Presented at the 2016 ASTMH conference

1. Evaluation of the Impact of Malaria
Control Interventions on All-cause
Mortality in Children Under-five in
Liberia
Victor S. Koko
National Malaria Control Program, Liberia
November 16th, 2016
American Society of Tropical Medicine and
Hygiene Conference

2. • Background
• Evaluation Objectives and Design
• Evaluation Results
o Trends in malaria intervention coverage
o Trends in malaria morbidity and all-cause child mortality
• Plausibility Analysis and Conclusion
Presentation Outline

3. • Substantial increase in funding for malaria control in the
past decade in Liberia
• Investment led to a progressive expansion of key malaria
control interventions
• Need to know the effect of the expansion of key
interventions on malaria burden to inform future
strategies and programs
Background

4. • To measure the degree to which malaria control
interventions have been implemented and expanded in
Liberia from 2005–2013
• To assess malaria-related morbidity, mortality, and
contextual factors before, during, and after expansion of
malaria control interventions in Liberia
• To assess the plausible attribution of the expansion of
malaria control interventions to changes in malaria-
related morbidity, all-cause and malaria-related mortality
in Liberia
Evaluation Objectives

5. Evaluation Design
Plausibility Framework

6. Evaluation Results
Key milestones on malaria intervention
Year Milestones in Malaria Policy and Implementation
2000 • First National Malaria Control Strategy (2000–2005) adopted and implemented
2003
• Ministry of Health (MOH) reinstated and Malaria Steering Committee formed
• Policy on IPTp adopted
• ACTs introduced in Liberia as first-line treatment for malaria
2004
• First implementation of IRS in targeted areas (camps for internally displaced people in
Montserrado and Bong Counties)
2005
• Second National Malaria Control Strategy (2005–2010) adopted and implemented
• Implementation of IPTp begins
• ACTs officially adopted by MOH as the first-line treatment for uncomplicated malaria
and rolled out nationally
• First ITN distribution through antenatal care and door-to-door distribution
• First Malaria Indicator Survey conducted
• Rapid diagnostic tests (RDTs) are officially introduced in Liberia and rolled out
nationally
2007 • Demographic Health Survey conducted
2009
• IRS implemented in dwellings and among protected populations began in two counties
• First rolling mass distribution of ITNs
• Malaria Indicator Survey conducted
2010
• Third National Malaria Strategic Plan (2010–2015) adopted and implemented
• Integrated Community Case Management, Private Sector ACT, Research, and Supply
Chain Management units in the NMCP established
2011 • Malaria Indicator Survey conducted
2013 • Demographic Healthy Survey conducted

7. Evaluation Results
Trends in Malaria Intervention Coverage
Source: 2005 Malaria Indicator Survey (MIS), 2007 Demographic Health Survey (DHS), 2009 MIS, 2011
MIS, 2013 DHS
* The 2005 MIS and 2007 DHS measured household ownership of any net
% of households that own at least one
insecticide-treated net
% that slept under an ITN the previous
night
0
20
40
60
80
100
2005 2007 2009 2011 2013
%ofhouseholds
0
20
40
60
80
100
2009 2011 2013
%usedITNthepreviousnight
Children under five Pregnant women

8. Evaluation Results
Trends in Malaria Intervention Coverage
% of women 15–49 with a live birth in the previous two years that received
one dose of SP and at least two doses of SP (IPTp)
Source: 2005 MIS, 2009 MIS, 2011 MIS, 2013 DHS
Note: For the 2005 MIS, no data is available on coverage of 1 dose of SP
0
20
40
60
80
100
2005 2009 2011 2013
%ofwomen15–49
1 dose of SP 2+ doses of SP (IPTp)

9. Evaluation Results
Trends in Malaria Intervention Coverage
0
50
100
2007 2009 2011 2013
%ofchildrenunderfive
Sought treatment from health provider Received diagnostic test for malaria
Source: 2007 DHS, 2009 MIS, 2011 MIS, 2013 DHS
% of children under five with fever in the previous two weeks for whom treatment was
sought from a health provider, who received a diagnostic test for malaria, were treated
with any antimalarial, and were treated with ACTs

10. Evaluation Results
Trends in Malaria Morbidity
0
20
40
60
80
100
2005 2009 2011
%children6-59months
6-59 months 6-23 months 24-59 months
0
200
400
600
800
1000
1200
2009 2010 2011 2012 2013
#ofconfirmedcasesper
1,000population
% of children 6-59 months with
parasitemia prevalence (via RDT), by age
group
# of confirmed cases of malaria among
children under five per 1,000 population
Source: 2005 MIS, 2009 MIS, 2011
MIS
Source: HMIS

11. Evaluation Results
Trends in Malaria Morbidity
% of children 6–59 months of age with severe anemia (hemoglobin <8g/dL)
0
10
20
30
40
50
2009 2011
%ofchildren6-59months
6-23 months 24-59 months 6-59 months
Source: 2009 MIS, 2011 MIS

12. Evaluation Results
Trends in All-cause Child Mortality (ACCM)
0
20
40
60
80
100
120
140
NN PNN 1q0 4q1 5q0
Deathsper1,000livebirths
2002-2006 2009-2013
Source: 2007 DHS and 2013 DHS
NN = neonatal mortality (first month); PNN = post-neonatal mortality (1-11 months); 1q0 = infant
mortality (first year); 4q1 = child mortality (1 year to 4 years); 5q0 = under-five mortality

13. Evaluation Results
Trends in Contextual Factors
Contextual Factor Baseline (2007)
%
Endline (2013)
%
% point change
(2007 to 2013)
Household has electricity 3.0 9.8 6.8*
Household has telephone 28.7 64.6 35.9*
Women 15-49 completed primary education 30.7 39.1 8.4*
Basic immunizations (BCG, measles, DPT3, polio3) 39.0 54.8 15.8*
Exclusive breastfeeding 29.1 55.2 26.1*
Under five years, stunted 39.4 31.6 -7.8*
Under five years, underweight 19.2 15.0 -4.2*
Children 6–59 months receiving vitamin A
supplementation
41.9 60.1 18.2*
Four or more antenatal care visits 66.0 77.8 11.8*
Tetanus toxoid (two or more doses) 74.6 84.1 9.5*
Delivery at a health facility 36.9 55.8 18.9*
Skilled attendant at birth 46.3 60.6 14.3*
*Statistically significant change
Source: 2007 DHS, 2013 DHS

14. Plausibility Analysis
Summary of trends in malaria control interventions, malaria morbidity and all-
cause child mortality
-30
20
70
120
0
50
100
2005 2006 2007 2008 2009 2010 2011 2012 2013
Numberofdeathsper1,000livebirths
Percentage
ITN ownership ITN use (children under-five)
ITN use (pregnant women) IPTp
Care seeking for fever ACT use
Source: 2005 MIS, 2007 DHS, 2009 MIS, 2011 MIS, 2013 DHS

15. Conclusion
• Data on malaria morbidity suggest a decline in parasitemia
prevalence and malaria cases; these declines are most likely due to
the expansion of malaria control interventions between 2005 –
2013.
• It is likely that intervention expansion is still in the early stages and
did not reach high enough levels to have had a significant impact
on ACCM during the evaluation period.
• Other contextual factors likely contributed substantially to the
declines observed in ACCM, and specifically in infant mortality.

16. This presentation has been supported by the President’s Malaria Initiative (PMI)
through the United States Agency for International Development (USAID) under the
terms of MEASURE Evaluation cooperative agreement AIDOAA-L-14-00004.
MEASURE Evaluation is implemented by the Carolina Population Center at the
University of North Carolina at Chapel Hill, in partnership with ICF International; John
Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University.
Views expressed are not necessarily those of PMI, USAID, or the United States
government.
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