfactory; S= Satisfactory, MD= Moderately Satisfactory, US=Unsatisfactory,
HI= Highly unsatisfactory
3.10 LESSONS LEARNED
3.10.1 Design and approach of the project
The delay in the implementation of the project, establishes the need to define
more real times for the projects execution, particularly in the multi central
projects (regional), because of the problems to adapt the project to the
institutional structures of the participant partners. The time of a regional project
with the actual complexity, should considerate a period of one year for the
administrative and personnel hiring arrangements.
The extend period between the phase of design and the phase of beginning of
the project meant the deactivation of alliances and discouragement of the
principal partners of the project, that deserved special attention and reactivation
with the implications that it takes.
The design and execution of the project, based in an eco systematic approach,
with strategies of selective vector control, has allowed to validate a strategy of
malaria control that promises to be a highly cost effective. The teams of local
and national health are in a process of apprenticeship and experimentation of a
new control model without persistent insecticides that will allow: to break the
verticality of the programs and their uni purpose approach.
3.10.2 Base line and relevant indicators of evaluation
It was formulated in the guide a large number of indicators, most of them have a
hard application in contexts of limited resources. The countries are using a few
indictors.
The selection of few basic indicators wil allow to evaluate the advances and the
impact of the project in a satisfactory way. These indicators could be: the
number of repeated cases, the reduction of malarious houses and the
standardized IPA. The GIS has been transformed in a useful tool for the local
workers and the communitarian agents. The geo referenced maps are an easy
alternative to monitor and to evaluate the results and advances of the project,
as also the community can understand the relationship between the presence of
positive breeding sites and the presence of malaria.
3.10.3 Cooperation mechanisms, team work and alliances policy
The national and local teams and the community have began a process of
apprenticeship to develop a model of multiple alliances and of inter institutional
and inter sectorial cooperation. Creative mechanisms of cooperation have been
developed and the team work between the national and local levels is breaking
the jerarquic and vertical predominant model in the malaria control program.
Another lesson learned is the great importance to conduct the project with the
existent natural organizations and not to create parallel structures, as well as
the intra and inter sectorial work that facilitated the execution of proposed tasks.
3.10.4 Socialization and information exchange and transference of
knowledge between countries.
The web page and the intranet, that were conceived as the mechanism to
exchange information and to transfer knowledge between countries, did not
have the expected successful. The telephone conferences and the regional
meetings have been the best scenarios and mechanisms to reach this
objective, because of the latin tradition of verbal communication. To promote a
documented model have demanded high creativity by the principal managers.
3.10.5 Other lessons
For all the interviewed, the most important apprenticeship is the importance of
communitarian work and the quick incorporation of the communities in malaria
control activities (NCI, LCI).
Even malaria is a public health priority in meso America, it is not a problem that
is in the agenda of the people who takes decisions at the ministries, or in the
politicy agendas, so it is not a politic problem, as it can be the dengue and HIV-
AIDS.
The flexibility of the program to adapt itself to the local realities, the
development of technical capabilities and about spaces to share technical
experiences and about human development.
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