VECTOR CONTROL NEEDS ASSESSMENT AND NATIONAL ACTION PLAN UNDER

VECTOR CONTROL NEEDS ASSESSMENT AND NATIONAL ACTION PLAN UNDER THE GEF/EMRO PROJECT “REDUCTION OF RELIANCE ON PESTICIDES IN VECTOR CONTROL” (1 Draft) Republic of Yemen November 2006 st TABLE OF CONTENTS (to be reviewed) List of abbreviations Foreword Introduction 1. Situation analysis General health statistics Malaria situation and recent trends (mortality, morbidity, burden, segregated datasets by season, by region, by vulnerable group). Eco-epidemiological stratification History of malaria control in Yemen and recent developments (i.e. decrees, policies, strategies) Distribution of malaria vectors in Yemen Description current vector control programme Chemical control Types of chemical used for IRS and for ITNs, imported quantities on an annual basis Number of houses sprayed (annual reports) Use of insecticide treated nets (annual reports) Larviciding (annual reports) Susceptibility status insecticide resistance (use of insecticides in agriculture, types, quantities) Biological control Malaria, vectors and the association with water resources Development Environmental management interventions Malaria epidemics Social dimensions (community acceptance, community participation, affordability of nets, local outreach through mosque, schools and agricultural extension) 2. Current capacity Components of current control programme Components of current vector control programme General: infrastructure (buildings, laboratories) Technical capacity 2 Chemical control: staff, vehicles, equipment, materials (incl. insecticides and nets) Technical support for the sound management of pesticides: institutions, staff, regulatory framework Laboratory support insecticide resistance testing: staff equipment, materials Biological control: staff, vehicles, facilities to rear fish and predators Environmental management: staff, vehicles, materials Malaria epidemics Research capacity in all vector control areas Management capacity Vector control decision making criteria and procedures IVM approaches (cost-effectiveness analysis, options analysis, synergy maximization, decentralization) Organogram for vector control programme with clear post descriptions Process of periodic progress review and formulation of plan of activities Independent quality control, monitoring and evaluation Sound management of pesticides Effective mechanisms for intersectoral collaboration Policy framework National public health policy National malaria policy and strategy National strategy for Integrated Vector Management National policy to promote intersectoral action for health National policy to decentralize health services Resources assigned to malaria control Resources assigned to vector control Human resources: regular staff, temporary staff, admin. support staff Financial resources: capital costs, recurrent costs; any cost recovery 3. NEEDS ASSESSMENT Goals 3 Where does the Government of Yemen want vector control to be five years from now? Assumptions and sensitivity What are the assumptions made in setting these goals and how do changes in the assumptions affect the capacity to reach the goal? Deficiencies Two scenarios: (1) business as usual (i.e. a repeat of the last five years, no progress) (2) action to achieve the new goals, in line with principles of Stockholm Convention Needs The difference in inputs required for scenario (1) and scenario (2) defines the additional activities that need to be undertaken, both in operational activities and in capacity building (policies, institutions, human resources). 4. INCREMENTAL COSTS Action Plan 2007-2011 Incremental costs Annexes 4 List of abbreviations API: Annual parasite incidence BDN: Basic developmental needs COMBI: Communication for behavioural impact ECHO: European commission EIA: Environmental impact assessment EM: Eastern Mediterranean EMRO: Eastern Mediterranean regional office GCC: Gulf cooperation council GDP: Gross domestic product GEF: Global Environmental Facility GFATM: Global Fund to Fight AIDS, TB & Malaria GNP: Gross national product HIA: Health impact assessment HQ: headquarters IMCI: Integrated Management of Childhood Illnesses IRS: Indoor residual spraying ITN: Insecticide treated net IVM: integrated vector management LLIN: Long lasting insecticidal net M&E: Monitoring and evaluation MMT: Malaria management team MoPH&P: Ministry of Public Health & Population NGO: Non governmental organization NMCP: national malaria control programme PHC: Primary health care PSM: Procurement and supply management system PW: Pregnant women SPR: Slide positive rate UAERC: United Arab Emirates Red Crescent Unicef: United Nations Children’s Fund VBD: Vector borne disease WB: World Bank WHO: World Health Organization 5 Foreword The Republic of Yemen is one of the poorest countries in WHO‟s Eastern Mediterranean Region; indeed, it ranks less than 30 from the bottom of UNDP‟s global development index. Intrinsically related to the level of poverty among the population of Yemen is the high burden of infectious diseases: respiratory infections, diarrhoeal diseases and tropical parasitic infections, all contributing to high infant mortality rates. Among this burden of ill-health, malaria stands out. With over 11 million of the almost 20 million Yemenis at risk, and an estimated number of 3 million cases annually till the early years of the current decade which has been successfully reduced to about 800-900 thousand cases in 2005/2006 after the establishment of the National Malaria Control Programme in 2000/2001, malaria is a drain on Yemen‟s economy and human resource base and a burden on its overstretched health services. Important inroads have been made over the past five years to interrupt malaria transmission, using a mainly chemical approach of larviciding, indoor residual spraying and the provision of insecticide treated nets. The economic reality of Yemen makes it imperative that the Government achieves maximum health benefits from its investments in health interventions. It is therefore tempting to focus on the short term exclusively on the application of residual pesticides, using the most cost-effective products available in the market. Yet the Yemen health authorities are very much aware of the need to ensure sustainability of their short-term achievements through an approach of chemical control. The specter of insecticide resistance always looms large and environmental and social risk factors will change as development progresses. Yemen is a signatory of the Stockholm Convention on Persistent Organic Pollutants and as such well aware of its responsibilities and options in the context of this international legally binding instrument. In the vision of the Government of Yemen, the critical situation of malaria and other vector-borne diseases calls for the development of an integrated vector management programme that builds on a sound knowledge of local ecological and epidemiological settings to develop optimal combinations of environmental, biological and chemical interventions. Cost-effectiveness and sustainability will be essential attributes. Clearly, this will incur increased costs over and above the current budget for the standard, singularly chemical approach. Investments to be made in capacity building and environmental management interventions will, in part, require important capital investments. In follow-up to the first meeting of Member States involved in the EMRO/GEF project on alternatives to DDT for disease vector control, the Government of Yemen carried out a situation analysis and a vector 6 control needs assessment, which are presented in this report. Based on the analysis and assessment, an action plan was developed for the required capacity building and demonstration projects in specific settings on biological control and environmental management approaches, with a budget of the additional resources required (the incremental costs) for the first steps in the upgrade of the existing vector control programme to the standards of integrated vector management. Head of the Intersectoral Steering Committee Dr Majed Al Jonaid Deputy Minister for PHC 7 Introduction: In Yemen, malaria continues to be one of the major and priority health problems since 60% of the population is at risk of contracting the infection in the malaria endemic areas they reside in. Pregnant women and children under five are the mostly affected groups whereas all age groups are at great risk in the epidemic prone areas where epidemics may occur following unusual climatic changes, e.g., heavy rainfalls, unexpected warming and rise in humidity. Plasmodium falciparum, the life threatening species of malaria, is the dominant species accounting for more than 90% of malaria cases annually. Anopheles arabiensis, one of the most effective malaria vectors worldwide is the major vector in the mainland and this aggravates the seriousness of the problem. In Socotra island and Al Mahra governorate, Anopheles culicifacies, a moderately effective vector, is the main malaria vector. Civil and political unrest during the 1980s –1990s led to the full arrest of all anti-malaria activities in the country, resulting in a serious aggravation of the malaria problem. In the late nineties, WHO estimated that the malaria burden in Yemen was an annual incidence of about 3 million cases with an estimate of 1% related deaths. It is also worth mentioning that some studies and reports estimated that families living in the malaria endemic areas spend considerable amount of their income on the management of malaria cases and this proves that an effective and successful NMCP will positively contribute to the „Poverty Reduction‟ strategy of the country. The national malaria control programme (NMCP) in Yemen has been reinvigorated from scratch in 2000/2001 and has been receiving since then a very high level of attention and support from the Yemeni government reflecting the political will and commitment. E.g. the budget of the NMCP has been YR 365 million annually, equivalent to USD 2 million since 2001 compared to just YR 50 million equivalent to about USD 270,000 in the year 2000 and about YR 25 million annually in the previous years. WHO, being the major partner of the NMCP and known to have the technical expertise, provided the services of a fixed-term medical officer and a short-term professional entomologist in December 1999 and August 2001 respectively, to support the RBM programme in the initiation of its various plans and activities. The main outputs since 2000 were in the form of strategic planning, organized structure, national capacity building, new qualified and dedicated staff, improved case management and setting a national anti-malarial treatment policy, monitoring the efficacy of anti-malarial drugs, quality assurance, an organized vector control based on geographical reconnaissance (or GIS) and entomological surveys, health education in addition to the efforts to improve surveillance and information system. All these components were developed in full collaboration with RBM/WHO. A Supreme National Malaria Control Committee was formed in 2000 to ensure a strong inter-sectoral collaboration. The National Strategic Plan for RBM in Yemen (2001-2005) was developed in 2001, consisting of 8 strategic directions as follows: 1. Human resource development 2. Early and correct diagnosis followed by prompt and effective treatment of malaria cases 3. Integrated vector control 4. Prevention of malaria in pregnancy 5. Epidemic preparedness and response 6. Strengthening the information system and surveillance 7. Increasing the capability of the community to recognize, prevent and control malaria 8. Developing the capacity to plan and implement operational field research 8 At the end of the 2001-2005 five year plan, and according to the available flow of information, it is estimated that the annual malaria incidence in Yemen has been dramatically reduced to range from 800,000 to 900,000 malaria cases. Lot of efforts still have to be done to strengthen the information and surveillance system especially that the public health services‟ coverage does not exceed 50% of the population and a plan to involve the private sector in the information and surveillance system should be developed. The national strategic plan for the NMCP for the five years 2006-2010 has the following strategic directions: 1. Maintenance and strengthening of the high level political commitment to combat malaria 2. Strengthening the infrastructure of the NMCP at the national, governorate and district levels. 3. Human resource development 4. Early and correct diagnosis followed by prompt and effective treatment of malaria cases 5. Integrated vector management 6. Efficient epidemic preparedness and response 7. Strengthening the information system and surveillance (M&E) 8. Increasing the capability of the community to recognize, prevent and control malaria 9. Developing the capacity to plan and implement operational field research Still „Human Resource Development‟ is an important strategic direction since there is still shortage of national cadres in some key areas, e.g. there is no senior staff specialized in vector control and entomology. Currently there is one national who got Diploma in Entomology from Ain Shams University in Egypt in 2005 and is now studying MSc in Entomology in the High Institute of Public Health in Alexandria and is supposed to finish his studies in 2007 to join the NMCP as the 1st qualified national in entomology. The NMCP has proved, since its re-organization and revitalization in 2001, its capability to demonstrate success stories in the once known to be the highest malarious areas in the country namely Tihama and Socotra island. Graphs will be shown under the situation analysis. Strong partnerships were built with lot of partners, e.g. WHO, Sultanate of Oman, Saudi Arabia, Japan, Italy, World Bank, Unicef, UNDP, local NGOs, international NGOs, ECHO and lastly the GFATM. The GFATM has approved the proposal submitted in the 2nd round in 2002 and has apportioned a grant of USD 11, 878,206 over 5 years. The phases of this grant started late in 2003. In 2004, the WHO regional office of the eastern Mediterranean (EMRO) presented its initiative of “Malaria Free Arabian Peninsula” in the light of the successes of Oman and United Arab Emirates, the progress achieved so far in the southern malaria endemic areas in Saudi Arabia and the progress achieved in Yemen within a very short period of time. Malaria is one of the most important health problems in Jazan and Asir regions in Saudi Arabia especially at the areas bordering Yemen. Again Anopheles arabiensis and Plasmodium falciparum are the dominant malaria vector and species in these areas. The United Arab Emirates and the Sultanate of Oman have managed to interrupt indigenous malaria transmission and have almost eliminated malaria, whereas Kuwait, Bahrain and Qatar have become almost malaria free countries. 9 A conceptual proposal was prepared by EMRO/WHO in 2005 aiming mainly at supporting the NMCP in Yemen and maintaining the malaria free status in the Gulf countries which have eliminated malaria to achieve the ultimate goal of “malaria free Arabian Peninsula” by 2015. The GCC countries issued the resolution no 5-D with this regard during the round no 31, the 60th conference in the Kingdom of Bahrain on 27-28 February 2006. This resolution approved the WHO/EMRO‟s concept proposal and decided to form a high level committee of deputy ministers from the GCC countries to follow up the implementation of a strategic plan set for this initiative by the technical Gulf Committee formed of the directors of malaria and vector control in the Gulf countries with the technical assistance of WHO. It is worth mentioning that the NMCP is not only managing „Malaria‟ but also other vector borne diseases known to be endemic in Yemen in collaboration with the relevant sectors, e.g. leishmaniasis, dengue and dengue haemorrhagic fever, filariasis, onchocerciasis, rift valley fever within the framework and context of integrated vector management. 10 1. Situation analysis 1.1 General health statistics: some important demographic and health indicators for the Republic of Yemen Demographic indicators: - Area: 555,000 km2 - Total Population (2004): 19,685,161 Urban population: 27% - Crude birth rate: 39.2 per 1000 - Crude death rate: 11.4 per 1000 - Population growth rate: 3.5% - Population < 15 years: 46.2% - Population 65+ years: 2.9% - Dependency ratio: 99% - Total fertility rate (R): 6.2 - Population density (as in 1994): 28 persons/km2 The map of Yemen showing the population densities Map of Yemen 11 Socioeconomic indicators: - Adult literacy rate (15+ years):  Total: 47%  Males: 63%  Females: 31% Gross primary school enrolment ratio:  Total: 72%  Males: 88%  Females: 55% Gross secondary school enrolment ratio:  Total: 41%  Males: 58%  Females: 23% Per capita GNP (US$): 473 Population with access to safe drinking water: 36% Population with adequate excreta disposal facilities: 41% Unemployed: 12% Regular smokers 15+ years:  Total: 24%  Males: 35%  Females: 13% - - Health expenditure indicators: - GDP per capita (in US$): 614 - Total expenditure on health per capita (in US$): 23 - General government expenditure on health per capita (in US$): 6.2 - Total expenditure on health as % of GDP: 3.7% - General government expenditure on health as % of total health expenditure: 27.2% - Household expenditure as % of total health expenditure: 62.5% - Ministry of Health budget as % of government budget: 5.2% Human and physical resources indicators: (Rate per 10,000 population) - Physicians: 2.2 - Dentists: 0.12 - Pharmacists: 0.8 - Nursing and midwifery personnel: 5.2 - Hospital beds: 5.9 - Primary health care units and centres: 1.5 Indicators of coverage with primary health care services: - Population with access to local health services:  Total: 50% 12 -  Urban: 80%  Rural: 20% Married women (15-49) using contraceptives: 23% Pregnant women attended by trained personnel: 45% Deliveries attended by trained personnel: 28% Health status indicators: - Life expectancy at birth:  Total: 62.9 years  Males: 62 years  Females: 63.8 years - Newborns with birth weight of least 2.5 kg: 79% - Children with acceptable weight for age: 54% - Infant mortality rate: 67.4 per 1000 live births - Probability of dying before reaching 5th birthday: 94.8 per 1000 live births - Maternal mortality ratio per 10,000 live births: 36.6 References: 1- Demographic and Health Indicators for Countries of the Eastern Mediterranean, 2005, by WHO/EMRO (reference year for data provided is 2001,2002 or 2003) 2- Yemen Family Health Survey, Principal Report, 2005 Recently, the Global Fund to Fight AIDS, Tuberculosis and Malaria extended its grant to the Republic of Yemen for a second phase with a three year duration from April 2006 to March 2009, worth US$7,718,574 (the total grant amount –phase 1 and phase 2- is US$11,878,206). The expected results are:  Construction of NMCP headquarters in Sana‟a and Tihama subregional malaria office in Hodeida  Two medical entomologists selected and trained in the field of monitoring the bionomics and behaviour of vectors in support of malaria vector control  Thirty national trained in “Epidemiology in Action” (from NMCP, other MoPH&P departments and from the private sector.  Eighty five national laboratory and clinical supervisors in the NMCP trained and certified in planning, monitoring and evaluation.  Number of governorates increased with complete, reliable, valid and continuous malaria information systems connected to the national health information system.  Number and percentage of pregnant women correctly using the ITNs increased.  Number and percentage of children correctly using the ITNs increased.  Hundred percent coverage with integrated vector control measures achieved in Socotra island.  Laboratory diagnosis and clinical management of all malaria cases perfected and meeting national protocol and guidelines criteria, for both uncomplicated and complicated malaria. 13  Coverage by integrated vector control operations in Tihama, especially IRS, LLINs and larviciding increased. Monitoring and evaluation: There is a national plan for Monitoring and evaluation, which is an essential component of any successful malaria control programme since monitoring measures the implementation of its range of strategic activities while evaluation measures the extent to which its objectives are being reached. This plan was prepared jointly by the NMCP and WHO and was approved by the GFATM. Monitoring is an ongoing and continuous process which means step-by-step follow up and recording of the progress of the programme; whether the implementation is carried out as per the plans and any problems or difficulties encountered to take the timely decisions to resolve them. Evaluation allows periodic assessment of the way in which strategies and implemented activities reach the planned objectives. Evaluation indicators are either outcome-based or impact-based. In Yemen, the NMCP adopted the 5 global M&E indicators which are 2 impact and 3 outcome indicators in addition to other indicators appropriate to its local epidemiological situation and specific strategies. The two global impact indicators are: 1) Malaria death rate (probable and confirmed cases) among target groups (under-fives and other target groups); and 2) Number of malaria cases, severe and uncomplicated (probable and confirmed) among target groups (under-fives and other target groups). The three global outcome indicators are: 1) proportion of households having at least one insecticide-treated mosquito net (ITN); 2) percentage of patients with uncomplicated malaria getting correct treatment at health facility and community levels, according to the national guidelines, within 24 hours of onset of symptoms; and 3) percentage of health facilities reporting no disruption of stock of anti-malarial drugs as specified in the national drug policy, for more than one week during the previous three months. Indicators of the M&E plan of the NMCP in Yemen 1) 2) 3) 4) 5) 6) 7) Annual Parasite Incidence (per 1,000) Prevalence of malaria or Prevalent malaria Malaria Death rate Malaria case fatality Incidence of confirmed and clinical uncomplicated malaria cases Incidence of confirmed and clinical severe malaria cases Percentage of clinical and confirmed uncomplicated malaria cases who received the correct treatment according to the national AMD policy within 24 hours of the onset of symptoms 8) Percentage of severe malaria cases correctly treated in the public hospitals 9) % of health facilities reporting no disruption of stock of AMDs (as specified in the national AMD policy) for more than one week during the previous 3 months 10) % of health facilities able to confirm malaria diagnosis according to the national policy (microscopy and/or rapid tests) 11) % of households having at least one ITN or LLIN 14 12) Number or Percentage of children under five and PW who slept under ITNs or LLINs in the previous night 13) Proportion of buildings including houses, shelters, etc sprayed with insecticide within the plan of Indoor Residual Spraying (IRS) 14) Proportion of potential breeding sites targeted and covered by larviciding in a governorate, found negative for Anopheline larvae on larval cross checking during field supervision during a specified period of time 15) Proportion of malaria epidemics detected within two weeks of its onset and properly controlled 16) Number of governorates having a malaria management team 17) Number of functional units 18) The presence of a national committee with the representation of the different relevant sectors 19) Number of functional sentinel sites for monitoring the efficacy of AMDs 20) Number of districts implementing the strategy of home management of malaria 21) Number of governorates implementing the Quality Control system on its laboratories 22) Number of sites established to monitor the efficacy of insecticides and detect any resistance by the vector(s) 23) Number of governorates where there is integration with the National Centre of Disease Surveillance 24) Number of cases reported on the “Malaria Case Notification Form” from Socotra to NMCP HQ in Sana‟a 25) Number of targeted districts with BCC services (Behavioral change and communication) 26) Number of Research studies conducted biennially M&E Unit: There is a technical committee in the NMCP responsible for M&E. This committee is formed of the following members: 1- Director General of the NMCP (chairman) 2- Director of Epidemiology (rapporteur and focal point for M&E until a new M&E focal point is appointed exclusively for this job) 3- Director of Vector control operations (member) 4- Director of Training and Research national centre (member) 5- Advisor to NMCP (member) 6- Directors of Malaria Sub-offices in Tihama, Aden and Hadramawt (members) 7- GFATM staff unit: Director of the unit, incharge of information technology and incharge of finance 8- WHO medical officer Malariologist (advisor) 9- WHO STP entomologist (advisor) The HQ members in the committee hold regular meetings on a weekly basis to monitor the ongoing activities and conduct formative and summative evaluations, and decide, when necessary, to call any member or all the members from outside the headquarters. At the subnational level, the plan is to form a malaria management team (MMT) in Tihama sub-regional office, in Socotra island and in each governorate formed of the following: - malaria coordinator, who will act at the same time as the M&E focal point - in-charge of MIS (malaria information system) - in-charge of IVM (integrated vector management) 15 - focal person for malaria case management focal person for laboratory diagnosis A copy of the national M&E plan is attached. The Poverty Reduction Strategy Paper (PRSP) for Yemen for the period 2003-2005 makes ample reference to the community health status in the country as both determining and determined by poverty. Malaria is among the diseases listed within the spectrum of ill health of the Yemeni population. The PRSP strategy refers to malaria under the heading development of human resources as follows: The strategy of the Government of Yemen is to gradually turn the public health sector away from direct service provision in hospitals and to focus its role in the following directions: - Providing limited basic health services, especially to the poor, on cost-sharing basis. - Providing basic preventive health service such as the Expanded Programme for Immunization, Food and Health education for all the population - Enhancing the programmes for combating endemic diseases, such as diarrhea, malaria, schistosomiasis, tuberculosis, hepatitis, AIDS and venereal diseases. The implementation section of the PRSP does not specify in detail the amount of funds allocated for this programme enhancement. 1.2 Eco-epidemiological stratification The topography and the climate zones of the Republic of Yemen are critical determinants of the distribution, intensity and seasonality of malaria in the country. Based on these determinants, the territory of Yemen is divided into the eco-epidemiological regions presented below. This stratification is one of the principal criteria in the decision making about the composition and deployment of the vector control programme. In addition to this zonal stratification, there are also a number of specific eco-settings that are discussed below. Coastal plains (from sea level up to 200m elevation): - malaria is hyper-endemic or meso-endemic in areas along the wadis. - inhabited by 25% of the total population. (Reference is made to the Tihama case description in annex 1). Slopes from the mountainous to the coastal areas (from 200-500m above sea level): - malaria is hyperendemic. - inhabited by 5% of the total population. Mountainous areas 16 (a) from 500m-1500m above sea level - malaria is hyper-endemic or meso-endemic - the endemicity is low in the higher altitudes - inhabited by about 30% of total population (b) from 1500m to 2000m above sea level - malaria transmission is rare; it follows marked meteorological events, especially heavy rainfall - malaria cases are imported from endemic areas due to active daily population movement - inhabited by about 20% of total population (c) above 2000m above sea level and in deserts - malaria free - inhabited by 20% of total population. Topographic Stratification Special settings (a) Islands Yemeni islands are scattered along Yemen‟s territorial waters spanning the Red Sea and the Arabian Sea. Such islands enjoy their own special weather conditions, environment, vegetation, landscape and natural set up. Most of the islands are in the Red Sea forming an archipelago along Yemen‟s coastal strip. The Island of Kamaran is the largest and most important island. It is inhabited and contains rare wildlife. To the north of Kamaran, there are the islands of Baklan, Al Tayer and Al Fasht and to the south the islands of Zugar, the archipelago of Hunaish (which includes Greater Hunaish and Small Hunaish islands). Meyoun Island (Perim) controls Bab-AlMandab and divides it into two parts. 17 In the Arabian Sea, there are a number of Yemeni islands close to one another. The largest and most famous is Socotra which enjoys abundant and rare fauna and flora. Malaria was hyperendemic in Socotra island before the malaria elimination project was initiated in 2000. Malaria transmission has been almost interrupted in 2005 (see Socotra case description in annex 2, refer to graphs no.4 &5) Malaria transmission season in the coastal areas and Socotra island takes place in winter form October to April and in mountainous areas in summer from May to September after rainfalls. (b) Water Resources Development Hundreds of wadis are distributed all over the country in addition to thousands of streams and running water canals flowing from the mountains to the sea. Hundreds of small dams are constructed along these wadis without environmental and health impact assessments (EIA and HIA). It is on settings where water resources development has had a predominant impact on the determinants of malaria transmission that the focus of the increased IVM efforts supported by the UNEP/GEF project will be directed, because here the biggest opportunities exist to reduce the reliance on insecticides by the promotion of environmental management measures. The criteria include:  Clear attribution of malaria transmission to environmental determinants modified by water resources development.  Realistic options to reduce the transmission risks through environmental management.  Cost-effectiveness of such interventions enhanced by dual benefits for health and agriculture.  Opportunities for community involvement in recurrent environmental manipulation activities. Vector distribution in relation to eco-epidemiological stratification and special settings Main vectors are A. arabiensis, A. culicifacies (in the East and the islands) and A. sergenti limited to foothills mainly. A. arabiensis is quite versatile, A. sergenti breeds in seasonal streams, and A. culicifacies in rockpools in wadis, in cisterns and wells (irrigation). 1.3 History of malaria control in Yemen and recent developments (i.e. decrees, policies, strategies) - 1940: Malaria unit in Abyan - 1969: Malaria Control Programme in Aden - 1978: Malaria Control Programme in Hodaidah - 1991: Malaria Control Programme (MCP) in Sana‟a Malaria control faced serious problems during the 1990s until the year 2000 due to political unrest and socio-economic instability which led to almost freezing of all the malaria control 18 activities and a serious rise in the incidence and prevalence of malaria and even malaria epidemics following heavy rainfalls in 1996 and 1997. - January 2000: A “Statement of Intent” was issued by the Ministry of Public Health committing Yemen to the WHO Roll Back Malaria (RBM) initiative with its six elements: a) Evidence-based decisions b) Rapid diagnosis and treatment c) Multiple prevention d) Focused research e) Coordinated action for strengthening health services, policies and providing technical support f) Harmonized actions to build a dynamic global movement - April 2000: the establishment of the Supreme National Malaria Control Committee by a prime ministerial decree no. 18/2000 - November 2000: A prime-ministerial decree to establish the HQ of the national malaria control programme in the capital Sana‟a. - December 2000: The “Inception Process” of Roll Back Malaria was started by the formulation of the 5-year plan 2001-2002 for RBM - March 2001: The prime-ministerial decree no. 19/2001 announced the year 2001 as the year of “Malaria Control” in Yemen The actual programme activities started during the first quarter of the year 2001. - February 2002: The ministerial decree no. 57/3 for the year 2002 made the management of malaria including the investigations and treatment free of charge in all the ministry of public health institutions. - 2003: Country Coordination Mechanisms for the Global Fund have replaced the Supreme Committee dealing with the three diseases: HIV/AIDS, malaria and tuberculosis. - February 2005: The ministerial decree no. 13/2 for the year 2005 formed a high level committee for „Vector Control‟ under the chairmanship of HE the deputy minister for primary health care and having the membership of the DG of the NMCP, director of operations in NMCP, a representative of WHO and representatives from the ministry of agriculture and irrigation, the ministry of water and environment, the ministry of information, the ministry of local administration, the ministry of education, the ministry of religious affairs, the ministry of general works, in addition to 3 representatives from NGOs and the private sector. 19 1.4 Malaria situation and recent trends Ranking of Yemen among the Eastern Mediterranean Region’s countries with regard the burden of malaria:     50% of EMR population live in areas at risk 15 million estimated clinical episodes per year 59,000 estimated deaths due to malaria per year >99% cases occur in 6 countries: Afghanistan, Djibouti, Pakistan , YEMEN, Sudan and Somalia  3 countries: Iran, Iraq and Saudi Arabia have limited transmission  13 countries have eliminated malaria or are very close to achieve malaria elimination. According to WHO reports, the burden of malaria used to be estimated as 2.5-3 million cases a year in the late nineties and till the early years of the current decade, with a toll of 1% mortality rate of the above mentioned figure. It was also estimated that 60% of the Yemeni population are at risk of contracting malaria. Falciparum malaria constitutes more than 90% of the recorded cases except in the eastern governorate of Al Mahra governorate where vivax malaria is the dominant species. Pregnant women and children under five the most vulnerable groups among the population, whereas all the population is at risk in the epidemic prone areas. The NMCP was established from scratch in the year 2000/2001 and a national strategic plan was set for the period 2001-2005 followed by the current strategic plan for the period 2006-2010. The interventions of the strategic plan, including IRS, introduction of ITNs/LLINs, larviciding, etc. within the context of integrated vector management, proved to reduce the incidence and prevalence of malaria in all the areas where these interventions were introduced (Refer to the annexes). These interventions were applied in a phased manner gradually all over the country. The trends of malaria morbidity are demonstrated in the following tables. 20 Table 1: Trend of malaria morbidity from 2002 to 2005 2002 No. of Malaria cases (clinical + lab confirmed) No. of clinical Malaria cases No. of Slides examined No. of Positive Slides % of Positive Slides % of P. falciparum 2003 265023 214212 414919 50811 12.2 92.5 2004 158561 109805 501747 48756 9.7 97 2005 200560 156410 472970 44150 4.4 96.5 187159 111651 556143 75508 13.6 97.6 Indicators No. of blood slides examined No. of positive blood slides for MP Table 2: Progress in Socotra island Year Year Year Year 2000 2001 2002 2003 4255 2331 54.8 8037 107 1.3 2146 21 0.98 6653 326 4.9 Year 2004 4218 30 0.7 Year 2005 10677 5 0.056 Slide positivity rate (%) 21 1.5 Distribution of malaria vectors in Yemen. One of the achievements of the NMCP with the help of the WHO office in Yemen: mapping of the anopheline species Distrbution 0f Anopheline Mosquitoes in Republic of Yemen r Sa'dah Y # Ê # # Ú$³ Al Mahrah Hajjah Amran # $ # Al Jawf r r Y # Ê# Ú Ú· Ê # Ê Ú ³ # # Al Mahwit Capital $ Ma'rib % Ê Ú Y $# r # Z· # Sana'a Y r # Al Hudayda Dhamar # Y # % r Ê Ú Ê Ê Ú Ú ³ # Al Bayda % Ibb r ³ # $ # Y # · Al Dala # Ê Ú Ê r Ú r #³ # Ta'izz Ê· Ú# r r # # Ê Ú Ê Ú % % [ Lahj · # r Ú Ê # $ # $ # Y Aden % · # Ê Ú $ r Hadramout Shabwah Y # c Ñ Y # $ % # Ê Ú $ Ê Ú % # c ³ # Ñ % $ Ê Ú r Abyan Socotra $ Ú Y Ê # N # An . arabiensis $ An . culicifacies % An . sergenti Ê Ú An . d'thali ³ An . cinereus # Y An . turkhudi # · # c An . rhodesiensis Ñ An . fluviatilis An . azaniae An . pretoriensis r % [ An squamosus Z $ An.coustani W S E 1 : 1500000 22 The main Anopheline malaria vectors in Yemen are Anopheles arabiensis, Anopheles culicifacies, Anopheles sergentii. Other Anopheline species are present, e.g. Anopheles d’thali, Anopheles turkhudi, Anopheles coustani, Anopheles rhodesiensis and others (refer to the above map) but have not been proved to be malaria vectors. The predominant Anopheles species in Yemen is Anopheles arabiensis which is one of seven species of the An. gambiae complex, except in the eastern governorate Al Mahra and Socotra island where the dominant species is An. culicifacies. An. arabiensis is morphologically indistinguishable from An. gambiae and has to be separated chromosomally or by DNA technology. Adults of An. arabiensis bite humans and animals, indoors and outdoors, and afterwards rest indoors or outdoors, however it has a greater tendency to feed on cattle and to rest outside compared to An. gambiae. Although less efficient than An. gambiae, when there are large populations it can be responsible for considerable transmission. These information is important when the vector control measures are planned, e.g. IRS. The larval habitats include rice fields, borrow pits and also temporary waters such as pools, puddles and hoof prints. An. arabiensis tends to occur in drier areas than does An. gambiae. It is important to know that some environmental vector control measures are impractical against important vectors like An. gambiae complex and An. arabiensis, e.g. filling-in habitats and drainage. An. culicifacies is an oriental vector and is the major vector in the Indian subcontinent. Larvae occur in a great variety of clean and polluted habitats, irrigation ditches, rice fields, swamp pools, wells, borrow pits, edges of streams, even occasionally brackish waters, and in sunlit or partially shaded habitats. The adult prefers domestic animals but commonly bites humans indoors or outdoors, and rests mainly indoors after feeding. An. sergentii larvae occur in rice fields, borrow pits, ditches, seepages, slow flowing streams, and sunlit or partially shaded habitats. The adult bites humans and animals indoors or outdoors, and rests in houses and caves after feeding. (References: Burce-Chwatt‟s Essential Malariology; M W Service Medical Entomology). 1.6 The current vector control programme 1.6.1 Chemical control: The principal vector control measure in Yemen is chemical control. The chemical measures applied are as follows in the order of importance and priority: indoor residual spraying, ITNs/LLINs and larviciding. The insecticide used for IRS since 2000 till date is lambdacyhalothrin (Icon) WP (pyrethroid) and that used for larviciding is temephos 50% EC (organophosphate). Since lambdachalothrin has some repellent effect, this may not be very effective since the adult mosquitoes may be repelled to rest outdoors after feeding and thus will not be exposed to the lethal dose of the insecticide and so to have maximum effect it should be ideally used with larviciding. The alternative is another insecticide for IRS without a repellent effect, which is bendiocarb WP (carbamate). However it is far more expensive than lambdacyhalothrin WP. Bendiocarb is USD 104 per Kg compared to USD 60 per Kg for lambdacyhalothrin. Space spraying operations, e.g. thermal fogging, are resorted to only as a supplementary measure in some exceptional cases, e.g. if there is an extraordinary high mosquito densities following heavy rainfalls. Besides it is applied in case of malaria epidemics or outbreaks provided that they 23 are early detected. The insecticide used is Deltamethrin or permethrin (pryethroids). Municipalities also use this kind of space spraying in the cities and urban situations mainly against mosquito nuisance which is mainly caused by Culex mosquitoes which breed mostly in the uncovered septic tanks. In general there is a need for environmental management in the urban situations to improve the sanitation and this may reduce the use of unnecessary space spraying operations. 24 Table no. 3: Insecticide consumption from 2001 to 2005 FORMULYEAR COMPOUND Lambdacyhalothrin Temephos Temephos Deltamethrin Delamethrin Lambdacyhalothrin Temephos Temephos Delamethrin Delamethrin TEMEPHOS TEMEPHOS Deltamethrin Deltamethrin lambadacyhalothrin Temephos CLASS ATION 2oo1 2001 2001 2001 2001 2002 2002 2002 2002 2002 2003 2003 2003 2003 2003 2004 Pyrethroid Organophosphate organophasphate Pyrethroid Pyrethroid Pyrethroid Organophospate Organophosphate Pyrethroid Pyrethroid Organophospate Organophospate Pyrethroid Pyrethroid Pyrethroid Pyrethroid Organophosphate WP Ec GR Ec ULV WP Ec GR Ec ULV Ec Sg Ec Ec WP Ec CONCENTYPE OF For control TRATION APPLICATION of 10% 50% 1% 2.5% 1% 10 % 50 % 1% 2.5% 1% 50 % 1% 2.5 % 1.5 % 10 % 50 % IRS Larviciding Larviciding Space spraying Space spraying IRS Larviciding Larviciding Space spraying, treatment of mosquito nets Space spraying Larviciding Larviciding Malaria Malaria malaria Malaria Malaria Malaria Malaria Malaria Dengue Malaria Dengue Malaria Dengue Anopheles Anopheles AMOUNT OF FORMUL-ATION USED (kg or L) 36 Kg 1640 L 500Kg 50 L 1062 L 390.03 Kg 4848 L 1900 Kg 150 L 899 L 2793 L 1120.44Kg 482 L 750 L 718.618 Kg 2715.479 3.6 Kg 820 L 5 Kg 5L 10.62 L 39 Kg 2424 L 19 Kg 3.75 L 8.99 L 1396.5 L 11.2044 Kg 12.05 L 11.25 L 71.8618 Kg 1357.7395 L AMOUNT OF ACTIVE INGRED. Aedes& Space spraying Anopheles Aedes& Space spraying Anopheles IRS Larviciding Anopheles Anopheles 25 2004 2004 2004 2004 2004 2005 2005 2005 2005 2005 2005 Temephos Deltamethrin Deltamethrin Organophosphate Pyrethroid Pyrethroid Sg Ec Ec Cs WP Ec SG Ec WG WP GR 1% 2.5 % 1.5 % 2.5 % 10 % 50 % 1% 2.5 % 25 % 10 % 0.5 Larviciding Anopheles 615 742.05 801.056 1056.33 1313.091 Kg 2410 L 39 1969.2 339 Kg 2313 Kg 224 Kg 6.15 Kg 18.55 L 12.01 L 26.4 L 131.31 Kg 1205 L 0.39 Kg 49.23 L 84.75 Kg 231.3 kg 1.125 Kg lambadacyhalothri Pyrethroid lambadacyhalothri Pyrethroid Temephos Temephos Deltamethrin Deltamethrin Organophosphate Organophosphate Pyrethroid Pyrethroid Aedes& Space spraying Anopheles Aedes& Space spraying Anopheles Bednets impregnation Anopheles IRS Larviciding Larviciding Anopheles Anopheles Anopheles Aedes& Space spraying Anopheles IRS IRS Larviciding Anopheles Anopheles Anopheles lambadacyhalothrin Pyrethroid sumilarv Juvenile hormone analogue 26 Table no. 4: Costs of insecticides consumed from 2001 to 2005 YEAR COMPOUND Lambda-cyhalothrin WP Temephos EC Temephos SG Deltamethrin EC Delamethrin (ULV) Lambdacyhalothrin WP Temephos EC Temephos SG Delamethrin EC Delamethrin (ULV) TEMEPHOS EC TEMEPHOS SG Deltamethrin EC Deltamethrin EC Lambdacyhalothrin WP Temephos EC CONCENTYPE OF TRATION APPLICATION 10% 50% 1% 2.5% 1% 10 % 50 % 1% 2.5% 1% 50 % 1% 2.5 % 1.5 % 10 % 50 % IRS Larviciding Larviciding Space spraying Space spraying IRS Larviciding Larviciding Space spraying, treatment of mosquito nets Space spraying Larviciding Larviciding Space spraying Space spraying IRS Larviciding AMOUNT OF FORMUL-ATION USED (kg or L) 2oo1 2001 2001 2001 2001 2002 2002 2002 2002 2002 2003 2003 2003 2003 2003 2004 36 Kg 1640 L 500Kg 50 L 1062 L 390.03 Kg 4848 L 1900 Kg 150 L 899 L 2793 L 1120.44Kg 482 L 750 L 718.618 Kg 2715.479 60 18 5 6 6 60 18 5 6 6 18 5 6 6 60 18 Cost per unit (USD) Total Cost in USD 2160.00 29520.00 2500.00 300.00 6372.00 23401.80 87264.00 9500.00 900.00 5394.00 50274.00 5602.20 2892.00 4500.00 43117.08 48878.62 27 2004 2004 2004 2004 2004 2005 2005 2005 2005 2005 2005 Temephos SG Deltamethrin EC Deltamethrin EC Lambdacyhalothrin CS Lambdacyhalothrin WP Temephos EC Temephos SG Deltamethrin EC Deltamethrin WG Lambdacyhalothrin WP Sumilarv granules 1% 2.5 % 1.5 % 2.5 % 10 % 50 % 1% 2.5 % 25 % 10 % 0.5 Larviciding Space spraying Space spraying Bednets impregnation Residual house spraying Larviciding Larviciding Space spraying IRS IRS Larviciding 615 742.05 801.056 1056.33 1313.091 Kg 2410 L 39 1969.2 339 Kg 2313 Kg 224 Kg 5 6 6 60 60 18 5 6 50 60 Unknown 3075.00 4452.30 4806.34 63379.80 78785.46 43380.00 195.00 11815.20 16950.00 138780.00 Unknown (Donated by Saudi Arabia) Total Cost 688194.80 28 Graph no. 1: IRS in Yemen from 2001 to 2005 IRS campaigns (2001 - 2006) 90000 80000 70000 60000 50000 40000 30000 20000 10000 0 88988 53943 42,284 11,919 600 2001 2002 11,919 13,148 2003 13,148 2004 42,284 2005 53943 2006 88988 No. of Shelters sprayed 600 N.B: Coverage area the surface area of water bodies treated. 29 IRS in 2000 and 2001: IRS started to be implemented in Yemen in the year 2000 in the pilot malaria elimination project in Socotra island using lambdacyhalothrin. The last IRS campaigns in Yemen were in the eighties of the last century using DDT. No IRS campaigns were conducted in the nineties. 600 houses were sprayed in Socotra island in 2000 and in 2001. Table no. 5: IRS in 2002 Governorate District Zabeed & Al-Jarahi Al-Hajailah Almusaimeer Hadibou 5 Village Month of spraying No. of houses 6,461 2,656 1,857 945 No. of rooms 12597 6617 Quantity of insecticide used in Kgs Lambdacyhalothrin WP 138 83 78 40 Al hudayda Al hudayda Lahj Socotra Total 98 September 111 December October October 11,919 339 30 Table no. 6: IRS in 2003 Governorate District Village Month of spraying June September June January September October June No. of houses 1,570 2,693 1,272 2120 2,411 2,749 333 13,148 No. of rooms 10,800 16,562 8,796 6,163 8,065 9,218 3,466 63070 Quantity of insecticide used in Kgs Lambdacyhalothrin 10 WP 114.746 167 92 80 101 118 46 718.746 K-Othrine WG 250 Dhamar Hadramout Ibb Lahj Lahj Socotra Taiz TOTAL Jabal_Asharg, AlManar & Maghrib A'ans 38 villages Hajr, Broom & Mayfa'a Al-Gafr Al-Musaimeer Al-Musaimeer Hadibou & Qalansiah Altaizia (Al- Amra Dam) 11 31 Table no. 7: IRS in 2004 District Azuhrs/ Wadi Moor Zabeed & Al-Jarahi (Wadi Zabeed) Village Month of spraying No. of houses 4,653 7,625 3,493 7,103 6,916 4,158 2,362 2,474 3,500 No. of rooms 11752 15842 25606 21437 21541 13410 6689 7345 12574 136196 Quantity of insecticide used in KGs Lambda-cyhalothrin 10 WP K-Othrine WG 250 Deltamethrin 10 WP 67 February 138 85 November September 0 208 299 78 185 139 0 86.54 177 1172.54 648 0 0 0 0 0 29 0 0 677 0 0 0 0 0 0 0 0 0 Hajr, Broom & Mayfa'a Meedi & Haradh Meedi & Haradh Al-Musaimeer Adha-Hir & Shida Adha-Hir & Shida Hadibou & Qalansiah TOTAL 207 February 219 September December 212 February 190 September 428 October 42,284 32 Table no. 8: IRS in 2005 Governorate Al Huddyda Al Huddyda Dhamar Hadramout Hajjah Hajjah Ibb Lhaj Sa‟dah Sa‟dah Sana‟a Socotra Socotra Taiz District Azuhrs/ Wadi Moor Zabeed Jabal_Asharg, Al-Manar & Maghrib A'ans Hajr, Broom & Mayfa'a Village Month No. of No. of of houses rooms spraying 13017 9257 4065 4299 7103 9190 1647 4132 2362 2612 1362 3671 3832 530 67079 32748 21437 26840 15385 15458 6689 8011 15062 12062 15050 3669 255189 32753 20835 29190 Quantity of insecticide used in Kg Lambdacyhalothrin 10 WP KOthrine WG 250 Deltamethrin WP 158 February 143 September 133 July 86 November 207 292 89 158 212 238 February September June November February September December 441.2 263.38 357.44 0 0 199 161 173.1 0 75 32 195 199 56.88 2153 0 0 0 147.69 78 18 0 0 29.4 80 0 0 0 0 353.09 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 & Haradh Meedi & Haradh Meedi Al-Gafr Al-Musaimeer & Shida Adha-Hir & Shida Adha-Hir Al-Haimah & Bani_Matar Hadibou & Qalansiah Hadibou & Qalansiah Altaizia (Al- Amra Dam) 440 January 442 October May 2598 Total 33 Table no. 9: IRS in 2006 Governorate Al Huddyda Al Huddyda Al Huddyda Dhamar Hadramout Hajjah Hajjah Hajjah Hajjah Sa‟dah Sa‟dah Sa‟dah Sa‟dah Lhaj Ibb Sana‟a Socotra Socotra Taiz District Azuhrs/ Wadi Moor Zabeed & Al-Jarahi (Wadi Zabeed) Wadi Siham Jabal_Asharg, Al-Manar & Maghrib A'ans Hajr, Broom & Mayfa'a Haradh Meedi Haradh Meedi Shada Adha-Hir Shada Adha-Hir Al-Musaimeer, Al-Azarig Al-Gafr & Assabra Hadibou & Qalansiah Hadibou & Qalansiah Altaizia (Al- Amra Dam) Village Month of spraying October September October No. of houses 13017 9862 9000 3785 4299 10073 2066 9169 2090 971 2269 822 2359 4132 6771 0 3846 3832 625 No. of rooms 0 0 0 0 26151 0 28489 7268 25735 7132 2848 6235 2511 6606 53182 0 15979 0 4082 Quantity of insecticide used in Kgs Lambdacyhalothrin 10 WP K-Othrine WG 250 0 0 0 0 337.563 0 0 0 323 78.2 0 26 34.6 81.9 43 0 0 0 0 0 0 0 0 0 0 108 26.7 0 0 12.3 0 0 0 180 0 0 0 20.425 151 June October 260 94 279 98 110 162 February February September September February February 103 September 195 September October 448 June 432 February September / October 15 May Total 88988 186218 924.263 34 347.425 Table no. 10: Sources and numbers of ITNs/LLINs distributed Source Number GFATM WHO United Arab Emirates Unicef Japan Total 155917 30181 13213 12960 7000 219271 Table no. 11: ITN / LLIN distribution by governorate and source No. of targeted No. of Governorate Date )PW & <5 ( groups ITNs/LLINs 2000 Mahweet 9932 9440 70730 18550 2984 Hajja 4009 9281 40947 Hadramout 5340 8400 Ibb Shabwa Taiz Hodaida Lahj Al-Jawf Raima 1920 6675 1789 2251 1231 73793 1269 1543 10868 793 1500 7897 7263 45095 12539 2295 2500 5800 23973 4450 7000 1600 5560 1500 1123 689 46802 1000 955 6000 600 ‫7991م‬ ‫5002م‬ ‫6002م‬ ‫6002م‬ ‫3002م‬ ‫4002م‬ ‫5002م‬ ‫5002م‬ ‫6002م‬ ‫2002م‬ ‫5002م‬ ‫4002م‬ ‫5002م‬ ‫5002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ Source WHO WHO UAERC GFATM WHO WHO UAERC UNICEF GFATM WHO JAPAN UNICEF UNICEF WHO GFATM GFATM GFATM UAERC UAERC GFATM UAERC 35 Dhamar Amran Ma'arib Almahara Sana'a Others 8306 27202 8321 3795 4943 979 5230 16951 5000 2000 3054 895 ‫6002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ ‫6002م‬ 2006-2005 GFATM GFATM GFATM GFATM GFATM UAERC&WHO Total 337291 219271 Table no. 12: Current situation of larviciding as in July 2006 Area No. of staff involved in larviciding Estimated coverage area in km2 Tihama Ibb Dhamar Socotra Aden Al Dalaa Lahaj Abyan Hadramout Sharas 244 63 12 36 10 10 12 12 10 2 1220 315 60 180 50 50 60 60 50 10 Total 411 2055 36 Table no. 13: Results of susceptibility tests conducted by the entomology team in the NMCP under the guidance of the WHO vector control specialist in 2004 and 2005 Exposure Exposure Governorate Locality Date Insecticide Conc. Time Hodeidah Hodeidah Elmaraiq Khalifa (W. Siham) AlAmra dam 10.2.2004 Temephos 8.3.2004 Temephos 0.125ppm 24h 0.125ppm 24h No. 100 105 Corrected Mortality 100% 100% Taiz Taiz Hodeidah 12.6.2004 Temephos 0.125ppm 24h 50 30 15 100% 100% AlMakasses 20.6.2004 Temephos 0.125ppm 24h Khalifa (W. Siham) 3.6.2004 Lambdacyhalothrine Lambdacyhalothrine 0.05% 1h 100% Taiz Hajjah Abyan Taiz Taiz Hodeidah Hodeidah AlMakasses 3.6.2004 Aslam Bataees AlAmra dam 0.05% 1h 30 100 105 50 30 75 73 100% 100% 100% 100% 100% 100%* 83 %* 22.3.2005 Temephos 8.4.2005 Temephos 2.6.2005 Temephos 0.125ppm 24h 0.125ppm 24h 0.125ppm 24h AlMakasses 3.6.2005 Temephos 0.125ppm 24h Hodeidah Hodeidah 22.2.2005 Deltamethrin 0.05% 22.2.2005 DDT 4% 1h 4h Currently there are 2 sentinel sites in Hajja and Lahj governorates especially for monitoring the susceptibility of malaria vectors to the different insecticides. The plan is to establish more sentinel sites to have 6 sites by the year 2010. 37 1.6.2 Biological control: With the cooperation of the Social Fund for Development, 4 fish pools were built in Bajil/Hodeida and Wadi Seham/Hodeida and the planned third one will be built in Abyan in the Southern part of the country. The local fish Aphanius dispar is intended to be grown in these pools as a store of this type of fish. This type of control is planned to be used in cisterns, water tanks, basins, irrigation canals, wells and dams. Supervision by larval cross-checking is indispensable to monitor and evaluate the efficacy and effectiveness. In Socotra island where there is a malaria elimination project since 2000, biological control was introduced in the year 2002 on a very limited manner in one of the villages. Aphanius dispar was the local larvivorous fish used. The plan of the NMCP is to promote the biological control measures on a larger scale during the next few years. 1.6.3 Malaria, vectors and the association with water resources development Yemen is one of the unique countries which have lot of development and environmental projects especially agricultural and irrigation ones. Dams and irrigation canals have been known in Yemen over centuries. Ma’areb Dam is one of the most famous ones and several reports claim that it has changed the epidemiology of malaria in Ma’areb governorate. There is a need to strengthen the inter-sectoral collaboration to properly manage this situation. Environmental and health impact assessment (EIA and HIA) studies should be conducted in coordination between the ministry of health and the relevant sectors. Yemen should study and learn from successful experiences in countries in the region. 1.6.4 Malaria epidemics There is a national plan of “Epidemic Preparedness and Rapid Response” functioning since 2001. There are well trained teams at the central and sub-regional offices ready to respond to any notification of any malaria epidemic anywhere in the country. The MMTs at the governorate level are also trained and well equipped to respond to any epidemic in coordination with the NMCP headquarters. These teams have their own vehicles and are well equipped with the necessary diagnostic facilities, antimalarial drugs, other drugs, spraying equipments, insecticides, LLINs, etc. 1.6.5 Social dimensions (community acceptance, community participation, affordability of nets, local outreach through mosque, schools and ag extension) Community participation is imperative to ensure ownership and sustainability. To achieve positive community participation there should be a national plan of health education and introduction of the regional initiative of communication for behavioural impact (COMBI). An inventory of the local and international non-governmental organizations (NGOs) in addition to the civil organizations and associations and any active international organization having staff and 38 health workers at the community level should be prepared to identify the efficient stakeholders and partners ready to deliver services at the district and remote levels. This is of utmost importance for the successful implementation of the all vector control measures including IRS, LLIN distribution, larviciding, biological control and environmental control measures. 2. Current capacity 2.1 Components of current control programme Table no. 14: Categories of the NMCP headquarters Department/Section in the NMCP HQ Staff 1 Physician DG 1 Public Health Officer Deputy DG 1 medical officer malariologist WHO consultant National advisors Secretaries attached to DG office Field supervision section attached to DG office Epidemiology department Parasitology laboratory section Entomology section M&E section Field operation Dept. and central supervision GIS section Equipment & Insecticide section ITN/LLIN section Training and research department Health Education and Information department GFATM unit Finance and Administration department Human resource section Auditing section Registration & delivery section Procurement & Stores section Maintenance & Transport section (one entomologist from August 2001 till May 2006) 1 medical doctor 3 1 physician 3 medical doctors 1 Chief & 4 lab technologists 1 Chief, 2 technicians 1 medical doctor 1 medical doctor and 3 sanitary inspectors 1 draftsman 1 sanitary inspector 1 medical doctor and 1 public health officer 1 medical doctor 1 medical doctor 1 medical doctor, 1 IT specialist, 1 finance officer, 1 secretary 1 director and 1 assistant 2 2 1 4 2 clerks, 11 drivers 39 Organizational Structure of the National Malaria Control Programme Minister (MoPH&P) Deputy Minister (PHC Sector) Sub-regional offices General Director (NMCP) Malaria coordinators/Governorates Socotra Island Field supervision Training & Research center/Abyan Secretariat WHO Experts Consultants GFATM Unit Finance & administration Dept. Epidemiology Dept. & M&E focal person Field operation Dept. and central csupervision supervision Entomology section Training & Research Dept. Health Education & Information Dept. Laboratory section M&E section Research section Training section HE division Information section Human Resources section Registration & delivery section Auditing section Procurement & Stores section Maintenance & Transport section GIS section Equipments & Insecticides section ITN/LLIN section 40 Malaria management teams (MMTs) at the governorates’ level: At the sub-national level, the plan is to form a malaria management team (MMT) in Tihama subregional office, in Socotra island and in each governorate formed of the following: - malaria coordinator, who will act at the same time as the M&E focal point - in-charge of MIS (malaria information system) - in-charge of IVM (integrated vector management) - focal person for malaria case management - focal person for laboratory diagnosis Staff at the district level: Temporary (on a daily paid basis) spraymen and field supervisors under the supervision of the MMT. 2.2 General: infrastructure (buildings, laboratories and vehicles) Currently almost all the offices including the NMCP headquarters in Sana’a and the subregional offices in Tihama, Aden and Hadramawt are rented houses. The GFATM has funded the establishment of a special building for the NMCP headquarters in Sana’a and Tihama sub-regional office in Hodeida. They are unique buildings having all the required rooms for the different departments, laboratories, stores, etc. They are supposed to be equipped, furnished and functional by the end of 2006. All the malaria offices in the governorates are either rented houses or a room within the governorates’ health offices. There are currently 8 malaria units at the district level and the plan is to have 60 malaria units by the year 2010. No. of vehicles at the central and peripheral levels: 92 out which 80% are in good and reliable condition - 2.3 Technical and research capacity Staff: Please refer to section 2.1 Since the NMCP has started from scratch since 2001, there was an emphasis on developing the national capacity and the skills of the staff in addition to appointing new qualified cadres. Lot of training courses were conducted as well collaboration with the academic institutions and TDR/WHO to promote the research studies as follows: 41 Local short-term training courses conducted in Yemen for medical doctors, paramedical staff and vector control staff: Indicator No. of training courses No. of trainees 2002 2003 2004 2005 10 397 13 1042 26 728 32 697 Special training and postgraduate courses: • • • • • • • • • • One national: Master degree in International Health Research upgraded to PhD in LSTM in 2003 (was discontinued due to financial and administrative problems) One national: Diploma in Entomology in Ein Shams University in 2004 One national Studying masters degree in Community Medicine – Aljazeera / Sudan 6 sanitary inspectors attended intensive course in Entomology in Ein Shams university in 2003 and 2004 7 medical doctors got a diploma in Planning and Management of malaria control programmes in Bandar Abbas- Iran 14 nationals passed a 3-month course in „Epidemiology in Action‟ conducted by LSTM (25th December 04 – 5th April 05). One national: Master in Entomology Alexandria (Sep. 2005) 13 medical doctors an 34 laboratory technicians passed the course on „Quality Control‟ conducted jointly by LSTM, WHO and OMAN in Dec. 2005 44 nationals were trained on “International Computer Driving License (ICDL)” in 2005 2006 5 nationals attended training courses on English language in 2005-2006 Collaboration with the academic institutions and TDR/WHO: 1- PhD study on “The Epidemiology of Severe Malaria Among Children” in Taiz governorate By Dr Abdu Allah Tayyar Faculty of Medicine, Sana‟a University Ph.D Student in London School of Hygiene and Tropical Medicine (LSHTM), UK TDR Grant/WHO/EMRO 2- Ph.D. STUDY on the efficacy of AMDs in Yemen By Dr Reem Mudjaber – Aden University Ph.D Student in Liverpool School of Tropical Medicine and Hygiene (LSTM), UK TDR Grant/WHO/EMRO 3- PhD study – Entomology – in Taiz governorate By Dr Samira Al Eryani – Sana‟a University Ph.D Student in LSTM, UK 42 4- Master in Entomology By Dr. Abdulla Amin – Dhamar University 5- Evaluation of Impregnated Bed Net in a Malaria Endemic Area in Yemen By Dr. Mhd Al-Jahafi – NMCP Funded by EMRO./ WHO 2.4 Management capacity The following vector control decision making criteria and procedures are in place:        Epidemiological data: disease incidence through monthly reporting and disease prevalence through cross-sectional surveys Mapping through GIS, albeit needs strengthening Eco-epidemiological stratification Distribution of vectors, entomological surveys Susceptibility of vectors Vector bionomics and behaviour Attribution of malaria burden to water resources development Procurement and supply management (PSM) system components: It is a cycle of PSM activities to ensure that the objectives are met: 1- Procurement of non-pharmaceutical products. 2- Product selection. 3- Forecasting. 4- Procurement responsibilities and practices. 5- Quality assurance. 6- International agreements and national laws. 7- Monitoring suppliers. 8- Distribution chain and inventory management. 9- Avoidance of diversion or improper use of the resources. 10- Ensuring the adherence and compliance by the end users to the recommendations set by the NMCP regarding the use of different services. 43 Table no. 15: Activities included in the PSM cycle and the responsible agencies for each of these activities Sr # Activity Agency responsible 1 2 3 4 5 6 7 Identification of requirements Development of procurement plan Setting the technical specifications for each of the items to be procured Approval of the technical specifications Appointment of the Evaluation Committee Identification of suppliers for calls for tenders with short lists For public calls for tenders: Development of the invitation to tender, schedule of activities and tender requirements Receiving queries on the tenders Preparation of the responses Sending of clarifications in writing Receiving the tenders Maintain custody of tender bonds Evaluation of tenders and preparation of the evaluation report NMCP with the help of WHO consultants NMCP with the help of WHO consultants NMCP with the help of WHO consultants NMCP with the help of WHO consultants Ministry of Public Health & Population NMCP Ministry of Public Health & Population according to the plan of the NMCP 8 9 10 11 12 13 14 15 NMCP NMCP with the help of the WHO NMCP with the help of the WHO Ministry of Public Health and Population Ministry of Public Health and Population - Ministry of Public Health Population - NMCP - WHO consultants in Yemen Sending of award notification Ministry of Public Health & Population Drawing up of contracts, signing the - Ministry of Public Health contracts and receiving performance Population bond - NMCP Sending thank-you letters to suppliers not selected and return tender bonds Ministry of Population NMCP Ministry of Population Ministry of Authority Public Health & & 16 & 17 Custom exemption - Public Finance Health / & Custom 18 19 Clearing the commodities/equipments NMCP at the entry points Checking the commodities or - Ministry of equipmetns Population Public Health & 44 20 21 Distribution Monitoring 22 23 Releasing of payments Returning the performance bond NMCP with the help of WHO consultants NMCP with the help of the contracted subrecipeints - NMCP with the help of the WHO consultants - CCM - LFA NMCP Ministry of Public Health & Population - Forecasting: Forecasts for required quantities of anti malarial drugs, ITNs and insecticides are based on what is available from the following: - consumption method - epidemiological data, e .g. morbidity, mortality rates, vital statistics, etc The forecasts are prepared at: - service delivery points, - district level, - regional level, - and finally the central level after compiling the above information The forecasts are validated by comparing previously estimated required quantities with actual consumption volumes and rates whenever relevant or appropriate. They include reserve stocks of products. Periodic standard reports from the districts and regions are sent on special standard formats to the headquarters in Sana‟a where the different indicators are calculated and used for forecasting, monitoring and evaluation. Although the NMCP decided to delegate the Unicef to procure some important products, it remains the full responsibility of the NMCP to maintain the lead of planning, forecasting, implementation, monitoring and evaluation, even if some local NGOs are out-sourced to carry out the implementation of some activities in the field. How to prevent stockouts and wastage at all levels? Proper planning, forecasting, supervision, monitoring and evaluation using standard formats and periodic reporting are all safeguards set up to avoid stockouts and wastage at all levels. 45 Table no. 16: Responsibility of preventing stockouts (who is responsible?) Level of responsibility At the service point At the district level At the regional level Who is responsible? The health worker or sanitary assistant The sanitary inspector - The malaria coordinator - The director of the malaria regional office (available in Tihama, Aden and Hadramawt) - The director general of the office of public health and population in the respective governorate - The director of procurement - The director of stores - The director of vector control - The director general of the NMCP - The director general of finance in the Ministry of Public Health & Population At the central level National law organizing the local tenders: There is the “Yemeni Tenders” law no. 3/1997. Suppliers: - The system in Yemen is that any supplier of any health related product submits registration number and a comprehensive product dossier for revision by a qualified specialist. - The supplier is subject to audit by a qualified inspector. - Product samples are randomly physically inspected by a qualified inspector. - There is a system of testing the samples in a quality control laboratory. - The insecticides and the ITNs and any health related product should meet the WHO specifications, e.g. WHOPES for insecticides. Tenders: When tenders are issued, the following criteria are used to choose among suppliers: 1- Quality of product 2- Available formulations 3- Available quantities 4- Delivery time 5- Delivery conditions Product Procurement: Generally the NMCP is forced to follow the national law no. 3/1997 and accordingly the commonly used procurement methods are: - National Competitive Bidding - Contract procurement 46 - Procurement through an UN agency (as is the case with Unicef in this proposal) The contracts are designed according to the financial system recommended by the GF. Tenders are issued and products are procured at the central level. The procurement plans take into account the following: - the inventory balance - the actual and anticipated product loss - the required order lead times of suppliers/donors - established min/max stock levels - shipment and handling schedules - the need for a safety stock There is a supplier tracking system by which the following information are captured: - Date of submission of the product order - Date of receiving the product order - Quantity of product received - Quantity and date received for back orders and delayed partial shipments - Date of submitting the payment request - Date of payment made to supplier - Date of receiving the payment by the supplier Quality Assurance: (A) For the items related to the 2 buildings in Sana‟a and Hodeida: Quality assurance will the responsibility of the „Engineering Consultancy Centre‟ already contracted by the PR. (B) For Anti-malarial drugs: This is the responsibility of the Supreme Board Of Drugs & Medical Equipments in the Ministry of Public Health & Population. They make sure that all the drugs registered and imported meet the WHO and international specifications. (C) For insecticides, sprayers, ITNs, etc.. (all products related to vector control): The system in the past years was to import the above items through the WHO. The new agreement with the Unicef is to get all the items related to vector control, as per the malaria proposal approved by the GF, through the Unicef. This means that these items meet the WHO and international specifications. Product specifications: The following specifications are required and clearly stated as pre-requisites for product purchases: product plant sources of active ingredients pharmacopoeial standards (for anti malarial drugs) 47 - specific packaging specific labeling on individual packages package insert in English and Arabic specific delivery date limits on back orders and partial shipments minimum product expiry dates / shelf life For insecticides for example, the protocol is that the supplier submits a certificate of analysis conducted in a WHO collaborating center or laboratory. Then the Unicef followed by the MoPH&P will apply their systems of quality control. The shelf life of products: There are systems to monitor and manage the shelf life of products at the recipient and subrecipient sites. Products will not be accepted by the NMCP in the following conditions: 1- Visible damage to products. 2- Billed price different from the contract. 3- Past or impending expiry date. 4- Incorrect item/size/dosage received. 5- Poor packaging of product. 6- Physical defect to product, e.g., discoloration. Storage: - Storage is done under very strict security measures. - There is at least one yearly physical inventory check of all products at the PR storage facility. Rational use: (A) The anti-malarial drugs: there is a written national anti-malarial drug policy with clear guidelines there are clear guidelines to ensure rapid and correct diagnosis followed by prompt treatment. there is a national plan for monitoring the efficacy of antimalarial drugs. Sentinel sites, representing the different epidemiological strata in the country, have been established. (B) Insecticides and ITNs: there is a written national strategy for scaling up the use of ITNs there are clear guidelines for the use of the different insecticides for indoor residual spraying, larviciding and space spraying. there is a protocol for monitoring the susceptibility of the malaria vectors to the available insecticides. there are protective measures to ensure the safety of the vector control team as well as the citizens or beneficiaries. - - 48 Health education campaigns are key elements accompanying all the malaria control and prevention activities in order to raise the community awareness and ensure community mobilization and participation which will mean the optimal and rational use of all the services provided. 2.6 Policy framework Political commitment: There is a strong political commitment to support the NMCP in Yemen. This is demonstrated by different prime ministerial and ministerial decrees. Examples of these decrees are as follows: April 2000: the formulation of the Supreme National Malaria Control Committee by a prime ministerial decree no. 18/2000 November 2000: A prime ministerial decree to establish the HQ of the national malaria control programme in the capital Sana‟a. December 2000: The “Inception Process” of Roll Back Malaria was started by the formulation of the 5 year plan 2001-2002 for RBM March 2001: The prime ministerial decree no. 19/2001 announced the year 2001 as the year of “Malaria Control” in Yemen The actual programme activities started during the first quarter of the year 2001. February 2002: The ministerial decree no. 57/3 for the year 2002 made the management of malaria including the investigations and treatment free of charge in all the ministry of public health institutions. 2003: Country Coordination Mechanisms for the Global Fund have replaced the Supreme Committee dealing with the three diseases: HIV/AIDS, malaria and tuberculosis. February 2005: The Ministerial Decree no. 13/2 for the year 2005 formed a high level committee for „Vector Control‟ under the chairmanship of HE the deputy Minister for Primary Health Care and having the membership of the DG of the NMCP, director of operations in NMCP, a representative of WHO and representatives from the Ministry of Agriculture and Irrigation, the Ministry of Water and Environment, the Ministry of Information, the Ministry of Local Administration, the Ministry of Education, the Ministry of Religious Affairs, the Ministry of General Works, in addition to 3 representatives from NGOs and the private sector. National public health policy National malaria policy and strategy There is a national strategy for the NMCP for the years 2006-2010. It has been endorsed and signed by the Minister of Public Health & Population and has 9 strategic directions as follows: 1. Maintenance and strengthening of the high level political commitment to combat malaria 49 2. Strengthening the infrastructure of the NMCP at the national, governorate and district levels. 3. Human resource development 4. Early and correct diagnosis followed by prompt and effective treatment of malaria cases 5. Integrated vector management 6. Efficient epidemic preparedness and response 7. Strengthening the information system and surveillance (M&E) 8. Increasing the capability of the community to recognize, prevent and control malaria 9. Developing the capacity to plan and implement operational field research National strategy for Integrated Vector Management It is being prepared. National policy to promote intersectoral action for health There is no written policy or document to promote intersectoral action for health. However the CCM which was formed in 2003 can be considered an example of this intersectoral collaboration and public-private partnership. National policy to decentralize health services Decentralization is promoted within the context of „Health Sector Reform‟. The local councils and governors‟ offices in addition to the local NGOs and civil associations are being involved in every vector control activity even though the strategies, supervision, monitoring and evaluation are highly specialized areas which are carried out by the NMCP staff. But still the above mentioned sectors are being kept aware of the results of all these activities. 2.7 Resources Resources assigned to malaria control … Resources assigned to vector control Human resources: regular staff, temporary staff, admin support staff Financial resources: capital costs, recurrent costs; (any cost Recovery (nets)?) 50 Challenges facing the NMCP: 1- High malaria incidence and mortality 2- Weak information system 3- Dearth of national capacity in important areas of expertise, e.g. vector control methodology, medical entomology and malaria diagnosis. 4- Vectors with an efficient vectorial capacity (Anopheles arabiensis) 5- Epidemic-prone areas 6- Low coverage of health services 7- Policy and legal framework for the sound management of pesticides is lacking 8- Limited accessibility and difficult logistics because of rough topography 9- Water scarcity leading to dramatic eco-epidemiological impacts of natural resources development 10- Limited financial resources, linked to poor career opportunities and few professional incentives 11- High rate of turnover and brain drain 12- Rising trend of extreme weather events (floods and droughts) with important health implications. 51 3. NEEDS ASSESSMENT The Government of Yemen wants to effect a transition from its conventional vector control programme to a programme based on the principles of integrated vector management (IVM). IVM has been defined by WHO as a combination of evidence-based decision-making criteria and procedures to plan, implement, monitor and evaluate targeted, cost-effective and sustainable combinations of regulatory and operational vector control measures, with measurable and sustainable impacts, through mechanisms of partnership and intersectoral collaboration. The needs assessment presented in this section lists the developments and action that will be required to achieve this transition with success. It starts with a statement of goals the Government of Yemen wants to achieve over a five-year period, over and above the goals already contained in its NMCP plan for the period 2006-2010 and those supported by the Global Fund. 3.1 Goals At the end of the five-year period covered by the GEF/EMRO project, the Government of Yemen aims to have completed the following: 3.1.1 Building an enabling policy and legal environment A national IVM policy framework and an associated national IVM strategy, and effective institutional arrangements between the health, agriculture and environment sectors for the implementation of the strategy. A common legal framework for the sound management of pesticides for use in agriculture and in public health, in accordance with WHO/FAO best practice guidelines, including the strengthening of institutions that can enforce the legislation effectively. 3.1.2 Human resources development A strengthened human resource base with the knowledge and skills to perform the following essential IVM functions:  Coordination, management, monitoring and evaluation of an integrated vector management programme  Cost-effectiveness analysis of vector control options in specific settings.  Intersectoral planning, design and implementation of environmental engineering and water management interventions for disease vector control.  Planning, design and implementation of biological control interventions.  Sound management and judicious use of pesticides.  Health impact assessment of water resources development projects. 52  Mobilization of local communities towards their engagement in vector control activities, particularly in relation to agricultural practices. Meanwhile the activities of capacity building in the already on-going areas of larviciding, indoor residual spraying and the distribution of LLINs will be continued per the current plans. 3.1.3 Strengthening the knowledge and evidence bases A number of operational demonstration projects to test environmental management and biological control measures for their effectiveness, efficiency, social acceptability, community involvement potential and options for their integration into regular IVM. 3.1.4 Upgrading infrastructure, facilities and services An expansion of existing facilities to monitor vector ecological and behavioural characteristics, to improve mapping exercises (GIS) by combining geo-referenced datasets from different sectors, and provide quality control of substances, materials and equipment used. 3.1.5 Increasing community involvement A comprehensive package of IVM information and training materials for community awareness creation and delivery of vector control messages through health workers and agricultural extension workers 3.2 Assumptions and sensitivity The achievement of the above goals is considered realistic under the prevailing conditions. The installation of the recently elected government will provide stability and is expected to reduce turn-over in senior positions in the various ministries. However, a number of situations may present themselves which would disrupt the processes towards reaching the set goals: Extreme weather conditions: floods and droughts will have a major impact on the malaria situation. After the El Niño rains of 1997 malaria transmission in Yemen peaked in 1998. Such events would substantially increase the pressure on the MoPH&P and interfere with progress towards reaching the goals. A drought would undermine the agricultural production system and make expeditious water resources development (without due attention to health impacts) a political imperative. The epidemic prone areas will need more attention. Yemen continues to rely on support from bilateral donors, including for health sector development. A reduction in donor support would slow down this development and this would mean that certain goals already set by the Government could not be met. It would also mean that the goals set in this document, which come over and above the other goals, would be affected as the overall financial picture would change. 3.3 Needs assessment for the proposed transition 53 Two scenarios serve as the basis to identify the needs to make the transition from a conventional vector control programme as currently in operation, to a programme of integrated vector management: (1) the goals, activities and deliverables as per the current plans of the Government of Yemen and (2) the additional actions needed to achieve the goals contained in the present document, in line with principles of Stockholm Convention. The first scenario bases itself on the following financial resources of the National Malaria Control Programme (in US$) • • • • • Government: WHO : GFATM: WB : GCC: USD 2,000,000 (annually) since 2002 till date Regular budget of USD 388,000 and an expected extra-budget of USD 1,084,000 (2006/2007) USD 11,878,206 (1st March 2004 till 28th Feb 2009) USD 2,200,000 (2005/2008) still being negotiated within the context of „Malaria Free Arabian Peninsula‟ initiative The vector control component of these allocated resources is: • • • • Government: WHO : GFATM: WB : 1,746,000 (annually) 48,000 (2006/2007) 8,000,000 (for ITNs only 2006-2009) 2,120,000 (2005/2008) Vector Control and Entomology The mandates for medical entomology and for vector control are in different parts of the MOH&P organogram. Currently, the focus of activities is on chemical interventions, supported by entomological monitoring and surveillance of relevant indicators (such as insecticide resistance). Scaling up of the vector control and entomology activities scheduled to take place within the context of integrated vector management (IVM) will require additional resources. Awareness creation about IVM has already started: a special educational poster on IVM was designed by the WHO medical officer in 2005 to raise the awareness of the relevant sectors and create a basis for intersectoral collaboration and community participation in this important area. Educational brochures were developed by the health education section in the NMCP with the help of the WHO vector control specialist and WHO medical officer. In the second scenario, needs are addressed that go beyond a vector control programme based on chemical interventions as a mainstay. This requires capacity building in terms on policy formulation, establishing institutional arrangements and the strengthening of human resources. It also requires development of training materials and approaches to reach the communities that can contribute to IVM. And it requires a strengthening of our knowledgebase on the potential of non-chemical methods to achieve transmission risk reduction to the level considered acceptable by the nation al authorities. The detailed needs are presented in the next section. 54 3.4 Needs identified Building an enabling policy and legal environment Within overall public health policy framework, there is a national malaria policy. No specific IVM policy and strategy have been formulated, however, and there are no formalized arrangements between the health, agriculture and environment sectors for intersectoral actions in the IVM context. Needs: a national policy on integrated vector management a national integrated vector management strategy institutional arrangements between the health, agriculture and environment ministries for intersectoral action in support of integrated vector management; essential issues to be addressed include the design of site-specific packages of vector control interventions; joint evaluation of IVM effectiveness; linking IVM and IPM. The 1999 Law concerning the Regulation of Handling Pesticides for Plant Pests addresses the import, use and disposal of pesticides for plant protection purposes. The need to address all pesticides (for agricultural and public health purposes) in a common legal framework is illustrated by the recent recommendation to replace Icon by Bendiocarb for indoor residual spraying. The extensive use of carbamates in agriculture (especially for Qat) enhances the risk of rapid resistance development in malaria vectors. Needs: a national common legal framework for the sound management of pesticides for use in agriculture and in public health institutional strengthening for a coordinated enforcement of the legislation new legislation on the management of obsolete pesticides international treaties with neighboring countries to stop the cross-border flow of illegal pesticides 55 Human resources development The staff responsible for vector control in Yemen must be able to perform a number of essential IVM functions. These functions should also be incorporated in a national system of post descriptions for posts contained in the organogram of entities with vector control responsibilities. The functions to be introduced over the next five years, and the needs to operationalize them are the following:  Coordination, management, monitoring and evaluation of an integrated vector management programme Needs: Restructuring of the vector control programme so it can effectively perform IVM functions. Definition of decision making criteria and procedures to support IVM. Definition of SMART indicators for the monitoring of IVM activities: vector-borne disease trends, entomological inoculation rate, compliance by other sectors with vector control measures within their remit. Establishment of intra-sectoral links with disease control, health promotion and environmental health in support of IVM. Human resource development in the area of IVM.  Cost-effectiveness analysis of vector control options in specific settings. Needs: Adoption of a methodology of cost-effectiveness analysis in the planning of IVM activities. Staff training in economic evaluation (through national and regional workshops). Establishment of good working relations with the Economics Department of the University. 56 Cost-effectiveness case studies on vector control options (and combinations of vector control options) in specific settings.  Intersectoral planning, design and implementation of environmental engineering and water management interventions for disease vector control. Needs: Awareness creating among engineers and water management professionals of vector-borne diseases and non-health sector action to reduce transmission risks Skills development of vector control, engineering and water management staff in intersectoral negotiations and decisionmaking in support of IVM Formalization of intersectoral links in support of IVM, in support of planning, design and implementation. Institutional arrangements between the health, agriculture and environment ministries for intersectoral action in support of integrated vector management. Case studies of successful implementation of environmental engineering interventions for vector control.  Planning, design and implementation of biological control interventions. Needs: Assessment of viable biological control activities in Yemen. Case studies of successful biological control interventions for vector control. Community involvement in fish rearing linked to commercial interests. 57  Sound management and judicious use of pesticides. Needs: National legislation on sound management of pesticides Capacity building for the enforcement of the legislation, including human resources development, establishing effective links between the agriculture and health sectors.  Health impact assessment of water resources development projects. Needs: A national policy on health impact assessment, linked to environmental impact assessment policies/legislation. Training in HIA: a national workshop on essential HIA functions of the health sector; training in intersectoral negotiation/decision making in support of HIA. Case studies of HIAs for a v ariety of development projects with a potential impact on vector-borne diseases. Formulation of Public Health Action Plans (intersectoral) for incorporation into development projects.  Mobilization of local communities towards their engagement in vector control activities, particularly in relation to agricultural practices. (It is assumed that capacity building in the already on-going areas of larviciding, indoor residual spraying and the distribution of LLIN’s will be continued as before). Needs: Preparation of an inventory of viable approaches to promote community participation in IVM (through health workers, agricultural extension, environmental NGOs etc) Preparation of training materials aimed at eliciting community participation in IVM. 58 Community action in biological control, aimed at plant protection and vector control. Strengthening the knowledge and evidence bases A number of operational demonstration projects to test environmental management and biological control measures for their effectiveness, efficiency, social acceptability, community involvement potential and options for their integration into regular IVM. Criteria will be developed to select a number of representative sites where different combination. Needs: criteria for site selection and for selection of vector control measures as part of an IVM package. Protocols for demonstration projects. National steering committee (multidisciplinary, intersectoral composition) for the monitoring and evaluation of projects. Upgrading infrastructure, facilities and services An expansion of existing facilities to monitor vector ecological and behavioural characteristics, to improve mapping exercises (GIS) by combining geo-referenced datasets from different sectors, and provide quality control of substances, materials and equipment used. Needs: Upgrading and expanding existing infrastructure for parasitology and entomology microscopy at district level Expanding transport capacity for outreach to districts Detailed plan for infrastructure sharing (buildings, transport, equipment) with other sectors. Increasing community involvement 59 A comprehensive package of IVM information and training materials for community awareness creation and delivery of vector control messages through health workers and agricultural extension workers Needs: A national plan for community involvement in malaria control Use of existing channels in various sectors to reach out to communities. Community awareness campaigns on non-chemical interventions to control vectors and reduce malaria transmission. 4. INCREMENTAL COSTS Action Plan 2007-2011 IVM action Policy development and implementation Institutional strengthening Human resources development Infrastructure improvement Incremental costs US$ 250,000 US$ 250,000 US$ 750,000 US$ 200,000 Case studies, demonstration projects, pilot studies US$ 500,000 Community involvement Total incremental costs US$ 150,000 US$2,100,000 60 10 20 30 40 50 60 Annex 1: Progress in Tihama 0 No intervention in 1998 48.3 Larviciding started in 2000 14.8 13 IRS started in 2003 SPR in Tihama from Nov 1998 to March 2006 7.2 11.5 3.4 5 No v9 Fe 8 bM 99 ay -9 Au 9 g9 No 9 v9 Fe 9 bM 00 ay -0 Au 0 g0 No 0 v0 Fe 0 bM 01 ay -0 Au 1 g0 No 1 v0 Fe 1 bM 02 ay -0 Au 2 g0 No 2 v0 Fe 2 bM 03 ay -0 Au 3 g0 No 3 v0 Fe 3 bM 04 ay -0 Au 4 g0 No 4 v0 Fe 4 bM 05 ay -0 Au 5 g0 No 5 v0 Fe 5 b06 LLINs in 2006 61 Annex 2 : Progress in Socotra island Malaria cases (PCD) and SPR(%) in Socotra island from January 2000 to Dec 2005 450 400 350 300 250 Start of the malaria elimination project in Socotra island in August/September 2000 API: 0.6 per 10,000 200 SPR: 0.05 % 2001 150 100 2002 2003 2004 50 2005 0 Ja Fe n Mb a Ar M pr Juay n Ju e A ly S ug e Opt Nct D ov e Jac Fe n Mb a Ar M pr Juay n Ju e A ly S ug e Opt Nct D ov e Jac Fe n Mb a Ar M pr Juay n Ju e A ly S ug e Opt Nct D ov e Jac Fe n Mb A ar p M ril Juay n Ju e A ly S ug e Opt Nct D ov e Jac Fe n Mb A ar p M ril Juay n Ju e A ly S ug e Opt Nct D ov e Jac Fe n Mb A ar p M ril Juay n Ju e A ly S ug e Opt Nct D ov ec Pos for MP SPR% 62 Annex 3: Progress in Wadi Hajr/Hadramawt in relation to IRS Malaria Prevalence in Wadi Hajar in Hadramawt 2003 - 2004 200 30 181 180 27 1st IRS campaign started in 10 Sept 2003 25 160 140 20 120 20 102 100 15 80 2 IRS campaign in 21 Sept 2004 nd 60 3rd IRS campaign started in Nov 10 40 23 3 28 2 Dec-04 28 2 SPR (%) 05 5 20 0 0 0 0 No. of malaria cases SPR (%) 0 Jul-03 102 20 Sep-03 181 27 Dec-03 23 3 No. of malaria cases Dec-05 0 63 Annex 4: Strategies of strengthening Vector Control (vision for the years 2006-2010) as per the national M&E plan Strategy Strategy description Strengthening the infrastructure of the malaria headquarters and all the malaria offices at the governorate and district levels to be fully Infrastructure established and equipped by the end of 2007 to be able to implement intensive malaria control strategies to achieve the ultimate goal of malaria elimination by the year 2015. National capacity Strengthening the national capacity building in the malaria headquarters and all the malaria offices at the governorate level so that malaria management teams (MMTs) are available and well trained by the end of 2007. The above two strategies include the strengthening of surveillance and information system through the MMTs and well equipped offices, besides they include the strengthening of epidemic preparedness and response. To ensure total coverage of 80% of pregnant women and children under five in all at risk areas in Yemen by long lasting insecticidal nets (LLINs) by 2010. To ensure total coverage by indoor residual spraying (IRS) in all at risk areas targeted by this tool (based on epidemiological indicators) by the year 2010. To ensure total and better coverage by larviciding in the targeted areas by the year 2010 To scale up biological vector control activities in the targeted areas by the year 2010 IVM Health Education (HE) Strengthening and expanding the health education activities at the national and district levels to ensure high level of awareness and community involvement ( including the introduction of „communication for behavioural impact known as COMBI approach and collaboration with programmes like BDN) 64 Strategy Service delivery area Indicator description Baseline Value Year Year 1 Year 2 Year 3 Year 4 Year 5 target target target target target 2006 2007 2008 2009 2010 Frequency of data collection Implementing the financial support by the GCC countries to the NMCP according to the 2-year plan of strengthening the infrastructure of the NMCP at the governorate levels National - Proper selection of capacity the members of the malaria management teams Infrastructure The infrastructure of the NMCP at the governorate levels is strengthened enough to carry out the malaria control activities as per the plan by the end of 2007 2006 50% 100% 100% 100% 100% Annual reports IVM - Training courses for the members of the MMTs Integrated vector management by scaling up the use of LLINs All the governorates have qualified, trained and skilled comprehensive MMTs able to carry out all the malaria control activities including preparedness and prompt and effective response to any malaria epidemic - % of households having at least one ITN or LLIN 3% 2006 50% 100% 100% 100% 100% Annual Reports 2004 15% 35% 50% 60% 80% Annually - Percentage of pregnant women and children under 5 who slept under ITNs or LLINs in the previous night Integrated vector management by Percentage of houses, shelters, etc covered by IRS in the targeted 0.8% 2002 15% 20% 40% 60% 80% By surveys every 2 years 36.7% (36,700 houses, 2004 65% 75% 85% 85% 85% Annually after compiling the data of the 65 scaling up the use of indoor residual spraying IRS areas shelters, etc.) rounds implemented during the year. Evaluation of each round is done during and after the completion of the round (formal and summative evaluation) HE - Training on COMBI Percentage of targeted districts covered having trained personnel on COMBI Number of malaria workshops or seminars held in the targeted governorates Percentage of targeted districts covered by health educational publications 10% 20% 40% 60% 100% Annual Reports - Seminars 0 10 20 20 20 - Health educational publications 10% 20% 40% 60% 100% 66 Annex 5: Report prepared by the Ministry of Environment (1) Status of the National Implementation Plan for the Stockholm Convention. The preparation of the NIP is still in its early stages and that the POPs issue is very urgent in Yemen particularly related to the landfills. Brief summary of NIP activities:  We completing the chemical profile and now we start to translate it and also to print Arabic virgin in Aden University.  We finish inventories of POPs pesticides.  We implement a workshops for discussing the results of the dioxin and furan and POPs pesticides inventories with related ministries and other organizations.  We finish the inventories of the transformers in all governates and we collect 52 samples which were sent to Kuwait Instiute for Scientific Research for analysis them and we receive the results.  Reviewing & Evaluating PCBs, PCDD/PCDF &POPs pesticides inventory results by contracting with One national consultant for helping the international consultants. Proposal for the work plan for the remaining activities: Conducting a workshop for discussing and approving the results of the PCBs inventory. 2. Meeting with the national coordinating committee, NCC of POPs, for the final approval of the POPs inventory (pesticides, PCBs and PCDD/PCDF) 3. Translation of the POPs inventory results into English 4. Drafting the action plans of PCBs, PCDD/PCDF& POPs pesticides by contracting: 5. Conducting a workshop for discussing the drafted action plans for PCBs , PCDD/PCDF & POPs pesticides (for3 days). 6. Meeting with NCC for final approving of the action plans. 7. Drafting the NIP by contracting with One national consultant.and revising with One international consultant (UNEP consultant). 8. Conducting a workshop for discussing and approving the NIP 9. Meeting with NCC for approving the NIP 1. Persistent Organic Pollutants (POPs): The Yemeni government have banned use of POPs Pesticides since 1990 according to the official notice from ministry of agriculture and irrigation and ministry of health and population and to the last inventory which was done for preparing NIP. However, it is believed that smuggling of such pesticides have taken place. and because of this we need to implement inventories from time to time. Some POPs existed in the environment of Yemen. The available study conducted by DouAul and AlShwafi, 2000), reveals that the fish and the molluscs collected from the Red Sea and Gulf of Aden regions were contaminated with certain and PCPs residues. Compounds of DDT were found in these organisms in both regions. 67 PCBs were also found in some samples of the fish collected from in both regions. PCBs are not manufactured in Yemen, so their presence can thus only be from electricity usage and the possible dumping of products containing PCBs. Dioxins and Furans, reach the environment through smokes and ashes resulted from burning processes at the public garbage landfill site of coastal governates and of the burning process of wastes at the open incineration sites. Environmental and Heath: POPs substances are serious environmental and public health problem. But there is no official data about the environmental and public health problems POPs are easy reached the environment & marine organisms by air, water fluds, their concentrations may be low or high No research has been conducted on the extent of their effects on people where receive POPs. in the Yemen environment. Public information and awareness: There is no activities on public information and awareness were being undertaken in the Yemene concerning POPs. Most of the population and decision makers are not aware about the POPs. There no action plans on public awareness. (2) Status of Environmental Impact assessment and health in the context of EIA. We are working only on EIA and Within the programme of the EPA and WHO for 2006- 2007 we have chance to have training on HEIA) After the unification in 1990 many development projects started to be implemented in the country leading to a series of environmental, health and social problems, because of this it was realized that EIA implementation as integral part of project development process is essential. Therefore, the Cabinet of Ministers was requested to issue a Decree in this regard. Then the Decree No (89) for 1993 was issued by which the EIA but not HEIA became a mandatory process, and all development projects should require EIA studies. In the same decree, the Cabinet instructed Environment Protection Authority (EPA) to develop a national EIA policy and regulations. Legal Framework: Since the implementation of EIA requires a legal framework. So, it was essential for EPA to prepare the Environmental Protection Law (EPL) No. (26) for the year 1995 in close coordination with all relevant agencies. By this EIA becomes enabled by The EPL, which contains one chapter (Chapter three) regarding the licensing for projects and EIA, also by the EPL Executive Regulations (By-law 148 of 2000). ISTITUTIONAL FRAMEWORK: According to the Cabinet of Ministers Decree No. (89) For 1993 and section three of Environment protection Law No. (26) for the year 1995, the Environment Protection Authority (EPA) administers the EIA process; any other requirements and procedures included in the EIA legislations. This does not only involve 68 the responsibility for the drafting of regulations, guidelines and standards but also a central position in the TOR preparation, review of EIA reports, and the monitoring process. Within EPA, the responsibility for EIA rests with Directorate General for Monitoring and EIA, which liaises with and provides advice to the competent bodies. The Directorate General making use of any technical staff within EPA or any specialized person from universities or line ministries if needed. Ideas of the line ministries about EIA vary from ministry to another and are different in terms of acceptance of management and application. Some of them consider that the EIA process is their responsibility with assistance of EPA, while others consider that EPA should be fully responsible of EIA process with their assistance. Line ministries have no formal structure for administrating EIA. They commission EIA studies at the request of funding agencies, from consultancies recommended by the funding agencies. EPA staffs are informed of such studies and are invited to participate in some of the EIA activities. A copy of EIA report is sent to EPA for review and approval. An approval committee consists of all Directors General, Deputy chairman of EPA, chaired by EPA chairman, undertakes the review, making use of any needed specialized person within EPA/MTE or from universities and line ministries. For some specific EIA a sub-committee could be created, with members from line ministries, universities, research institutions etc., who have specific knowledge of aspects involved in the proposed activity. These sub-committee members are not permanent members of the EIA committee, but are contracted for each specific EIA separately. Monitoring is the responsibility of EPA and line ministries. In general it occurs only when complains are received or problems arises. This is due to the lack of clear mechanism, which identifies the role and responsibility of each agency. EPA can’t enforce EIA itself, either in requiring EIA studies, or in implementing mitigation or other requirements resulting from them. It can do so by coordination with line ministries, in accordance with their own obligations under the Environment Protection Law. According to the existing legislation, EPA is supposed to play the key role and to act as a lead agency in the following activities of the EIA process: 1. Process joint screening and scoping, together with competent bodies. 2. Developing of EIA Term of Reference for development projects. 3. EPA and line ministries joint review of EIA reports and provide the necessary comments or amendments according to alternatives, mitigation measures or needs for further studies. 4. Approval of EIA statement, including the mitigation measurement and monitoring system. The EPA usually consults the ministries in this process. 5. Follow up the implementation of EIA studies together with line ministries and funding agencies. 69 6. Monitoring the implementation of EIA condition and mitigation measures together with line ministries. Regardless the existing situation and in order to strengthen the relationship between EPA and line ministries in the implementation of environmental projects they should work closely and can undertake their responsibilities according to Environment Protection Law. Lessons learned: From experience gained of EIA implementation during the last seven years and since the EIA becomes a mandatory process the following lessons were identified:  Clear legal framework, guidelines and regulations including integrated monitoring system of  EIA implementation requires a clear EIA system/mechanism that clearly identifies the role         and responsibility of each party in EIA process. Technical and financial assistance is required to prepare and set up such mechanism. This could include consultants, documents preparation, organizing workshops etc. The enforcement of EIA process could be implemented on gradual and internal stages. The EIA is a good planning tool to identify the potential impacts, alternatives and set up monitoring plans. The application of EIA requires skills, professional experience to implement and evaluate the study reports. Although the implementation of EIA requires additional cost and time, but in the long run it has positive impact on environment, society and economy. Training is very important factor for all persons involved in the EIA process at different levels (technical, directors and reviewers). Awareness rising among the decision makers and public should be part of the EIA implementation program. Public participation of local communities, NGOs etc. is an essential element of EIA. EIA are essential basis towards EIA implementation. Problems and constraints: EIA process for development projects did not applied properly due to the following reasons:  There is no clear mechanism/system for EIA.  Lack of financial resources for the review and follow up of EIA studies.  There are many agencies responsible for Licensing, while coordination process with EPA is      very week. Very limited land-use planning and identification of sensitive areas. Inadequate environmental information and databases. There is no integrated monitoring system. Lack of awareness about EIA at different levels. (Decision makers, proponents and local communities) Training and capacity building in EIA related issues are very limited. 70 Needs: EIA and HEIA implementation usually requires a very close coordination and cooperation between all relevant agencies. This coordination will not be achieved without clear EIA system, which identifies the role and responsibility of each party. Therefore, technical and financial assistance from international organizations is required. This assistance could include International consultant for six months to one-year period to assist EPA in the following:  Set up EIA/ HEIA system/mechanism.  Training and capacity building of EPA personnel in regard to EIA & HEIA.  Organizing three-four workshops for EIA/HEIA awareness raising among different stakeholders including line ministries, local councils, NGOs…etc. (3) Institutional and technical capacities for Pollution testing pesticides, their residual There are no laboratories for pollution testing pesticides in general. There is no Reference Centre for pesticides poisoning. Laboratory for Quality Control available but not working because of these Problems and obstacles:  lack of some equipment  Lack of training  Lack of standard solutions and chemicals. The Pesticides Residue Analysis Lab. Still not functioning due to the need for: * Some equipment and chemicals. * Tech. Assistant. * Capacity building.       Regulation of pesticide use, stopping illegal transactional flow Environment Protection Law (26/1995) Regulation of Handing Pesticides for Plant Pests Law (25/1999) The Bylaw of the Environment Protection Law (26/1995), issued in 2000. The Bylaw (10/2002) for pesticides The Bylaw of Occupational Safety & Health, issued under the decision No (78) of the Minister of labour, Ins. and social affairs. The Pesticides Manual for the Republic of Yemen, 1990. 71  Procedures for Registration and handling of Pesticides in Yemen Aug. 2002 by the Ministry of Agriculture & Irrigation. Questions to the Ministry of Agriculture (1) Status, trends in pesticide use in Yemen o Types of pesticides and quantities imported ; types of application. o Which crops are most pesticide intensive; distribution of crops (and consequently, distribution pesticide use ) o Institutional set up for pesticide safety o Programmes for stockpile management o Status of integrated Pest management Perspectives Min. of Agriculture for collaboration with MOH on sound management of pesticides. 2- Status and trends in irrigation in Yemen o o o o Types of irrigation, size categories, distribution in the country. Plans for further irrigation development Irrigation water management ( nation and farmer level.) Institutional framework irrigation development (3) Agricultural Extension o Structure and organization of the Agricultural extension programme o Are there any farmers field schools ? o What are the core messages subjects of Agricultural. Extension in Yemen ? 72 o Does Ag. extension already cover health messages ? (4) Livestock o Distribution by type o Traditional Livestock management 73