Methods for Measuring Impact of Malaria Control Efforts on Child Deaths

MEASURE Evaluation has co-authored six of nine publications contained in a special supplement of the American Journal of Tropical Medicine and Hygiene.

© 2014 Sanghamitra Sarkar, Courtesy of Photoshare
© 2014 Sanghamitra Sarkar, Courtesy of Photoshare
WASHINGTON, DC—MEASURE Evaluation has co-authored six of nine publications contained in a special supplement of the American Journal of Tropical Medicine and Hygiene focused on impact evaluations and other studies demonstrating that malaria control and prevention efforts have contributed to saving millions of children’s lives across malaria-endemic areas.

Malaria remains a major cause of preventable death, killing an estimated 429,000 people and causing more than 212 million illnesses in 2015, according to the World Health Organization (WHO). The September 2017 supplement focuses on evaluating the impact of malaria control interventions in sub-Saharan Africa, where most of malaria deaths are among children under the age of five years. As the flagship project of the United States Agency for International Development (USAID) MEASURE Evaluation is mandated to improve health information systems, expand capacity for rigorous evaluation, and for monitoring and evaluation (M&E) of health programs. Based on this experience, the project’s contributions to the supplement center on ways to measure a proxy indicator of reduced child deaths from malaria—referred to as “all cause child mortality (ACCM).”  

Several factors affect the ability to measure this impact, among them the ethical issues of designating a control group or counterfactual, the presence of concurrent interventions that may be contributing to reductions in child mortality, the lack of high-quality data for analysis, and environmental changes that alter malaria severity. Nevertheless, the authors of these five studies—in varying degrees—offer evidence that a plausibility design can accommodate these challenges and offer a framework for evaluating the impact of national malaria interventions on child mortality.

The supplement was released September 27 by the American Society of Tropical Medicine and Hygiene (ASTMH), at a conference in Washington, DC. Attending were experts from the U.S. President’s Malaria Initiative (PMI), the U.S. Centers for Disease Control and Prevention (CDC), the Center for Global Development, the Roll Back Malaria Partnership, WHO, ASTMH, the Kaiser Family Foundation, the United Nations Children’s Fund (UNICEF), and the director of the National Malaria Elimination Centre in Zambia.

The report highlights the success of malaria control efforts such as insecticide-treated bed nets (ITNs), residual indoor spraying, rapid diagnostic tests, and prophylactic treatment provided to pregnant women. These interventions are proven to reduce the incidence of malaria—between 2000 and 2015, malaria deaths declined by 60 percent, and almost seven million lives were saved—but their specific contribution to reducing child deaths is difficult to quantify. This supplement seeks to offer reliable methods and evidence on reducing child deaths.

“In sub-Saharan countries, where health programs implement various different interventions that target children—and thereby reduce child mortality—impact evaluation offers a scientific approach to understanding the contributions of all the combined malaria interventions that make up our national malaria control program,” says Médoune Ndiop, monitoring and evaluation officer at the National Malaria Control Program (NMCP) of Senegal. “The plausibility approach also allows us to examine how the overall malaria control policy contributed to changes.”

One of MEASURE Evaluation’s studies is a seminal work that outlines a methods framework for evaluating interventions such as malaria control in settings where many programs and factors coincide. The method is a plausibility design that recognizes the non-linear nature of the question under investigation—in this case, the attribution for reduced numbers of child deaths.

The plausibility approach is a good avenue to document evidence of malaria control achievements in endemic countries,” says Yazoume Yé, senior infectious disease specialist with MEASURE Evaluation at ICF, and lead author of Framework for Evaluating the Health Impact of the Scale-up of Malaria Control Interventions on All-cause Child Mortality in sub-Saharan Africa. “Further improvements are possible as better-quality data are available and health information systems are strengthened.”

Another article offers lessons that country ownership and involvement of stakeholders throughout are crucial to avoid duplication of effort and that evaluations must be tailored to the country context, follow a standard method, and develop informative products for a broad range of stakeholders. The other three articles examined studies in Malawi and Senegal, finding that national malaria control efforts reduced ACCM in Malawi by 41 percent from 2000 to 2010; that an evaluation in Malawi of population-level association between ownership of ITNs and ACCM between 2006 and 2010 may have contributed to a decline in child mortality, and that Senegal dramatically increased malaria control intervention coverage during 2005–2010 and—in that same time frame—ACCM declined significantly, especially among the age groups, epidemiologic strata, and socio-economic strata most at risk for malaria.

The papers in the supplement and the accompanying editorial and commentaries indicate the need to strengthen in-country capacity for generating strategic information through improved routine health information systems for program monitoring and malaria surveillance. The editors of the supplement argue that malaria deaths will not indefinitely decline in countries that have successfully controlled the disease, and that, therefore, a shift to improved data quality for tracking malaria infection and illness rates will be necessary to ensure current gains are not lost and to guide programs toward elimination.

Framework for Evaluating the Health Impact of the Scale-up of Malaria Control Interventions on All-cause Child Mortality in sub-Saharan Africa
Yé Y, Eisele TP, Eckert E, Korenromp E, Shah J, Hershey CL, Ivanovich E, Newby H, Liliana Carvajal-Velez, Lynch M, Komatsu R, Cibulskis R, Moore Z, Bhattarai A

Implementing Impact Evaluations of Malaria Control Interventions: Process, Lessons Learned, and Best Practices
Hershey C, Bhattarai A, Florey LS, McElroy PS, Nielsen CF, Yé Y, Eckert E, Franca-Koh A, Shargie E, Komatsu R, Smithson P, Thwing J, Mihigo J, Herrera S, Taylor C, Shah J, Mouzin E, Yoon S, Salgado R

Malaria control interventions protect against malaria parasitemia, severe anemia and all-cause mortality in children less than five years of age in Malawi, 2000–2010
Hershey C, Florey LS, Ali D, Bennett A, Luhanga M, Mathanga DP, Salgado R, Nielsen CF, Troell P, Jenda G, Yé Y, Bhattarai A

Declines in malaria burden and all cause child mortality following scale up of control interventions in Senegal 2005-2010
Thwing J, Eckert E, Dione D, Tine R, Faye A, Yé Y, Ndiop M, Cisse M, Ndione JA, Diouf BM, Ba M

Impact of Insecticide-Treated Net Ownership on All-Cause Under-Five Mortality in Malawi, 2006–2010
Florey LS, Bennett A, Hershey C, Bhattarai A, Nielsen CF, Ali D, Luhanga M, Taylor C, Eisele T, Yé Y

Methodological Considerations for Use of Routine Health Information System Data to Evaluate Malaria Program Impact in an Era of Declining Malaria Transmission
Ashton RA, Bennett A, Yukich J, Bhattarai A, Keating J, Eisele TP