Malaria Program Implementation in BFaso

A Documentation of Malaria
Program Implementation in
Burkina Faso
Prepared by MCHIP/USAID in Collaboration with the
National Malaria Control Program
March 2013
This report was made possible by the generous support of the American people through the
United States Agency for International Development (USAID), under the terms of the Leader
with Associates Cooperative Agreement GHS-A-00-08-00002-00. The contents are the
responsibility of the Maternal and Child Health Integrated Program (MCHIP) and do not
necessarily reflect the views of USAID or the United States Government.
The Maternal and Child Health Integrated Program (MCHIP) is the USAID Bureau for Global
Health’s flagship maternal, neonatal and child health (MNCH) program. MCHIP supports
programming in maternal, newborn and child health, immunization, family planning, malaria,
nutrition, and HIV/AIDS, and strongly encourages opportunities for integration. Cross-cutting
technical areas include water, sanitation, hygiene, urban health and health systems
strengthening.
Prepared by:
Bill Brieger
Ousmane Badolo
Aisha Yansaneh
Rachel Waxman
Elaine Roman
Published by:
Jhpiego
Brown’s Wharf
1615 Thames Street
Baltimore, Maryland 21231-3492, USA
www.jhpiego.org
© Jhpiego Corporation, 2013. All rights reserved.

Table of Contents
ABBREVIATIONS AND ACRONYMS ........................................................................................................... vi
ACKNOWLEDGMENTS ............................................................................................................................... v
INTRODUCTION ..........................................................................................................................................1
Background ...........................................................................................................................................1
Epidemiological Profile of Malaria in Burkina Faso ..............................................................................2
Endemicity ............................................................................................................................................ 2
Morbidity and Mortality ........................................................................................................................ 3
Malaria and HIV Interactions ............................................................................................................... 3
Progress on Malaria Indicators............................................................................................................ 4
DOCUMENTATION METHODS ....................................................................................................................6
STRATEGY AND POLICY DEVELOPMENT ...................................................................................................7
Historical Development .........................................................................................................................7
Current Strategy for 2011–2015 .........................................................................................................9
Current Levels of Support .....................................................................................................................9
IMPLEMENTATION PROGRESS .............................................................................................................. 10
Case Management ............................................................................................................................. 11
Intermittent Preventive Treatment..................................................................................................... 13
Vector Control ..................................................................................................................................... 14
Insecticide-Treated Nets ................................................................................................................... 14
Indoor Residual Spraying .................................................................................................................. 15
Larviciding .......................................................................................................................................... 16
Management of Supply of Commodities against Malaria ................................................................. 16
Advocacy, Information, Education, Communication and Social Mobilization................................... 16
Epidemiological Surveillance, Monitoring, Evaluation and Research ............................................... 17
NMCP Program Management and Coordination ............................................................................... 17
SYSTEMS FACTORS INFLUENCING IMPLEMENTATION PROGRESS ..................................................... 19
Policy and Strategy Formulation and Dissemination ........................................................................ 19
Integration and Coordination with Relevant Primary Health Care Service Areas and Partners ...... 19
Reproductive and Maternal Health .................................................................................................. 19
HIV and AIDS ...................................................................................................................................... 20
Financial Sources and Adequacy ....................................................................................................... 21
Community Awareness and Involvement........................................................................................... 23
Commodities and Procurement ......................................................................................................... 25
A Documentation of Malaria Program Implementation in Burkina Faso iii

Monitoring, Evaluation and Research................................................................................................ 27
Routine Service Data ........................................................................................................................ 28
Other Data Sources ........................................................................................................................... 29
Research to Support Malaria Programming .................................................................................... 29
Capacity Building and Training........................................................................................................... 31
In-Service Training ............................................................................................................................. 31
NMCP Capacity .................................................................................................................................. 31
Pre-Service Training .......................................................................................................................... 32
Quality Assurance including Supervision ........................................................................................... 33
Leadership, Governance and Structure ............................................................................................. 34
DISCUSSION ........................................................................................................................................... 35
Recommendations ............................................................................................................................. 39
REFERENCES/BIBLIOGRAPHY ............................................................................................................... 41
ANNEX 1: IDENTIFICATION DES MEMBRES DU PNLP (NMCP STAFF LIST) .......................................... 45
iv A Documentation of Malaria Program Implementation in Burkina Faso

Acknowledgments
The authors of this documentation thank the Ministry of Health of Burkina Faso and the
National Malaria Control Program (NMCP) for their assistance and contributions. We also
acknowledge the contributions of Dr. Patrice Combary, Coordinator of the NMCP, as well as
Kathleen Webb and Dr. Victor Nana, U.S. Agency for International Development (USAID)
Malaria Advisors.
Staff from the following offices and organizations were central to informing this documentation:
 Program for Health Development (PADS)
 General Directorate of Health Protection, Ministry of Health of Burkina Faso
 General Directorate of Pharmacies, Medicines and Laboratories
 Directorate of Maternal and Child Health, Ministry of Health of Burkina Faso
 Directorate of Disease Control (DLM)
 Directorate of Public Hygiene and Health Education
 Directorate of Community Health
 Regional and District Health Directorates
 Ecole Nationale de la Santé Publique (National School of Public Health)
 Central Essential Medicines and Generic Drugs Purchasing Agency (CAMEG)
 USAID DELIVER PROJECT
 Abt Associates
 U.S. Peace Corps
 Plan Burkina
 United Nations Children’s Fund (UNICEF)
 World Health Organization
A Documentation of Malaria Program Implementation in Burkina Faso v

Abbreviations and Acronyms
AB Accoucheuses Brevetées (Midwife)
ACT Artemisinin-Based Combination Therapy
ANC Antenatal Care
ASC Agent de Santé Communautaire (Community Health Worker)
BCC Behavior Change Communication
CAMEG Centrale d’Achat des Médicaments Essentiels Génériques (Central Essential
Medicines and Generic Drugs Purchasing Agency)
CBO Community-Based Organization
CCM Country Coordinating Mechanism
CDC U.S. Centers for Disease Control and Prevention
CHW Community Health Worker
CSPS Centre de Santé et de Promotion Sociale (Health Center)
DGPML Direction Générale de la Pharmacie, du Médicament et des Laboratoires (Pharmacy,
Medicines and Laboratories Directorate)
DHS Demographic and Health Survey
DLM Direction de la Lutte contre la Maladie (Disease Control Directorate)
DPV Direction de la Prévention par les Vaccinations (Directorate for Vaccination
Program)
ENSP Ecole Nationale de Santé Publique (National School of Public Health)
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
IEC Information, Education and Communication
IMCI Integrated Management of Childhood Illnesses
IMTP Integrated Malaria Training Package
IPTp Intermittent Preventive Treatment in Pregnancy
IRS Indoor Residual Spraying
ITN Insecticide-Treated Bed Net
LLIN Long-Lasting Insecticide-Treated Bed Net
LMIS Logistics Management Information System
LNSP Laboratoire National de Santé Publique (National Public Health Laboratory)
MCH Maternal and Child Health
MCHIP Maternal and Child Health Integrated Program
M&E Monitoring and Evaluation
MIP Malaria in Pregnancy
MIS Malaria Indicator Survey
MNCH Maternal, Neonatal and Child Health
MOH Ministry of Health
NGO Nongovernmental organization
NHA National Health Accounts
NHMIS National Health Management Information System
vi A Documentation of Malaria Program Implementation in Burkina Faso

NMCP National Malaria Control Program
PADS Programme d’Appui au Développement Sanitaire (a GF principal recipient)
PHC Primary Heath Center
PMI U.S. President’s Malaria Initiative
PMTCT Prevention of Mother-to-Child HIV Transmission of HIV
PNLP Programme National de Lutte Contre le Paludisme (National Malaria Control
Program)
PNEFL Programme National d’Elimination de la Filariose Lymphatique (National
Lymphatic Filiarisis Program)
PR Principal Recipient of a GFATM grant
PCV U.S. Peace Corps Volunteer
RAOPAG Le Réseau d’Afrique de l’Ouest contre le Paludisme Pendant la Grossesse (West
Africa Network Against Malaria in Pregnancy)
RASI Rapports Activité de Santé Informatisé (Computerized Health Activity Reports)
RBM Roll Back Malaria
RDT Rapid Diagnostic Test
SMC Seasonal Malaria Chemoprevention
SP Sulfadoxine-Pyrimethamine
STI Sexually Transmitted Infection
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
A Documentation of Malaria Program Implementation in Burkina Faso vii

viii A Documentation of Malaria Program Implementation in Burkina Faso
Introduction
This documentation of malaria program implementation in Burkina Faso was undertaken in
2012 by Jhpiego as the lead organization for the U.S. Agency for International Development
(USAID) Maternal and Child Health Integrated Program (MCHIP), in collaboration with the
National Malaria Control Program (NMCP), to document the extent of program implementation
and point a way forward. Specific objectives of the documentation were:
 Document the current status of malaria indicators
 Review the extent of malaria program implementation by all partners
 Identify best practices/strategies that have supported malaria programming success
 Determine existing bottlenecks in malaria program implementation and recommend how these
could be overcome
BACKGROUND
With a population of 16.2 million, Burkina Faso is a poor West African country, ranking 181 out
of 187 countries on the United Nation’s Human Development Index (MOH 2012a; World Bank
2011). The country’s annual growth rate is 3.7% (UNICEF 2011). The majority of the population
(80%) resides in rural areas, versus 20% living in urban areas. Burkina Faso is a land-locked
country that is surrounded by Mali in the north, Niger in the northeast, and by Benin, Togo,
Ghana and Côte d’Ivoire in the south. The country has a tropical climate with two seasons: dry
and rainy. Burkina Faso is one of six Sahelian countries along the Sahara desert with yearly
seasonal variations in rainfall (Wuehler et al. 2011). More than 80% of Burkina Faso’s burden of
disease is due to communicable diseases, with the population affected by high rates of infectious
diseases, such as malaria, diarrhea and neglected tropical diseases (WHO 2006b).
Administratively, Burkina Faso is divided into 13 regions, 45 provinces, 70 health districts and
351 rural and urban municipalities (MOH 2012). The Ministry of Health (MOH) comprises
three administrative levels: the central, regional and district levels. Three university hospitals,
one national hospital, nine regional hospitals, 44 district hospitals and 1,443 health centers
serve the health needs of the country. Formal health services for the rural population are
limited to small health centers staffed by two nurses and one midwife (Kouyaté et al. 2007).
The private sector includes about 450 for-profit facilities, 45 nongovernment organizations
(NGOs) and faith-based facilities, and 140 biomedical laboratories. This sector has increased
exponentially since the 1970s when there were only 10 (IRIN 2009). Regulation of these private
facilities varies. In 2009, there was a crackdown on 20 illegal facilities. IRIN News (2009)
reported that, “Operators of illegal clinics may be licensed doctors, but do not employ licensed
staff.”
Officially, there are no informal medicine sellers in Burkina Faso, though researchers have
documented their existence (Tipke et al. 2009). The private pharmaceutical sector essentially
consists of registered pharmacies staffed by trained and licensed pharmacists. The bulk of these
are found in Ouagadougou and the larger cities.
The NMCP is a small unit within the MOH, under the Disease Control Directorate, which is
under the Directorate General of Public Health, and comprises three physicians, one pharmacist
and 17 staff. Four research centers are engaged in malaria research in Burkina Faso: Centre
National de Recherche et de Formation sur le Paludisme, Institut de Recherche en Science de la
Santé, Centre Muraz and Centre de Recherche en Santé de Nouna.
A Documentation of Malaria Program Implementation in Burkina Faso 1

EPIDEMIOLOGICAL PROFILE OF MALARIA IN BURKINA FASO
Endemicity
Malaria is the leading cause of morbidity and mortality in Burkina Faso (Kouyaté et al. 2007).
Specifically, malaria is highly endemic in the country, with high malaria transmission intensity
and three levels of transmission seasons increasing from the north to the south (Figure 1). The
northern-most Sahelian region is prone to epidemics, with short seasonal transmission of two to
three months. The central Sudano-Sahelian region has long seasonal transmissions of four to
six months, while the southwestern Sudano region experiences permanent transmission, with
an increase in transmission during the rainy season (INSD: DHS-MICS 2010). In fact, almost
half of all fevers are attributable to malaria during the rainy season (Bisoffi et al. 2010).
Coulibaly and colleagues (2007) studied pregnant women in Boromo District and found a higher
prevalence in December (32.2%) than in May (11.9%), which is the end of the dry season.
Figure 1. Malaria-endemic zones in Burkina Faso
The 2010 Demographic and Health Survey/Multiple Indicator Cluster Survey (DHS-MICS) for
Burkina Faso documented a high prevalence of malaria in children aged 6–59 months. The
average determined by rapid diagnostic test (RDTs) was 66%, and varied by district as seen in
Figure 2. A 2004 study in northwestern Burkina Faso followed more than 6,000 children aged
less than five years for over two years and found through verbal autopsies that 49% of all
deaths were due to suspected malaria. All cause and malaria-specific mortality rates were 26.7
(95% CI: 24.2–29.2) and 15.8 (Ramroth et al. 2009).
2 A Documentation of Malaria Program Implementation in Burkina Faso

Figure 2. Prevalence of malaria in children less than five years of age, MICS 2010
Morbidity and Mortality

Malaria is a major public health problem in Burkina Faso, with the entire population at risk for
infection. It is the first cause of doctor visits, hospitalizations and deaths in health facilities
(GFATM 2008). Pregnant women and children less than five years of age are most at risk. In
2011, malaria was reported as being responsible for 45.4% of health facility visits, 52.5% of
hospitalizations and 34.2% of deaths. Children less than five are the most at risk, with 54.2% of
reasons for visits, 80.38% of hospitalizations and 87.9% of deaths (MOH 2012b). Most of the
malaria burden in Burkina Faso is among children less than five years of age as seen in a
mortality rate (MR) of 2.0% for all malaria deaths and 3.1% for children under five.
Malaria in pregnancy (MIP) is a global health concern that results in adverse birth outcomes
and poor maternal health. Malaria infection during pregnancy poses substantial risk to the
mother, her fetus and the neonate (Sirima et al. 2006), including preterm delivery, congenital
infection and reproductive loss (Pell et al. 2011). Placental malaria infection contributes to low
birth weight (LBW)—a major risk factor for neonatal mortality and a major contributor to
infant mortality (McCormick 1985). As a result of MIP, an estimated 10,000 women and up to
200,000 infants die annually in Africa (WHO 2008). In stable endemic areas, women acquire
some immunity to malaria, similar to other adults in the population. Conversely, these women
are more susceptible to placental malaria, in which case the woman may not show frank
malaria signs and symptoms even though she and her fetus are at risk. MIP can also lead to
maternal anemia, placental malaria infection and LBW, with first- and second-born children at
highest risk (Newman et al. 2003; Steketee et al. 2001). Ultimately, it may be difficult to
diagnose MIP in stable transmission areas; hence, the need to clear malaria parasites using
intermittent preventive treatment in pregnancy (IPTp) regardless of symptomatic or
asymptomatic presentation.
Malaria and HIV Interactions

Burkina Faso has a low-level generalized HIV epidemic. The country has an adult prevalence of
1%, with 1.2% among adult women and 0.8% among adult men (INSD: DHS-MICS 2010). There
is markedly high urban/rural variation, with a prevalence of 2.1% in urban areas versus 0.6% in
rural areas. An estimated 120,000 people are living with HIV/AIDS in the country (UNAIDS
2011). Similar to other West African countries with low HIV prevalence rates, Burkina Faso’s
HIV epidemic is concentrated in higher-risk groups, such as female sex workers (16.3%
prevalence in 2005) (CNLS, 2010).

The interaction of HIV with malaria is an important factor in most African countries where the
two epidemics overlap and the majority of HIV-infected individuals are exposed to P. falciparum
(Saleri et al. 2009). HIV infection increases the frequency and severity of clinical malaria
(Corbett et al. 2002; Cohen et al. 2005). On the other hand, immune activation and pro-
inflammatory cytokines associated with malaria in co-infected individuals may increase HIV
replication and accelerate disease progression (Hoffman et al. 1999). Among pregnant women,
HIV contributes to higher malaria infection rates, higher parasite density, more clinical illness,
increased anemia and diminished response to treatment (Hewitt et al. 2006). In young children,
malaria-induced anemia often leads to blood transfusions that may contribute to HIV
transmission (Hewitt et al. 2006). Malaria infection also contributes to higher maternal HIV
viral load, a risk factor for mother-to-child transmission of HIV.
To assess the relationship between HIV-1 and P. falciparum infection, a study was conducted
using population-based cross-sectional data from West Africa, including Burkina Faso. The
study did not identify an association and suggested that there may not be a malaria/HIV
interaction in populations where HIV prevalence is low (Cuadros et al. 2011). Between 2004 and
2006, another study was conducted to describe the clinical presentation and predictors of death
among HIV-positive individuals hospitalized in Ouagadougou. The study results showed that,
along with other factors (i.e., WHO clinical stage, neurological syndrome, wasting syndrome),
malaria infection at admission was a significant risk factor for death (Saleri et al. 2009). To
date, there is no mention of HIV co-infection in the NMCP policy documents in Burkina Faso.
This absence may not be surprising given that, “malaria might not play an important role in the
spread of HIV in populations where the HIV prevalence is low” (Cuadros et al. 2011).
Progress on Malaria Indicators

Three key sets of malaria indicators were spelled out during the 2000 Roll Back Malaria (RBM)
Summit in Abuja. They focus on use of insecticide-treated bed nets (ITNs), update of IPTp and
prompt and appropriate treatment of malaria episodes. The Monitoring and Evaluation
Reference Group of RBM updates and refines these indicators as needed. National indicators
are obtained through two main sources: DHS or Malaria Indicator Surveys (MIS) completed
every two to five years, and a national health management information system (NHMIS) that
captures routine service data on a regular basis.
Table 1 compares the most recent DHS-MICS (INSD 2010) with that of 2003. While few of the
current malaria indicators were collected in 2003, considerable progress has been made. That
said, it is important to note that the RBM target of 80% achievement by 2010 has not been met
for any of the key indicators, including ITN use, accessing IPTp and appropriate case
management of malaria episodes.

Table 1. Priority malaria indicators and corresponding data sources for Burkina Faso
SURVEY/SOURCE
PERCENTAGE
INDICATOR
DHS 2003 DHS-MICS
2010
Proportion of women who received two or more doses of IPTp during their
* 10.6
last pregnancy, leading to a live birth within the previous two years
Proportion of households with at least one net of any kind - 65.5
Proportion of households with at least one ITN** 4.6 56.9
Proportion of children <5 years of age who slept under any net - 53.2
Proportion of children <5 years of age who slept under an ITN/LLIN - 47.4
Proportion of children <5 years of age in a house with ITNs who slept
- 71.3
under an ITN/LLIN
Proportion of women (aged 15–45) who slept under an ITN the previous
2.3 -
night
Proportion of pregnant women who slept under any net the previous night - 52.7
Proportion of pregnant women who slept under an ITN/LLIN the previous
2.6 44.5
night
Proportion of pregnant women in a house with ITNs who slept under an
- 73.7
ITN/LLIN the previous night
Proportion of children <5 years of age with fever in past 2 weeks who
- 8.7
received ACTs
* 92.5% used chloroquine for prophylaxis at the time of this survey.
** For the purpose of this report, the term “ITN” has been used as most secondary sources of data refer to ITNs. LLINs are
mentioned specifically when data sources have indicated LLINs.
Table 2 provides NHMIS data from the past four years (2009–2012). Of note, these routine data
begin to capture the use of diagnostic tests and inferred application of test results to
prescribing. Routine data help in understanding service delivery issues over time in ways that
national surveys do not. Fluctuations in medicine and test use, for example, reflect procurement
and supply issues. The likely improvement in use of ACTs based on RDT results over time
corresponds not only with training, but also with commodity supplies. Table 2 also shows an
uptake in IPTp1 based on antenatal care (ANC) first registration and a rather steady state of
IPTp2 that is consistently below IPTp1, implying missed opportunities or attendance factors.
Table 2. Malaria indicators obtained through routine monitoring and evaluation

NHMIS DATA AND 2009 2010 2011 2012
INDICATORS/VARIABLES
Case Management
Total Outpatient Visits 8,649,053 10,986,072 11,321,013 13,392,989
Malaria Outpatient
3,986,426 5,428,178 5,030,904 6,569,461
Consultations
Microscopy Performed in Clinics 148,385 124,066 211,828 227,780
Microscopy Positive 72,370 64,218 63,613 104,040
RDTs Performed in Clinics 182,658 957,296 389,578 4,462,650
% of RDTs performed for suspect
5% 18% 8% 68%
malaria
RDTs Positive 123,107 729,482 296,144 3,711,581

NHMIS DATA AND 2009 2010 2011 2012
INDICATORS/VARIABLES
% of RDTs performed that were
67% 76% 76% 83%
positive for malaria
ACTs provided at outpatient
3,946,366 4,626,704 3,136,894 5,184,068
clinics
% of ACTs distributed at malaria
99% 85% 62% 79%
consults
% ACTs likely provided based on
parasitological diagnosis (RDT 5% 17% 12% 74%
positive/ACT provided)
ACTs by Community Agents
646 218,724 719,906 90,810
(ASCs)
Malaria in Pregnancy
Estimated Population of
759,078 817,404 866,985 -
Pregnant Women
ANC One Visit 738,907 688,138 564,007 752,622
ANC Two Visits 606,180 593,919 484,533 651,742
IPTp1 549,401 511,115 434,150 532,128
IPTp2 446,297 429,197 348,505 447,648
IPTp2 Coverage from ANC
60% 62% 62% 71%
Registration
IPTp2 Estimated Population
59% 53% 40% 59%
Coverage
Insecticide-Treated Nets
Estimated National Population 15,155,849 15,713,422 15,982,625 -
ITNs Distributed 1,130,049 6,943,147 743,002 271,781
DOCUMENTATION METHODS
This malaria program implementation documentation was completed in three main stages. The
first was a desk review of available documents, agency reports, published articles and websites.
Information obtained was organized and guided by the implementation framework described
below.
For the desk review, data were analyzed from existing population-based surveys, such as the
DHS-MICS; from peer-reviewed articles, existing documents and reports on malaria in Burkina
Faso by the Global Fund; and from recent press releases by leading local news agencies. The
review focused on: 1) current status of malaria indicators, 2) extent of malaria program
implementation by all partners, 3) best practices/strategies that have supported malaria
programming success, and 4) existing bottlenecks in malaria program implementation and how
these could be overcome. To obtain a comprehensive picture of the levels of malaria program
implementation, a framework was used for analysis. This framework examines the following
nine key areas of malaria programming:
 Policy Formulation and Dissemination
 Integration with Relevant Primary Health Center (PHC) Service Areas

 Financial Sources and Adequacy
 Community Involvement/Awareness/Education
 Commodities and Procurement
 Monitoring and Evaluation
 Capacity Building and Training
 Quality Assurance including Supervision
 Leadership, Governance and Structure
The desk review was followed by in-depth

interviews of key stakeholders within the
MOH and among partner organizations.
Gaps and questions arising from the
review served as the basis of an informal
interview guide that was adapted to the
focal area of particular stakeholders. Site
visits were conducted to verify actual
knowledge and practices at the service
delivery level.
The final phase of the review shared the

draft report with NMCP staff and selected
partners for validation and additional
inputs. Figure 3. Scoring system for malaria program implementation
framework
As part of the analytical process, the nine components were scored on their level of
implementation (Figure 3). These scores were derived from a consensus among internal and
external reviewers of the document.
STRATEGY AND POLICY DEVELOPMENT

Malaria control has been a major component of Burkina Faso’s national health development
policy and strategy in the past years and one of the strategic priorities in the country’s anti-
poverty policies (INSD: DHS 2010). Burkina Faso has supported and adopted various global
initiatives, including RBM, the Abuja Convention and the Millennium Development Goals
(MDGs). The first National Malaria Strategic Plan covered 2002–2005, followed by the 2006–
2010 plan and the current 2011–2015 plan.
HISTORICAL DEVELOPMENT
The NMCP was formed in 1991 to manage all aspects of malaria activities in the country. A
steering committee was put in place to provide advice and guidance to the NMCP and
implementing partners. The NMCP is housed within the MOH and falls under the Disease
Control Directorate (Direction de Lutte contre la Maladie).

Malaria activities are organized at the three levels of the health system (USAID 2011):
 The central level is responsible for developing strategies, mobilizing resources, coordinating
partners and evaluating performance.
 The intermediate level comprises 13 health regions with nine regional hospitals, which serve as
referral centers.
 The peripheral level comprises 70 health districts with a total of 1,583 health facilities. The
private sector includes about 450 for-profit facilities, 45 NGOs and faith-based facilities, and 140
biomedical laboratories.
The NMCP has developed strategic plans to use as a framework for malaria control activities.
As a result of the 2000 Abuja Convention, the 2002–2005 National Malaria Strategic Plan was
developed with the following objectives: 1) decrease malaria morbidity by 25% and 2) decrease
mortality by 25% by improving facility-based and community-based treatment of malaria. These
objectives, however, were not met by 2005 due to the high cost of malaria treatment, low
coverage of ITNs due to insufficient financing, low level of advocacy and low institutional status
of the NMCP within the MOH.
In response to the challenges encountered by the 2002–2005 strategic plan, the 2006–2010 plan
was developed with an objective of reducing malaria morbidity and mortality by 50%. The 2006–
2010 plan also stated that treatment should be based on biological diagnosis, using blood
smears or RDTs in facilities that do not have a microscope. The 2006–2010 plan was created to
address three identified challenges by: making ACTs available and accessible to the population,
providing free ITNs and IPTp using SP for malaria prevention among vulnerable groups (e.g.,
children under five and pregnant women), and strengthening the capacity of the NMCP (MOH
2007). The strategic plan included the following activities:
 Make ACTs available and accessible for treatment in health facilities and in the community
 Promote community-based intervention by clarifying the status and role of CHWs
 Make treatment of severe malaria available in referral centers
 Accelerate the scale-up of integrated management of childhood illnesses (IMCI)
 Promote integrated vector management
 Make ITNs available and accessible through different channels in the public and private sectors
 Scale up IPTp through ANC
 Strengthen advocacy, social mobilization and behavior change communication (BCC)
 Strengthen the institutional capacity of the NMCP
 Strengthen partnership and multi-sectoral collaboration in malaria control
 Contribute to the achievement of research on malaria
 Strengthen monitoring and evaluation (M&E)
The new five-year strategic plan (2011–2015) is a complement to the previous strategic plan,
with indoor residual spraying (IRS) included as an additional preventive measure (MOH 2011).
The NMCP develops annual work or action plans and has an annual assessment of progress
that forms part of planning for the next year.

CURRENT STRATEGY FOR 2011–2015
The vision of this strategy is “a Burkina Faso without malaria for sustainable human
development.” Likewise, the strategy outlines the following mission:
The mission of the Ministry of Health in the fight against malaria through the NMCP is to
ensure universal access to prevention and treatment of malaria across the country for the
reduction of morbidity and mortality due to malaria. This strategic plan to fight against malaria
for the period 2011–2015 should enable the NMCP to strengthen the control of the disease, in the
context of coordination of partners, to strengthen the national leadership.
The overall goal of the strategy is to reduce morbidity by 75%, compared to 2010, and mortality
from malaria to a level close to zero in Burkina Faso by the end of 2015. The current objectives
of the NMCP are to achieve the following by the end of 2015:
 100% of suspect cases of malaria will be confirmed and treated with appropriate antimalarials
in all public and private health facilities and at community level.
 100% of pregnant women and children 3–59 months will have received intermittent preventive
treatment for malaria.
 100% of the population sleeps under long-lasting insecticide-treated nets (LLINs)
 100% of the population in four target regions benefit from IRS (Sud-ouest, Cascades, Hauts-
bassins et Boucle du Mouhoun).
 100% of targeted larval breeding areas are covered by antilarval treatment in the regions of
Centre and Haute Bassins.
 100% availability of quality commodities is ensured at health facilities and community level.
 At least 80% of the population demonstrates behaviors favorable to the fight against malaria.
 100% of health districts produce quality monthly malaria data from all public and private
health facilities and the community level.
 Capacity of NMCP to manage the fight against malaria, including the coordination of partner
interventions, is reinforced.
The current NMCP malaria control strategy, therefore, includes prevention, treatment and
support strategies. Prevention strategies include vector control through LLIN use and IRS, as
well as prevention of MIP. Treatment strategies include early and adequate treatment of
malaria using ACTs and the treatment and care of severe malaria cases in referral centers.
Support strategies for malaria control include advocacy, information, education communication
(IEC)/BCC and monitoring and evaluation of malaria programs. The rapid scale-up of malaria
prevention and treatment interventions and the achievement of high coverage rates with ACTs,
ITNs and IPTp are common goals of the NMCP and its partners (MOH 2011).
CURRENT LEVELS OF SUPPORT

It is important to examine financial support for malaria in the context of overall health
expenditure. From 2005–2008, total health expenditures increased from 202 billion FCFA to
254 billion FCFA—a 26% increase over three years (Zida et al. 2011). Of note, from 2003–2008,
household expenditures for health (often known as out-of-pocket expenses [OOP]) declined from
50% to 38% of total health expenditure, public expenditure increased from 26% to 31% and
international funding rose slightly, hovering around 30%.

In 2009, the volume of expenditures dedicated to efforts to control malaria in Burkina Faso was
estimated at 37.2 million FCFA, compared to 24.5 million in 2008, up from 18.7 million in 2006
(WHO 2009). Unlike the overall picture of sources for the general health expenditures, two-
thirds of the spending on malaria in 2009 was “private” or OOP. Public spending was about 20%
and international/donor support was around 12%.
Table 3. Sources of financial support to NMCP in FCFA

SOURCE 2009 2010 2011
National Budget 3,032,500 498,262,000 697,782,117
PADS (basket funds) 8,205,770 1,290,060,113 97,272,337
WHO 5,000,000 7,875,520 49,513,800
UNICEF 12,519,990 230,000,000 70,126,500
Global Fund Round 7 378,280,562 21,635,914,971 973,181,441
Plan Burkina (Global Fund PR) 1,000,000 - 1,052,500
Deliver - - 34,793,020
USAID1 - 3,430,913,010 993,287,078
JICA 11,239,317 - 0
Westergraad 1,311,910 - 0
BMG - 133,112,629 -
LWR - 2,250,000 -
FICR - 225,000,000 -
Other - 9,861,955 0
Sanofi Aventis - - 16,398,925
RTI - - 8,028,200
TOTAL 420,590,049 27,463,251,000 3,241,469,168
Source: NMCP Action Plan for 2013, May 18, 2012.
IMPLEMENTATION PROGRESS
Seven specific strategic interventions have been defined to achieve the objectives in the national
malaria strategy as outlined below:
 Malaria case management
 Intermittent preventive treatment of malaria in women, pregnant women and children
 Control of malaria vectors
 Management of the supply of commodities against malaria
 Advocacy, information, education, communication and social mobilization
 Epidemiological surveillance, monitoring, evaluation and research
 Program management
1As reported by NMCP, does not match with USAID/PMI Malaria Operational Plans, which have allocated $6 million per year. Most likely
due to funds not directly provided to government or NMCP, activities, such as procurement and capacity building, are conducted through
cooperating agencies.

A review of progress based on these strategic interventions is discussed below.
CASE MANAGEMENT
Even with the current case management guidelines in place, Burkina Faso continues to face
treatment challenges. There are problems with adherence to ACT treatment due in part to
complaints that ACTs make people weak (USAID 2009). Many patients delay treatment at
health facilities in favor of using local herbs for self-treatment. As a result of this delay, many
referral cases require blood transfusions for severe malaria. There are also challenges in
treating severe malaria due to a limited supply of blood for transfusion services. There is no
provision for management of severe malaria in the Global Fund Round 7 or 8 proposals. USAID
has provided treatment kits for the management of severe malaria.
In terms of treatment of MIP, national case management guidelines in 2010 recommended:

“Quinine is the drug recommended for treatment of uncomplicated malaria in pregnant women,
at a dose of 8 mg/kg quinine base orally (not to exceed 480 mg per dose) every 8 hours for 7 days.
In case of intolerance to quinine, refer pregnant women for appropriate management.” Current
policy does not include the World Health Organization (WHO) recommendation to combine
quinine with clindamycin (WHO 2010). While some countries have adopted the use of ACT for
treatment of MIP in the second and third trimesters, based on WHO Guidelines for the
Treatment of Malaria (WHO 2010), Burkina Faso has yet to adopt this policy.
Malaria case management has been hindered by the fact that not all providers routinely
perform the test for clients presenting with fever. Frequent RDT stock-outs are partly to blame,
but health worker performance is an equally challenging factor. As in many countries, health
workers trust their clinical judgment for treating “uncomplicated malaria.” They have doubts
about the efficacy of RDTs, some of which was reinforced by early training run by the MOH
(Gallagher et al. 2010). Performance has rarely been reinforced due to inadequate supervisory
tools and visits. This may be changing as stocks and supervision improve, as witnessed in a
recent report from field supervision:
During our supervision (March 2012), we noticed that there are some best practices in some
health facilities like in Sissamba CSPS, where the ICP said us that since he received RDT stocks,
whenever it was necessary to do this test, he did it and he observed that he saved around 76% of
ACT because RDT was negative and if he didn’t have test, he may have considered all as malaria
cases and should have prescribed 100% of ACT (MCHIP project reports).
For case management, the NMCP has developed guidelines to expand diagnostics for biological
diagnosis (e.g., microscopy, RDTs) of all presumptive malaria patients in health facilities by
2012. The 2006–2010 National Malaria Strategic Plan states that treatment should be based on
a biological diagnosis, using blood smears or RDTs in facilities that do not have a microscope.
With Global Fund Round 7 support, the NMCP introduced RDTs into all health facilities
without microscopic capability. The initial focus for RDT introduction is use in health facilities,
and eventually may be rolled out to the community level for use in community-based case
management (USAID 2011). Training for RDT use was originally rolled out from the national to
the regional level, then to district and facility levels in six pilot regions (Gallagher et al. 2010).
In 2008, Burkina Faso received its initial stock of RDTs from Global Fund. Then with funding
from USAID, RDTs were provided in all regions during 2010. The USAID stocks were supposed
to meet the country need until more Global Fund stocks could be acquired, but ongoing delays
with the consolidation of the Global Fund contracts led to intermittent shortages and stock-outs
in 2011 and 2012.

A rapid assessment of RDT use in Burkina Faso, conducted in July 2010, showed that RDT use
was low, with an indication that most people were treated without RDT (Gallagher et al. 2010).
The general practice in clinics had been that any person presenting with “uncomplicated
malaria” was treated with ACTs—without RDT confirmation. Later, this practice was amended
to require all adults be tested first. Finally, when it was expected that RDT supplies would be
adequate, the guidelines expanded the requirement of RDT use to all age groups. During the
2010 rapid assessment, old treatment algorithms were still found in some clinics and were not
consistent with the updated policy. Regardless of guidelines and training, many health workers
continued to believe that RDT results are probably incorrect.
Subsequent incorporation of RDT use with national case management guidelines and in-service
training protocols has likely contributed to the increased, though not universal, use of RDTs in
clinics. Irregular supply of both ACTs and RDTs is another factor that jeopardizes appropriate
case management procedures.
Since approximately 70% of presumed malaria cases are treated in the home, Burkina Faso has
supported home-based management of fever since 1997 (USAID 2011). Objective 2 of the
Burkina Faso Global Fund Round 8 proposal is to provide home treatment with ACTs for at
least 80% of simple malaria cases seen at the community level, in line with the national
treatment policy, by 2013 (USAID 2009). Community-based treatment with ACTs was rolled out
nationwide in 2010 and 2011. While treatment has been provided free of charge, it is
anticipated that treatment will later be sold at the subsidized price at which it is currently sold
in public health facilities (USAID 2011).
Community health workers (CHWs) (or Agent de Santé Communautaire [ASCs]) have been used
for malaria case management for many years, but not in a coordinated way until recently. They
used to provide chloroquine in the community until national policy changed to ACTs; then,
ASCs were no longer allowed to perform treatment. A return to community case management
has come as part of Global Fund Round 8. For Round 8, the country aimed at providing home
treatment with ACTs for at least 80% of simple malaria cases seen at the community level, in
line with national treatment policy, by 2013. The target for trained ASCs was 9,000. By July
2011, 100% of the target had been achieved. Subsequently, only 16% of 2,725,897 targeted cases
had been treated appropriately (GFATM 2011). There has been some resistance by health
center staff to community case management, especially when they themselves are having ACT
stock-outs.
Table 4. Malaria case management by health service level

LEVEL OF CARE TYPE OF PERSONNEL CAPACITY OF CARE
Tertiary Doctor/specialists Treatment and management of
University teaching severe malaria and complications
hospitals/referral hospitals
Secondary Medical doctors, midwives Treatment and availability of a
Regional hospitals, district laboratory for diagnostic
hospitals (CMAs), private clinics confirmation and follow-up;
Evaluation of complications
Primary Nurses, auxiliary health workers RDT for confirmation of malaria;
Community health centers (CSPS), Treatment of uncomplicated
dispensaries, private clinics malaria with ACT; Treatment and
referral for severe malaria.
Community Community health workers Syndromic malaria treatment with
Household visits (CHWs/ASCs) ACT
Source: Manuel de formation pour la PEC du paludisme au niveau du district 2010.

Of note, CHWs/ASCs are technically not part of the health system pyramid seen in Table 4.
Thus, they are not salaried public workers. They are volunteers in the strict sense of the word.
The MOH created a new directorate for community work in 2011 in an attempt to coordinate all
the different types of CHWs in the country and develop standard protocols for their selection,
supervision and duties. Since the CHWs working on malaria at present were recruited through
efforts of NGO recipients of Global Fund Round 8, there have been some challenges in trying to
bring their work into the overall protocols being developed by the MOH for CHWs.
Table 4 shows CHW reports being integrated with NHMIS data summaries. A gap remains
though, in terms of community-level use of RDTs to ensure appropriate treatment, as is the
standard in countries such as Rwanda.
INTERMITTENT PREVENTIVE TREATMENT

Burkina Faso was among the malaria-endemic countries in which clinical trials and program
evaluations have shown that IPT with sulfadoxine-pyrimethane (SP) is efficacious and effective
in preventing maternal anemia, placental parasitemia and LBW (Sirima et al. 2006).
The current strategy recommends prevention of malaria during pregnancy and in children
under five through IPT of malaria. For pregnant women, this includes providing them with two
doses of SP under direct observation in the second and third trimesters at antenatal
consultations (WHO 2004). In July 2012, WHO increased the recommended doses of IPTp to one
at each ANC visit after quickening (assuming these are at least a month apart) (WHO 2012).
Specifically with the four-visit focused antenatal care approach being implemented, a pregnant
woman could have a minimum of three IPTp doses, assuming the first visit might be in the first
trimester when SP is not given. Burkina Faso will soon begin the process of updating the IPTp
component of the strategy. This update also needs to be taken into consideration within policy
in Burkina Faso.
For children, IPT for infants under one year and seasonal malaria chemo-prevention (SMC) for
children aged 1–5 has been recommended. This program is receiving attention by the WHO
Global Malaria Program, and most countries across the Sahel may start the SMC process
during the 2013 rainy season.
MIP prevention with IPTp with SP has been a national policy since 2005 and is included in the
national case management guidelines. This inclusion was based on positive results from
research conducted by the U.S. Centers for Disease Control and Prevention (CDC) and other
partners, including Jhpiego (Sirima et al. 2006). Previous MIP policy guidelines recommended
that pregnant women receive initial treatment with chloroquine, followed by weekly chloroquine
chemoprophylaxis throughout pregnancy. However, poor compliance with weekly regimens and
increased resistance of P. falciparum to chloroquine caused the MOH to change its
recommendation from MIP chemoprophylaxis to IPTp with SP.
In 2001, the MOH conducted an evaluation to determine coverage of chloroquine

chemoprophylaxis and the burden of malaria during pregnancy in Koupéla District (Sirima et
al. 2006). The assessment showed moderately high rates of malaria during pregnancy despite
widespread use of chloroquine chemoprophylaxis and no association between use of chloroquine
chemoprophylaxis and reduction in adverse outcomes, such as anemia, LBW and prematurity.
In response to the evidence of chloroquine resistance shown in the study, the MOH
implemented a pilot program of IPTp with SP in Koupéla District as part of a package of
focused antenatal care in February 2003, which was supported by the CDC and partners
including Jhpiego.

In late 2004, a rapid assessment of the pilot program found very high coverage of IPTp with SP
among women attending antenatal and delivery facilities. The assessment showed a reduction
in the proportion of women with MIP and its adverse outcomes, comparing 2004 rates with
those of 2001, when a program of chloroquine chemoprophylaxis was in place. These results
suggested that IPTp with SP and ITNs may be a more effective strategy to prevent MIP in
Burkina Faso than chloroquine chemoprophylaxis. As a result of these findings, the MOH
adopted IPTp with SP for prevention of malaria and its adverse consequences in pregnant
women and their fetuses in 2005.
Two important challenges to IPTp are adolescent pregnancy and a gap between ANC coverage
and IPTp. A recent study found that pregnant adolescents attended ANC less often that their
older counterparts and had lower IPTp coverage rates (Grietens et al. 2010). Similarly, there
are missed opportunities in ANC, although 91% of women attend two or more ANC
consultations during pregnancy (INSD: DHS-MICS 2010). The same study also found that only
10.6% of women received two doses of SP as part of ANC care for a pregnancy in the previous
two years (Grietens et al. 2010).
While the revised National Malaria Strategic Plan for 2011–2015 includes expanding training
for the delivery of IPTp during prenatal consultations, a shift in training strategy between 2011
and 2012 may be counterproductive to the effort to strengthen IPTp. In 2011, training sessions
targeted two providers per facility. For health centers, this usually included the nurse in-charge
of curative care and the auxiliary midwife responsible for ANC. In 2012, to reach more districts,
one provider per facility was targeted for training. This person was usually the nurse in-charge
of curative care (MCHIP 2011). The gap in training on IPTp and MIP, more broadly among the
providers of ANC, should be taken into account in future malaria programming.
NHMIS data in Table 4 show an increase in IPTp1 coverage in clinics using ANC first
registration as a denominator, but no real improvement in IPTp coverage. Since IPTp delivery
presently uses ANC as a delivery platform, the fluctuation of ANC attendance over the years
using this NHMIS data should be noted. The 2010 DHS reports that nearly 95% of pregnant
women surveyed attended ANC at least once during their most recent pregnancy, and 91%
attended at least twice. The relatively low coverage of both IPTp1 and IPTp2, compared to
targets of 80%, imply that health system factors lie at the heart of the clinic-based coverage
problems.
VECTOR CONTROL
Although the strategy mentions antivectoral prevention through utilization of LLINs, IRS and
antilarval treatments, the IRS component is currently not being implemented. A pilot study in
one district did not justify expansion of IRS at this point in time.
Insecticide-Treated Nets
Studies have shown that vector control of malaria (e.g., bed nets and insecticides) produces a
significant decrease in overall mortality, especially in high-transmission areas (Lengeler 2004).
Despite evidence that ITN use decreases malaria-related morbidity and mortality, ITN use
continues to remains low in sub-Saharan Africa, including Burkina Faso. Challenges to ITN use
include: longevity of impregnation, insecticide resistance and ensuring that people use them
(especially in hot areas). WHO recommends that pregnant women receive an ITN/LLINs as part
of routine ANC to be used throughout pregnancy (Pell et al. 2011).
A study carried out in a malaria-endemic area in southwestern Burkina Faso indicated that an
initial increase in use of ITNs after a pilot ITN campaign in 2007 declined after several months.
The initial high acceptance rate was most likely related to the adoption and spread of a new

technology, whereby people believed it was enough to be an “ITN owner” and accepted a free net
because they were offered it, rather than because they planned to use it or thought that they
needed it (Toe et al. 2009). The main reasons for the decreased motivation of ITN use was due to
community perception of malaria, perceived usefulness of ITNs and problems of having a bulky
product suspended in a room (Toe et al. 2009).
The results of the pilot campaign led to the scale-up of a broader national ITN mass-distribution
campaign in 2010. Because of gaps in supplies, rather than providing three LLINs per
household, two were provided to ensure national coverage. The July 2011 Round 8 progress
report indicated that 93% of 8,062,757 LLINs had been distributed through the campaign
mechanisms (GFATM 2008). Currently, there is the intention to have national distribution of
LLINs through routine services, such as ANC and child immunization, but the availability of
LLINs for this has been sporadic. UNICEF has obtained 100,000 LLINs for annual distribution
through ANC in two regions only.
Table 2 shows the distribution of ITNs over a four-year period as part of efforts supported by
Global Fund grants and USAID to achieve universal coverage. More than 9 million nets have
been distributed to a population of around 16 million, the majority through the campaigns in
2009 and 2010. The target of one net per two persons was likely achieved. However, the 2010
DHS shows that even when nets are present in a house, actual use is below expectation.
Another national survey is needed to learn the outcome of the massive scale-up in net
distribution. With regard to longevity, studies have shown that durability of long-lasting nets is
much less than the five years projected originally, and is closer to two to three years—indicating
that nets distributed over the recent campaign years will need replacement beginning in 2013.
The NMCP action plan for 2013 includes a second mass-distribution campaign for this
replacement.
According to a study conducted by Centre National de Recherche et de Formation sur le

Paludisme (CNRFP 2012), one year following the net distribution campaign, net coverage
reached one net for every 2.48 people, and 95.5% of households reported having at least one
LLIN, as compared to 56% reported in the 2010 DHS-MICS. Use by pregnant women and
children under five exceeds DHS figures by 20%. The data collection was conducted in
December, a lower transmission period and a period when communities in the north may use
nets to protect from cold and dust. Further study during the high-transmission period may be
warranted.
Indoor Residual Spraying

According to WHO, IRS is most effective when 80% of households in targeted areas are treated
(IRIN 2009). With assistance from USAID, IRS was piloted in Burkina Faso in 2010. In late
2009, Diébougou District, a high-transmission area (permanent transmission zone) located in
Bougouriba Province in the southern-most zone of the country, was selected for the IRS pilot.
This site was also the beneficiary of a pilot universal distribution of LLINs in July 2009, which
was done as preparation for the nationwide campaign carried out in 2010. Based on an
assessment completed in December of 2009, carbamates were selected to begin spray operations.
A total of 574 people were trained in spraying and supervision, and 34,284 structures were
identified. Spraying began in May 2010 and was completed several weeks later after reaching
33,897 structures and protecting 118,691 people. The initial results indicated high vector
mortality. However, later sampling showed variable results, with increasing resistance in some
structures. Plans are underway to consider other insecticide options for future spray rounds, in
addition to improved training and supervision of spray operators (USAID 2011).
A long-term IRS plan with assistance from several partners, including USAID, can be found in
the malaria strategic plan. However, with funding uncertainties due to economic changes

worldwide, the NMCP decided in early 2012 to suspend IRS activities. A key objective of this
strategy (currently on hold) will be to build capacity at the national, district and local levels to
manage IRS operations, including planning, evaluation, spraying and resource allocation. A key
partner in ongoing and future IRS plans in Burkina Faso is the Institute of Research on Health
Sciences/Centre Muraz. The Centre Muraz has participated in several vector-resistance studies
over the last several years and has five medical entomologists who can provide technical
guidance and oversight of vector-control activities. The input of Centre Muraz will be needed to
monitor the IRS target zones and to conduct vector resistance surveys before and after spraying,
so as to determine the type of insecticide that will be used and help implement appropriate
vector-surveillance activities.
The USAID-supported pilot IRS project in one district has come to an end. No clear plans or
sources of support for continued IRS deployment have been identified.
Larviciding
The NMCP has an integrated vector management strategy that also includes use of larvicides
and environmental management to remove mosquito breeding sites. Larviciding is currently
supported by a Cuban-led, West African Economic and Monetary Union (UEMOA)-funded
project targeting Ouagadougou.
MANAGEMENT OF SUPPLY OF COMMODITIES AGAINST MALARIA

Procurement of commodities is done by the Central Medical Stores (CAMEG) for commodities
not funded by the U.S. President’s Malaria Initiative (PMI) and by the USAID | DELIVER
PROJECT for PMI-funded malaria commodities. CAMEG was created in 1994 and works in
close collaboration with the MOH to provide access to affordable essential medicines. (The
essential drug list is based on a WHO standard list of essential medicines.) CAMEG’s facilities
include a large central warehouse and nine regional depots, which serve Burkina Faso’s 70
health districts. Though CAMEG is fully functional and does not appear to need extensive
support in managing commodities, there are pharmaceutical management deficiencies and
challenges that remain (USAID 2011). There have been significant delays in the procurement of
RDTs under the Global Fund Round 7 grant due to the long time spent on discussing the
specifications of the RDT to procure, resulting in widespread stock-outs. In 2010, ACT
quantities purchased under the Global Fund Round 7 grant were not sufficient to cover annual
needs.
RDTs from Global Fund resources were procured and distributed by CAMEG. The RDTs funded
by USAID and procured by the DELIVER PROJECT are distributed directly to the districts by
the NMCP. Dispatching of USAID-funded RDTs is paid by the MOH, using part of the revolving
funds of ACTs. Subsequent procurements were made through the Pharmacy, Medicines and
Laboratories Directorate (USAID 2009). There were major stock-outs of RDTs in 2011.
CAMEG procures SP for IPTp using its own budget. The MOH provides funding to the districts
to purchase SP from CAMEG, which is given to pregnant women at ANC facilities free of
charge.
ADVOCACY, INFORMATION, EDUCATION, COMMUNICATION AND SOCIAL

MOBILIZATION
The information, education and communication (IEC) component of the national strategy is
being implemented through several approaches. CHWs/ASCs have major health education and
promotion duties. They have recently been trained and supplied with malaria flipcharts through
Global Fund support. A variety of NGOs are also involved in health education efforts.

IEC materials have been revised over the years and consist largely of posters for clinics.
Through the Global Fund grant, flipcharts have been produced and disseminated to
CHWs/ASCs. The use IEC materials by CHWs has been reinforced in several communities by
U.S. Peace Corps volunteers who have been trained by Jhpiego/MCHIP on the national malaria
strategy. Finally, the NMCP, in collaboration with MCHIP, convened partners who drafted a
National Malaria Communications Plan in 2012.
Epidemiological Surveillance, Monitoring, Evaluation and Research

The NMPC engages in a variety of epidemiological and health information activities. Examples
of survey data and routine HMIS results are presented in Tables 3 and 4. Other activities that
the NMCP currently monitors include the procurement and distribution of commodities; the
availability of commodities for the prevention, diagnosis and treatment of malaria; health
worker performance; efforts in BCC; and the supervision and training of health care workers. To
supplement this information, targeted operational evaluations and record reviews are required
to answer specific questions or identify problems with program implementation.
The NMCP relies on routine health information gathered at the health facility level, which is
transmitted to the district offices, then to the regional unit in charge of HMIS and finally to the
central level for its monitoring and evaluation (M&E) component. In addition, there is a
national reporting tool (Rapport de progrès sur la mise en œuvre des activités de lutte contre le
paludisme dans les formations sanitaires) used for reporting malaria indicator results from
health facilities.
The USAID malaria monitoring framework aims to complement and support existing NMCP
M&E efforts. According to this framework, specific activities are monitored on a regular basis to
allow in-country program managers to assess progress and redirect resources as needed.
Activities within the major intervention areas (e.g., ITNs, IPTp, case management with ACTs)
will be tracked through periodic reports from groups providing commodities, including health
facilities and international and local partners. The DELIVER PROJECT provided support to
update a database and trained the data managers from all health districts to improve report
completeness and data quality.
The HMIS depends greatly on the responsiveness of health facility staff and the interest and
commitment of the district health team chief. Annual reports are generated from HMIS, which
provide an overview of health information from health facilities. These reports, however, do not
include community-level information or report on people who do not attend public facilities. The
NMCP also relies on specific surveys to monitor progress toward achieving objectives, including
but not limited to, the DHS and the MICS.
NMCP PROGRAM MANAGEMENT AND COORDINATION

The NMCP is involved in intersectoral and intrasectoral collaboration in malaria program
management and coordination with research centers, schools, international agencies, other
departments within the MOH and the private sector. In addition to the NMCP, the main
partners involved in malaria control include the Global Fund, WHO, UNICEF, World Bank,
USAID, JICA, Red Cross, West Africa Health Organization and the Roll Back Malaria (RBM)
Partnership. The NMCP is also involved in regional collaborations with a network of malaria
control initiatives in West Africa. These networks used to include the West African Network for
MIP Control (RAOPAG) and currently include RBM West Africa Regional Network (WARN)
that provides technical assistance to member countries. The NMCP coordinates financial and
programmatic levels of malaria control with support from partners at the international,
national and local levels.

Key coordinating bodies include: the Malaria Steering Committee (Comité de Pilotage), the
Global Fund Country Coordinating Mechanism (CCM) and the RBM Partnership. The Malaria
Steering Committee provides directives and guidance to the NMCP and implementing partners,
and also works to strengthen partnership and coordination. The committee includes the NMCP,
implementing partners such as USAID and WHO, departments within the MOH, relevant
government ministries and agencies, and international and indigenous NGOs. The committee
meets two times per year, and the NMCP produces a report based on the outcome of these
proceedings. These meetings were, however, infrequent in 2010 or preempted due to the mass
LLIN distribution campaign (USAID 2011). Instead, the partners review annual malaria action
plans (MOH 2009c). In addition, semi-annual technical committee meetings are held. Partners
also work with the NMCP for Global Fund grant writing.
The Global Fund CCM meets regularly with health sector stakeholders to review options and
plans for submission of proposals to the Global Fund. The CCM has guided successful malaria
proposals for Round 2, Round 7 and Round 8, and a new application for the transitional funding
mechanism to help sustain the malaria program after the Round 7 and 8 consolidated grant
finishes and until regular Global Fund funding resumes in 2013–2014.
Research institutions, such as the Centre Muraz and the National Malaria Research and
Training Center (Centre National de la Recherche et de Formation sur le Paludisme), are
involved in malaria research in Burkina Faso. These institutions provide the NMCP with
scientific data to guide malaria control programs. Universities and schools, such as the National
School of Public Health (Ecole Nationale de Santé Publique), provide long- and short-term
training, research and supervision for malaria. The NMCP collaborates with other programs
within the MOH, such as: the Maternal and Child Health Directorate (DSME); Directorate for
Vaccination Program (DPV); the Directorate for HMIS, which is located within the General
Directorate of Information and Health Statistics Studies DGISS); the National Lymphatic
Filiarisis Program (PNEFL); the Pharmacy, Medicines and Labs Directorate (DGPML); and the
National Public Health Laboratory (LNSP). The DSME is involved in MIP activities through the
provision of ANC and IMCI. The DPV and DGISS are involved in data collection of malaria
indicators in health facilities. The PNEFL works with the NMCP in the implementation of
integrated vector control. The DGPML works on the development of antimalaria pharmaco-
surveillance, and the LNSP is involved in quality control of antimalarials and laboratory exams.
The NMCP works with the private sector in a limited manner through training of private clinics
in management guidelines. The private sector is, however, not linked to the HMIS for malaria.
The NMCP does not meet with wholesalers and private providers of malaria commodities.
Key MIP implementing staff are based in the DSME and are located at district and local levels;
there is little evidence of their role in MIP management and coordination. There is a focal
person responsible for disease control, but this person is not positioned to supervise frontline
malaria service delivery. The maternal and child health (MCH) focal person at the district level
may not have specific malaria responsibilities. Although there is collaboration among the
NMCP and the various research centers, there is a lack of a formal coordination mechanism to
generate research needs and share research results, so that the NMCP is up-to-date on all the
latest findings and can integrate these with national policies and guidelines.

SYSTEMS FACTORS INFLUENCING
IMPLEMENTATION PROGRESS
POLICY AND STRATEGY FORMULATION AND DISSEMINATION
The NMCP has adopted various malaria policies over the years. There are challenges in the
implementation and dissemination of these policies, which include delays in policy
implementation and non-compliance with national directives at the health facility level. As
noted previously, the MOH adopted ACTs in 2005 as the first-line treatment against malaria.
The actual implementation of the policy change took time, and ACTs only became available in
government health facilities by the end of 2007 (Tipke et al. 2009).
Although the NMCP has developed guidelines for RDT use for diagnosis of all suspected
malaria patients in health facilities, RDTs are commonly not used to define treatment choices
for patients. According to an assessment done by USAID in 2009, only 11% (75/691) of patients
classified as having simple malaria were tested using RDTs in a health facility in one of the
districts. This low use of RDTs is partly due to unavailability and/or stock-outs of RDTs in the
country and partly due to attitudes about validity of RDTs compared to clinical judgment. Since
March 2012, RDT stocks were available in the whole country, and a better use of them to
diagnose malaria cases has been reported. The national reproductive health policies and norms
mention malaria only in the context of case management (MOH 2010).
MAJOR FINDINGS CHALLENGES AND BOTTLENECKS STRENGTHS AND BEST PRACTICES

Policy and Strategy  Most recent documents not  Malaria case management
Formulation and disseminated to all CSPS. guidelines have been recently
Dissemination  Policies from other sections of the updated.
MOH are vague about malaria  Discussions are underway for
components to their programs. revising and implementing
 There is a need for more up-to- policies as needed in areas such
date epidemiological research on as IPTi and management of
malaria in the country’s different severe malaria.
regions to better target  NMCP performance review was
intervention. done in 2011.
 Listing of problems, as often done  There is a new strategic plan for
in various strategic and program 2011–2015.
reviews, needs to be
strengthened by analysis of
causes and action plans to
address those.
INTEGRATION AND COORDINATION WITH RELEVANT PRIMARY HEALTH

CENTER SERVICE AREAS AND PARTNERS
During a meeting among NGOs and other partners for the 2009 USAID Needs Assessment,
attendees noted that it was rare for them to gather together with the NMCP to coordinate
activities. In December 2012, there was a meeting among NMCP and partners to review the
results of the LLIN distribution campaign. The NMCP indicated interest in holding quarterly
coordination meetings in 2012, but none have occurred to date.
Reproductive and Maternal Health

ANC services are one of the main primary health center (PHC) service areas in which malaria
prevention and treatment services are integrated with reproductive health services. WHO

recommends four visits for ANC during pregnancy (WHO 2006). In Burkina Faso, women
attending ANC receive services free of charge, including SP and an LLIN for malaria
prevention. According to the 2010 DHS-MICS preliminary report, 91% of pregnant women in
Burkina Faso were found to make at least two ANC visits during pregnancy, and 66% of births
took place in a health facility. This frequent use of health facilities by pregnant women makes
the integration of the malaria prevention with PHC services through ANC feasible.
While these linkages occur naturally at the CSPS level, other than a general mention that
malaria prevention and case management should be provided to pregnant women, national
reproductive health policy documents do not specify the nature of MIP services that should be
integrated with ANC (MOH 2010), except to note that case management of malaria in pregnant
women is important.
IPT delivery is closely linked to the access and utilization of antenatal clinics (Grietens et al.
2010). Even with high percentage of first ANC attendance, subsequent visits are much less
frequent. The distribution of free SP to ANC is done through the DSME. Both first and second
doses are free, though doses need to be paid for from private pharmacies if the facility is out of
stock of SP at the time of the ANC visit. This has led to a low usage rate for subsequent doses of
SP (USAID 2009). The 2010 DHS also shows that during pregnancies occurring in the two years
before the survey, 11% of women took two or more doses of SP, with at least one dose given
during an antenatal visit. Even with the high utilization of ANC services, women visit health
facilities for ANC fairly late in their pregnancies. An assessment of women in health facilities
showed that women did not make a first ANC visit until a median of 28 weeks (Sirima et al.
2006). Late delivery of IPTp1 may result in diminished effectiveness of the intervention unless
ITN use is already in place early in pregnancy. Late start may also reduce the total number of
doses a woman may receive.
Previously, LLINs have been provided to vulnerable groups during routine ANC and child
health. However, there is no consistency in routine distribution. There was even a shortage of
nets in 2009 (USAID 2009). Mass-distribution LLIN campaigns can achieve rapid initial
coverage, but need to be supplemented by routine delivery to pregnant women through
antenatal services and to infants at immunization clinics (USAID 2011).
HIV and AIDS

Integration of malaria and HIV/AIDS services is another area of interest. Currently, both IPTp
and HIV testing as part of prevention of mother-to-child transmission of HIV (PMTCT) services
are integrated with ANC. The current National Malaria Strategic Plan does not address the
integration of malaria and HIV/AIDS services, in particular provision of malaria services as
part of care and support (MOH 2011). The HIV Strategic Plan also does not mention malaria
specifically, but calls for prevention and treatment of opportunistic infections (CNLS 2010b).
The Global Fund Round 6 HIV grant, which is currently in closure, did address care and
support for orphans and vulnerable children and the chronically ill. This grant apparently had a
malaria focal person on staff, but specific malaria activities were not mentioned in the grant
documents.
A review of the new/current Global Fund HIV grant entitled, “Universal access through
securing ARV treatments, strengthening of PMTCT and strengthening HIV prevention for
most-at-risk populations,” does not reveal direct mention of malaria. However, the grant has a
community strengthening component that uses local community-based organizations (CBOs) to
“Ensure treatment, support and care services are available and used by at least 90% of HIV-
infected women and their children by the end of 2015” (GFATM 2012). Such supportive care can
include malaria treatment and prevention.

The most recent national HIV/AIDS policy for 2011–2015 does mention case management for
illnesses suffered by those living with HIV/AIDS, as well as integrated care and support for
others affected by HIV/AIDS, such as orphans and vulnerable children. Such activities usually
include malaria treatment and provision of LLINs, but the new policy does not include the
specific illnesses to be covered.

Integration and  The Malaria Steering Committee  A Malaria Steering Committee was
Coordination with meets irregularly, possibly the last established for the NMCP to offer
Relevant PHC Services time in December 2010; some technical guidance and includes
members originally appointed are program people, scientists and
no longer available. partner agencies.
 No official program coordination  De facto integration of PMTCT and
mechanism to bring malaria malaria services occurs during
partners together on a regular ANC.
basis to address management  There is an ACT Monitoring
issues has been established. Committee designed to coordinate
 No coordination meetings were malaria commodities, which meets
called last year by NMCP because at least quarterly.
it was perceived that there had  Partners worked together to
been a number of activities during develop a transition funding
2011 where all partners were request to Global Fund in light of
involved, such as strategic review, Round 11 cancellation.
new strategy planning, ACT
committee and the annual review,
though most partners did not see
these activities as meeting the
needs of ongoing, regular program
coordination.
 At present, only one donor focuses
on providing LLINs as part of
routine ANC in just two regions.
 Reproductive health policy and
related documents mention
prevention and case management
of MIP, but not what specifically
should be done in ANC.
 No specific statements for HIV and
malaria service integration are
found in policy documents of either
program.
 There is a lack of coordination,
activities/programs integration
between DSME (in charge of ANC)
and NMCP at policy (national),
regional and field levels.
FINANCIAL SOURCES AND ADEQUACY

Increased donor funding to combat malaria has resulted in comprehensive integrated malaria
control interventions implemented in many sub-Saharan African countries, including Burkina
Faso. To implement malaria strategies over time, Burkina Faso has received financial and
technical support from partners, such as the Global Fund, USAID and WHO. The NMCP
receives funding from the Global Fund, USAID, WHO, UNICEF, PADS/World Bank and the
national budget (Table 2). In 2008, the country received large increases in donor funding for
malaria. A three-year $12 million World Bank Booster Program grant began in 2008, as did the

$36 million Round 7 grant from Global Fund. In 2009, Burkina Faso was awarded an additional
$88 million through the Global Fund Round 8 for malaria.
In the most recent National Health Accounts (NHA) report to WHO for 2009, 26% of
expenditures were supported by external aid. Looking specifically at the subaccount for malaria,
68% of expenditure is born by households, and the funding from bilateral and multilateral
sources accounts for only $7.9 million or 11% of expenditure, including the first tranche of
Global Fund Round 8. The NHA reports a total of $74.4 million in malaria expenditure in 2009.
The malaria program supported by the Global Fund aims to: reduce malaria-related illness and
death by implementing a new antimalarial treatment policy using RDTs to diagnose simple
cases of malaria and providing ITNs for all populations at risk, with a priority of delivering nets
to pregnant women and families with children less than five years of age. The NMCP has
benefited from three rounds of Global Fund funding (Rounds 2, 7 and 8). Round 8 of Burkina
Faso’s Global Fund application supplements Round 7, which mainly focuses on pregnant women
and children less than five years of age, by emphasizing routine distribution of LLINs,
confirmation of diagnosis and treatment of uncomplicated malaria cases. Under the Global
Fund Round 8 grant, Burkina Faso started delivery of malaria treatment at the
community/household level with ACTs in 2010 (USAID 2011). After the cancellation of Round
11 by the Global Fund, Burkina Faso did apply for the transition funding that will maintain
supplies of commodities during any gap period between the end of current grants and the
restart of Global Fund funding processes (approximately 2014).
In recent years, with assistance from the World Bank, UNICEF, USAID, the Canadian Red
Cross, Plan Burkina, JICA and the Global Fund, Burkina Faso has increased ITN coverage and
use, to move toward achievement of their goal of universal coverage of one ITN for every two
persons nationwide. The Global Fund Round 8 grant provided significant funding for the 2010
nationwide LLIN distribution campaign of more than 7.5 million LLINs. The majority of these
LLINs came from the Global Fund Round 7 and 8 grants, but LLINs were also contributed by
UNICEF, USAID and the Red Cross to reach the total number distributed between September
2010 and January 2011 (USAID 2011).

Financial Sources and  Out-of-pocket expenditure by  In response to the Round 11
Adequacy households remains a major Global Fund grant cancellation,
source of funding for malaria Burkina Faso turned its intended
services. proposal into a request for
 Ongoing integration of Global transition funding.
Fund Rounds 7 and 8 has led to a  Government has provided some
hiatus in funding while new grant funding for malaria medicines.
papers are being signed.  CAMEG has the capacity to
 Global Fund Round 11 was perform cost-recovery if malaria
envisioned as a means to acquire medicines are put into the
replacement LLINs and maintain system.
commodity stocks, but its
cancellation has created
uncertainty.
 PADS (common basket) funding
amount is reduced at the district
level, where implementation
needs to occur.

COMMUNITY AWARENESS AND INVOLVEMENT
Community groups and associations contribute to malaria control through the following
interventions as outlined in the 2006–2010 strategic plan:
 Home-based treatment of simple malaria cases
 Referrals of severe malaria cases
 Case reporting and transmission of health data to the primary level
 Distribution, impregnation and re-impregnation of bed nets
 Community awareness and health promotion
NGOs, such as Plan Burkina, the Burkinabe Red Cross and Rotary International, are involved
in malaria prevention through the acquisition and distribution of LLINs, as well as community
awareness and health promotion (MOH 2006).
The NMCP has developed and validated training and supervision guidelines for malaria
prevention, case management and mobilization at the community level (USAID 2009).
Normally, each community of 3,000 people or less selects two ASCs, one male and one female.
Larger communities can select four ASCs.
Now, ASCs are again used for malaria prevention and treatment, including for pregnant
women. Agents provide the following services to pregnant women (USAID 2009):
 Encourage pregnant women to accept IPTp
 Promote awareness of sleeping under ITNs
 Refer pregnant women with suspected malaria
 Trace women who miss ANC appointments (occasionally)
 Promote vector control measures such as environmental management
ASCs have now been incorporated with the

consolidated Round 7/8 Global Fund grant
process, wherein Plan Burkina is the
Principal Recipient (PR) responsible for
community intervention. Plan Burkina has
four other NGO sub-recipients (SRs) who in
turn divide responsibility for the country’s 13
regions and the health districts within those.
These SRs include Africare, CREDO, RAME
and URCB.
Each SR has hired a district supervisor and

recruited animators to work with each CSPS.
Plan Burkina has used the Global Fund
support to print additional ASC manuals, Figure 4. Relationship between NGO and public sector
ASC record books, and a 19-page flipchart on for community case management
malaria cause, prevention and treatment.
The animators train the ASCs in the use of these materials. Figure 4 shows the parallel
relationship between the public and NGO sectors in the malaria work of community ASCs.

ASCs are now trained in case management and referral of severe malaria to health facilities. A
key point is that only one of the available ASCs in a community is selected to perform malaria
duties. For small villages, this may not present a problem. For larger villages, however, the
malaria duties being assigned to only one ASC may put extra pressure on the person, who as a
volunteer also has a regular occupation. The NMCP plans to pilot-test RDT use by ASCs in a
couple of districts.
The U.S. Peace Corps is heavily involved in the national malaria control efforts. All 173 current
volunteers are encouraged to engage in malaria control activities appropriate to their primary
assignments in health, education and environment. There are 40 health volunteers specifically
assigned to a CSPS from where they also collaborate with the local ASCs in the CSPS
catchment area. In July 2011, MCHIP provided training for these health volunteers and some of
their ASC counterparts on the national malaria treatment protocols.
An important development was the creation in March 2011 within the MOH of a new
Community Health Directorate. Plans had been in the works since 2008 to consolidate
community work, since different programs and NGOs had created a variety of CHWs with
different tasks. Effort was made to develop an integrated ASC role. The initial efforts at
consolidation in 2008 found a vast variety of ASC tasks. Now, efforts are underway to confirm a
minimum package for better coordination.
At first, it seems ironic that among existing ASCs, one per village has been selected as a
malaria volunteer—an apparent “throwback” to the earlier days of different community workers
for different programs. The new directorate has been in communication with the NMCP, Plan
Burkina and others about this situation. Yet, since the Global Fund Round 7/8 started before
the new directorate was created and it has funds to back up its efforts, there does not seem to be
an immediate solution. One ideal solution would be that all ASCs conduct malaria community
case management as part over overall community case management.
Also, there apparently is a structure for CHW supervision in the public sector. Each CSPS is
supposed to have a minimum of three staff: 1) the clinical officer in-charge, 2) an MCH worker
(nurse, midwife), and 3) an “itinerant” health worker. The latter is expected to devote his/her
full time work to supervise ASCs and link community work with the CSPS. Problems of staff
shortages and limited transportation have often meant that the itinerant worker frequently
stays in one location and sees clients in the clinic—at least a sustainable foundation for
community support theoretically exists in the public sector. This is backed up by the fact that
district health team has a member whose main responsibility is community activities.

Community  Normally, ASCs are not supervised  A new directorate within the MOH
Involvement, by nearest CSPS and are not well- has been created for community
Awareness, Education linked to frontline health services. health.
 There is a question of whether the  There is a NMCP focal point for
system of animators is sustainable community level activities.
after Global Fund grants finish.  Each CSPS has a dedicated staff
 Existing CSPS staff are overworked member, an “itinerant” health
or case shortages such that worker, who should support ASC
designated community outreach and conduct other community
staff do not have the time, and outreach.
often not the resources, to do this  ASCs have been trained in malaria
job. prevention and treatment.
 There is a lack of sensitization  ASCs receive support from NGO
toward the community so that they animators to link them with CSPS.
understand their rights for malaria  Some ASCs have support from 40
services. Peace Corps volunteers (PCVs)
attached to CSPS.
 All 170+ PCVs are doing some
malaria control work in their
respective technical
areas/communities.
COMMODITIES AND PROCUREMENT

A major factor responsible for stock-outs is lack of timely placement of orders for non-PMI-
funded procurement. A minimum of six months of lead time is needed for most commodities.
The lead time becomes even longer, particularly for ACTs, due to global demand and limited
stock availability or production schedules. The primary factor in 2011 stock-outs of ACTs was
an overestimation of the reduction of malaria cases that would result from the scale-up of
interventions, especially at the community level.
There is a committee for ACT monitoring that is responsible for quantification and follow-up on
all antimalarial commodities. Both USAID and the DELIVER PROJECT are members of this
committee. The quantification of malaria commodities is done by a sub-committee of the ACT
committee, composed of NMCP, CAMEG, DSME and DGPML, with technical support from the
DELIVER PROJECT. In 2011, the quantification sub-committee was meeting regularly and
identified that consumption was exceeding expectations. This information was not acted on by
the ACT Monitoring Committee in time to avert a stock-out. The DELIVER PROJECT has been
and will continue to work with this sub-committee to build capacity of the quantification team
in forecasting and quantification of national antimalarial medicines and development of
procurement planning.
Delay in receiving the ACT orders was caused mainly by production constraints with the
manufacturer SANOFI, which was the only manufacturer prequalified for ASAQ FDC. The
delay in placing orders concerns the non-PMI-funded procurement.
The consolidation of the Global Fund Rounds 7 and 8 grants created further delays. Although
the Global Fund rightly saw a need to combine resources to maximize access to malaria
medicines for both community and public sector case management, the consolidation process
meant that new approval processes were needed, which in effect stalled any funding and
placement of commodity orders. Since the national program did not place any orders before the
consolidation was completed, it effectively had to wait until after the new papers were signed,
thus precluding the possibility of obtaining RDTs and malaria drugs for the 2012 peak
transmission season.

In theory, CAMEG and the MOH have some leeway. ACTs put into the system by USAID and
other partners in 2011 were distributed through CAMEG at subsidized prices. As with the
Global Fund, CAMEG collects 7% of the value of USAID-funded ACTs for operation costs (i.e.,
management and distribution of the ACT) through the supply chain. The MOH could authorize
the procurement of more ACTs using the revolving funds collected. Part of the revolving funds is
also used by the MOH/NMCP to distribute to the districts other malaria commodities funded by
USAID (e.g., severe malaria kits, RDTs) that are not distributed through the CAMEG system.
The ASCs obtain their ACTs from health facilities. With the consolidated Global Funds grants,
budgeting has been put aside for the head of the health facility to supervise the ASCs, in
addition to the supervision conducted by NGOs.
Districts order ACTs from CAMEG based on distribution to health facilities. This distribution-
based procurement system, however, does not allow prediction of need. The districts order
according to their available budget, rather than trends in service provision that might reflect
seasonal transmission patterns—sometimes leading to insufficient stock to serve all the health
facilities. The ACTs are distributed through the MOH supply chain on subsidized prices with a
markup at each level of the system. (Under the Bamako initiative cost recovery approach,
patients are charged 100 CFA per packet for children under five, 200 CFA for children aged 6–
13 years, and 300 CFA for adult treatments.)
PADS, which also has a procurement unit, has been responsible for LLIN procurement.
Following the 2010 mass-distribution campaign, an estimated 1.5 million LLINs will be needed
annually for routine distribution to newly pregnant women. It is anticipated that Global Fund
Round 7 will provide 300,000 LLINs per year, thereby leading to a gap in availability and
coverage of LLINs during mass campaigns. To date, the NMCP has not identified any funding
source to fill the gap of 1.2 million LLINs (USAID 2011). Note that there were gaps in LLINs for
the mass distribution, and decisions were made to give fewer nets per household due to a
combination of inadequate quantities and delayed ordering and delivery of the LLINs.
Considering that the lifespan of LLINs is not as long as expected—closer to two years rather
than five—a second distribution campaign to replace nets is to be planned for 2013. Further, the
management of LLINs, because of their size and storage requirements and the long lead times
to fill orders, presents special challenges to CAMEG (USAID 2011).
The main challenges with RDTs are that they been procured from multiple sources and
estimation of need has been poor. USAID procured RDTs for 2012; but at the time of the
assessment in February 2012, there were stock-outs. The USAID-funded shipment was
delivered in March 2012 and was expected to last for only 6–9 months. A portion of the RDTs
purchased with Global Fund Round 7 funding was delivered in April 2012. Underestimation of
the stock needed, as well as some irrational use of RDTs found at the health facilities (e.g.,
testing all clients regardless of symptoms of suspect malaria), contributed to the inadequacy of
stock of RDTs to cover the needs through the end of 2012. Stock-outs of RDTs were seen in most
of the districts during the last quarter of 2012 and January 2013.
Private pharmacies sell SP at a low cost of 500 FCFA (around US$1), although such supplies of
SP are inappropriate for treatment and not accessible for IPTp. During the February 2012 data
collection period for this report, there was a significant stock of SP at the central level
(CAMEG), and the government was working to ensure an uninterrupted supply of SP for IPTp
(USAID 2011). Unfortunately, the stock was due to expire in August 2012. CAMEG ordered
additional stocks, which did not arrive until late August. There were stock-outs in some
facilities during this period due to short shelf life of remaining stocks and delays in getting new
stocks out to facilities.

There are plans outlined in the Global Fund Round 7/8 grant for piloting IPTi in the country.
Actual arrangements had not been finalized at the time of this assessment.
Some challenges with commodities include:

 The inventory system is not functioning.
 Stock cards are not used at all in health facilities for the products distributed free of charge,
such as RDT, LLIN and severe malaria kits.
 Timely commodity planning is not being practiced.
 Forecasting/quantification of need for commodities requires improvement.

Commodities and  ACT quantifications were  An ACT committee exists that has
Procurement underestimated based on two the responsibility to coordinate
assumptions that did not among all donors and agencies
materialize: 1) greater use of LLINs involved in ACT and antimalarial
would reduce cases, and 2) RDTs procurement and supply
would prevent false presumptive management.
treatment. Nets were not  CAMEG is capable of ensuring
distributed in a timely manner, but malaria drugs reach the district
phased over 2–3 years. RDT level.
supplies have been inadequate  National budget commitments to
with health workers who do not provide funds for some
always respect the results of the antimalarial commodity
tests. procurement.
 Delays in placing orders cause
delays in receiving timely medicine
supplies.
 Global Fund efforts to merge
grants for better access to
commodities have actually delayed
funding for medicines for the 2012
malaria transmission season.
 MOH has yet to decide to use
profits from donated ACT sales
through CAMEG to order more
medicines.
 Although policy now permits ASCs
to provide ACTs, they experience
stock-out since the CSPS that
should supply them are also out of
stock.
 There are frequent stock-outs of
ACTs, RDTs and kits for severe
malaria case management.
MONITORING, EVALUATION AND RESEARCH

Several health information needs are explored in this section. These needs include timeliness
and integration of routine data systems, as well as needs for intervention-specific research
needs.

Routine Service Data
Improvements in HMIS have evolved over time. In 2009, when a pre-intervention assessment
was undertaken for USAID malaria efforts in Burkina Faso, the collection of malaria data at
the front line and flow to the upstream levels was difficult to understand. There were neither
simple places to record IPTp data on front-line health forms nor ways to distinguish IPTp1 from
IPTp2. Hence, it was unclear how national-level statistics could report IPTp1 and IPTp2
coverage rates.
Recently, major changes have taken place. The individual green ANC cards have clear places to
record IPTp and the number of the dosing, as do the individual blue take-home booklets. The
IPTp dose is now correctly recorded in the ANC register book. Table 2 summarizes major
malaria indicators from the NHMIS from 2009–2011. Based on either ANC registration of total
population estimates, IPTp coverage is lagging behind RBM targets.
Since ASCs are now trained to provide community case management for malaria, they also have
record booklets that distinguish treatment by age and record ACTs given and community health
education sessions held. Through the community arm of the Global Fund consolidated Round
7/8 grant, NGOs hire animators who, among other duties, compile all the malaria treatment
data of the ASCs in the clinic catchment area where they are assigned. These combined data are
given to the local CSPS, as well as to the animators’ supervisor at the district. Thus, data flow
to the district, region and then on to the NMCP, as well as through the NGO system and the
Principal Recipient of the community component of the Global Fund grant. Table 2 shows that
the ASC role in provision of ACTs has greatly increased.
At the CSPS, the staff compile two summary forms at the end of the month. The regular
NHMIS format and the NMCP format. The two forms share in common only the reporting of
malaria cases, including uncomplicated and severe, and RDT or microscopy results, if
undertaken. In addition to the IPTp results, the NMCP format includes provision of nets, if
available, and community education activities. The NMCP format also incorporates the data on
malaria treatment and education activities conducted by ASCs. Data on community-based case
management is not currently found in NHMIS reports and summaries.
At the district level, an M&E officer compiles data in Microsoft ACCESS formats for both the
NMCP and the NHMIS, which is called RASI. These data sets are not merged as the entry
formats have different fields, according to one M&E officer. Thus, certain malaria data reach
only the NMCP and must be shared further, especially IPTp data to DSME, if proper service
coordination is to take place.
The data presented in Table 2 require reporting from many levels, including the community,
health center, district, regional and national levels, in a timely and complete fashion. The
Microsoft Excel spreadsheets from which these data were derived break down the information
by region and health district. In addition to providing information on population and number of
health facilities, they focus exclusively on malaria indicators. Another component of the data is
reports of stock-outs.
Figure 5 was extrapolated by MCHIP based on the data in Table 2 to look at trends in RDT
performance for suspect malaria and treatment based on case confirmation, both key elements
in the revised malaria directives.

Figure 5. Availability of commodities and provider skills coincide to increase parasitological case
confirmation of malaria
100%
90%
80%
70%
% of RDTs performed for suspect
60% malaria
50%
40% % ACTs likely provided based on
parasitological diagnosis (RDT
30% and microscopy postive)
20%
2012 data tentative pending
10%
validation
0%
2009 2010 2011 2012
Assuming data are reviewed closely and shared with other divisions, it is possible to identify
key areas for intervention to improve services. For example, the proportion of women
registering for ANC appears to drop over the three-year period. While the proportion of ANC
registrants who get both IPTp doses remains steady, the proportion of the population of
pregnant women getting IPTp is dropping. It is important to assess why the proportion of
women who attend ANC and get IPTp remains low at around 60%—are there major missed
opportunities or stock-outs to blame? Ultimately, is not apparent that these data are used for
decision-making or efforts to improve coverage at any level of the health system.
An additional new feature of district data collection is the weekly epidemiological reporting of
notifiable diseases, including severe malaria. Each person in charge of a CSPS uses a cell phone
to communicate his/her data to the district M&E officer. (They do not send text messages.)
These reports are then filed through the regional to the NHMIS levels. The sustainability of
some of these improvements does depend on supportive funding for cell phone calls,
transportation and other data transmission tools.
Other Data Sources

With support from USAID, a DHS-MICS was carried out in 2010 with a malaria module that
was completed in January 2011 (Table 1). Data gathered from the DHS will gauge progress
toward the coverage targets the NMCP had hoped to achieve by 2010 following the mass
distribution of LLINs throughout the country. DHS-MICS has shown that Burkina Faso
coverage indicators, as seen in Table 1, are well below target levels set by RBM. Even in
households that own nets, the target for proportion sleeping under nets was not achieved.
Coverage can only be achieved if commodities are available, distributed and tracked for
replacement, in addition to improving human capacity at all levels of the health system.
According to the FY11 MOP, the Logistics Management Information System (LMIS) has
difficulty getting essential data from health facilities.
Research to Support Malaria Programming

The 2011–2015 National Malaria Strategic Plan notes that there are many national research
institutes that could provide relevant field and operational research to strengthen malaria
programming in the country.

These institutes include:
 Centre National de Recherche et de Formation sur le Paludisme (CNRFP)
 Centre de Recherche en Santé de Nouna (CRSN)
 Centre Muraz
 Institut de Recherche en Sciences de la Santé
 Institut de Recherche pour le Développement
 Institut Supérieur des Sciences de la Population
 l’Unité de Recherche Clinique de Nanoro
These centers and institutes can and have furnished the NMCP with scientific information to
help malaria control. At present though, the National Malaria Strategic Plan voices concern
that there is: “insufficient follow-up of research activities and weakness of partnership,
communication and coordination between stakeholders acting in research field.” As such, the
strategic plan proposes “strengthening MOH institutional and operational capacities for
research.”
An example of research to policy includes the 2004 study led by the CDC with Jhpiego as
partner. This study documented the benefits of IPTp with SP (Sirima et al. 2006) and actually
prompted adoption of IPTp throughout the sub-region, not just in Burkina Faso.

Monitoring, Evaluation  Timely submission of data is still a  Summary HMIS data for malaria
and Research problem. are now available for review.
 Dual databases for NMCP and  ASCs have malaria treatment and
NHMIS overlap in terms of health education forms so that
malaria case management, but their data can now be
the NMCP formats include incorporated with CSPS reporting
information on LLIN promotion systems.
and community activities;  Several strong national research
discussions are underway to find institutes exist that have or could
ways to merge these since health contribute to relevant malaria
workers complain of extra tasks. operational research.
 Many malaria research activities  Updated ANC record system
are undertaken, but the results (registers, cards, booklets) now
are not shared within country by reflects IPTp doses 1 and 2.
institutions other than NMCP  Institution of mobile phone-based
(e.g., CNRFP, Nouna Research reporting of notifiable diseases
Center, IRSS). including severe malaria.
 Better epidemiological mapping is  Research was commissioned on
needed to better target LLIN use in 2011, one year after
interventions. the distribution campaign, and
 Concerns have been expressed reported very high levels of
about malaria data reporting; availability and use of nets,
malaria as a percentage of in- and although it was conducted in a
out-patient cases does not give a low-transmission period (CNRFP
true reflection of prevalence since 2012). The next DHS-MICS will
the denominator is variable. provide an important comparison.
 HMIS data show service delivery
gaps; it does not appear that
these findings are used for
decision-making.

CAPACITY BUILDING AND TRAINING
In-Service Training
According to the 2011 annual HMIS report, there are 1,500 health facilities across the three
levels of the health care system, of which 1,443 are PHCs or CSPS (MOH 2012). These facilities
are staffed by 7,835 health professionals (e.g., doctors, nurses, midwives) and 6,576 auxiliary
health care workers (e.g., auxiliary midwives, attaché de santé, agent itinerant de santé).
Partners have provided assistance to build national capacity in malaria control through in-
service training of staff on malaria guidelines as these are updated.
The government of Burkina Faso received assistance from the Global Fund for training of 1,700
public and 400 private facility nurses in malaria prevention and treatment and in supervision of
health aides under Round 7 funding. As of 2009, it was reported that most providers in the
country have been trained on national malaria guidelines and keep copies of manuals given at
the trainings for use at health facilities (USAID 2009), though no training specific to MIP was
found at that time. Treatment of malaria in pregnant women and IPTp protocols are covered
under the national standard treatment guidelines (MOH 2010a). In addition to prevention and
case management, there is training provided in logistics management to store keepers at the
district and facility level. However, the 2009 USAID Assessment found that no standard
operating procedure manuals were provided to store keepers and that they were not applying
what they learned from training.
From October 2010 to December 2012, MCHIP supported the NMCP to update the in-service
training curricula, referred to as the Integrated Malaria Training Package (IMTP), based on
updated clinical directives for malaria. The IMTP includes both treatment directives and skills
for providing clients with information and education about malaria prevention. Key updates to
the IMPT included implementation of RDTs for case confirmation, IPTp using SP and LLIN
promotion. A total of 2,648 providers and 165 trainers received the training on the updated
materials in 2011 and 2012. In the first 20 districts reached in 2011, two providers per facility
were trained on the IMTP. While in 2012, in order to expand to all 70 districts nationally,
training sessions targeted one provider per facility. Scaling up the reach of training by reducing
the targeted cadres to be trained may have had an inadvertent negative effect on IPTp
specifically. Although auxiliary midwives who provide ANC were included in training sessions
in the first 20 districts reached to scale up the reach of training with the same resources, this
was cut to one provider per facility, which was usually the nurse in-charge, who is often not
directly providing ANC services.
To date, training has not focused on the private sector. Private sector health care is limited and
primarily found in the largest cities. The public sector is normally in charge of quality
assurance and follow-up, including training, supervision, control and inspection of the private
sector. In general, when training sessions are planned, the public sector rarely integrates
private sector health workers because, according to them, the training sessions do not fill the
gap for training public health providers and, as such, do not prioritize private sector staff.
NMCP Capacity
The number of the NMCP staff is insufficient for the management of a national program of its
size (Annex 1). The NMCP staff includes three physicians, two pharmacists, nine public health
nurses, two hospital managers, one communications specialist, two accountants and support
staff (five drivers). Eight of the 23 positions are funded with Global Fund resources, while the
rest are civil service positions. The current staff have not received technical and management
training. Resources are also needed for the implementation of routine activities, such as
monitoring and supervision. The NMCP relies on national health staff comprising pediatricians

or public health officers from the MOH for field activities, such as training, supervision and
evaluation.
With MCHIP support, work was begun to clarify job descriptions and initiate quarterly action
planning among the different technical and administrative teams within the NMCP. Further
support is needed to build staff capacity to carry out their job functions and manage the
technical support role of the NMCP to regional and district health directorates.
Pre-Service Training
The National School of Public Health (Ecole Nationale de Santé Publique or ENSP) trains a
variety of cadres to work at the front line. The ENSP trains health staff who work in districts
and local health facilities. The school offers courses mainly for primary-level health workers,
though it needs to update its curricula on malaria (USAID 2009). During the October 2009
USAID assessment, the team discovered that there was little formal malaria content spelled out
in the various school curricula.
A review of sample curricula in 2011 revealed that malaria is mentioned as a topic. For
example, in the Programme de Formation des Infirmiers et Infirmieres Brevetes (IB) (ENSP
Undated), malaria is listed as a disease under general case management and pediatric case
management, but the details of what medicines are to be used and how diagnosis it to be
determined are not provided. These training guides do not specify learning methods to be used.
There is general mention of “prevention of malaria in pregnancy” and the use of
“chemoprophylaxis” during pregnancy, which is no longer national policy.
Likewise, the training program/guide for accoucheuses brevetées (AB) lists malaria as a topic
for disease case management, as well as chemoprophylaxis and prevention of malaria during
pregnancy (ENSP 2008). A curriculum committee has been formed at the ENSP to review these
and the programs for other cadres, with a view to harmonizing the curriculum with current
national policy and to design appropriate training content and methods for teaching.
At present, the ENSP has no formal relationship with the NMCP. In July 2011, MCHIP did
provide training to 60 teaching staff of the various schools within the ENSP. Feedback was
positive. Participants noted that the pre-test showed weaknesses in their malaria knowledge,
which motivated them to learn from the workshop. They subsequently requested that this
training be extended to all 120 teaching staff.
During 2012, MCHIP supported the review and revision of the malaria components of training
curricula for the seven cadres trained by ENSP schools. Members of the faculty participated in
an Effective Teaching Skills course to strengthen their ability to convey key knowledge and
skills to students.
Currently, there are three categories of teaching staff: 1) permanent/fulltime, 2) contract/part-

time and 3) facility-based trainers/preceptors. Occasionally, staff from the MOH provide some
guest lectures in their specialty area (e.g., HIV, TB), but none from NMCP has lectured recently
at ENSP. Further, some units within the MOH have provided teaching materials and aids. For
example, models were provided for teaching family planning and emergency obstetric care, but
no learning materials or job aids have been received from the NMCP.

Capacity Building and  Malaria topics are listed in most  The ENSP has established a
Training curricular outlines of programs committee to review aspects of
offered by ENSP, but are not malaria in curricula for all courses
elaborated in terms of content or taught.
teaching methods.  Technical training has occurred for
 Salaries of approximately one-third about half of ENSP staff based on
of NMCP staff are currently covered the revised malaria case
only by Global Fund, though some management guidelines.
may be regularized later this year.  Each unit within the NMCP has
 Only two NMCP staff have been given instructions for
advanced public health training; developing appropriate job
more opportunities are desired. descriptions.
 At the district and CSPS levels,  In the past two years, nearly 2,700
parallel staffing structures exist for frontline CSPS staff have received
community outreach personnel in-service training on the updated
between the MOH and the PR for malaria guidelines.
the Global Fund Round 7/8 grant.
 The number of CSPS has increased
by about one-third from around
1,200 to 1,600 since 2009,
requiring more resources for
training and supervision.
QUALITY ASSURANCE INCLUDING SUPERVISION

Supervision is performed in an integrated fashion, where facilities are visited and monitored for
the entire package of services they provide. Supervision is carried out by a team at the district
level. However, funding constraints sometimes limit the frequency of supervisory visits (USAID
2011). Due to varying skills/roles of the supervision team members and the limited amount of
time that they have to review multiple components within a health facility, these visits are not
able to look closely at the correct performance of procedures and protocols or at specific diseases,
such as malaria. The documentation of the supervision findings is very poor and does not allow
for effective follow-up of recommendations.
There are also malaria-specific supervisory activities done separately with support of the
NMCP. Although the malaria supervision guidelines have been updated recently, they are still
applied separately from regular health center supervision by the district teams. These centrally
led visits are only able to reach a limited number of facilities. In 2012, the funding allocated
from Global Fund to NMCP to conduct these visits was unavailable due to contracting delays.
Documentation and communication of findings of these NMCP-led supervision visits are
inconsistent and contribute to poor follow-up. The limited reach of these supervision visits
means that a facility is unlikely to be visited again within six months or a year.
In addition to the time and cost demands of supervision visits, this sort of quality assurance
may be too infrequent to effect and/or register behavior change and improvements in service
quality in facilities. Development of performance standards based on malaria directives may be
one way to engage providers and facility managers in their own performance monitoring.
External supervision can use performance standards to guide visits and support based on a
commonly known set of criteria.
Job aids and communications materials can help to improve performance and consistent care.
Seven job aids were developed and distributed: focused antenatal care, including the prevention
of MIP using IPTp; treatment algorithms for management of simple and complicated malaria;
use of RDTs; assessment of consciousness (Blantyre Coma and Glasgow Coma scores for infants
and for children and adults, respectively); and equivalence of different formulations of quinine

available in the country. Brochures for community distribution include prevention of MIP,
general prevention strategies and management of simple cases of malaria, including the
importance of completing three days of treatment. Through the Family Health Directorate,
1,800 job aids and 36,000 leaflets related to MIP were disseminated. A further 10,800 job aids
and 72,000 leaflets related to case management, use of RDTs and malaria prevention strategies
were provided to NMCP for distribution. These materials are to be distributed to 1,600 health
centers, 45 district hospitals and 12 regional and national hospitals. During malaria supervision
visits in 2012, the revised job aids were inconsistently available in facilities, with better
distribution of MIP materials than other job aids (MCHIP 2012).

Quality Assurance  Job aids on case management  Job aids on most aspects of
including Supervision made available to NMCP in October malaria case management and
2011 have not consistently service provision have been
reached CSPS, based on developed.
supervision reports.  Updated supervisory checklists for
 Malaria supervision by district malaria service delivery have been
teams for CSPS staff is an developed.
additional activity to the existing  With USAID support, 165 district-
integrated supervisory process. level supervisors have been trained
 There is no standardized to use the new supervisory
documentation on follow-up of guidelines; mentored and
supervision. monitored supervision is taking
place in 20 districts, with more
supervisor training in 2012.
LEADERSHIP, GOVERNANCE AND STRUCTURE

Annex 1 lists current NMCP staff. They can be grouped in six functional categories, five of
which are technical. The technical groupings are: 1) case management, 2) vector control, 3)
planning, monitoring, evaluation and
Figure 6. NMCP organogram
documentation, 4) communications and
mobilization, and 5)
logistics/procurement. The sixth group is
administration. An official organogram
appears in Figure 6.
There is no official deputy coordinator. -

Although this appears to be a general
structural challenge in other sections of
the MOH, it is especially troublesome to
malaria partners when the NMCP
coordinator is unavailable, and no one is
available to make timely decisions in
such a large program effort.
Further, the position of NMCP within

the MOH may hinder timely decision-
making, coordination with donors and communication with regional directors in order to
disseminate information to the facilities. Despite the health care burden of malaria in Burkina
Faso, malaria is not prioritized as strongly as it could be. This may also be a function of the
resources available for malaria, as compared to HIV, maternal health, etc.

Leadership,  No deputy coordinator exists, a  Major program areas are covered by
Governance, common situation in many units; staff.
Structure delegation is weak.  There is good structure with major
 The positioning of the NMCP under components as recommended by
the DLM discourages timely RBM: case management unit, M&E
decision-making and relations with unit, communication unit, vector
other program partners, including control unit, logistics and
those within the MOH, although this procurement unit, financial and
has not inhibited coordination in administration unit.
other countries where ministries of  Staff are motivated, though
health give high priority to malaria. overstretched.
 Delegation appears weak, in that,
many NMCP staff attend functions
and workshops where only one or
two key persons would suffice.
 Number and quality (skills) of the
staff.
 Workshops are better prepared in
terms of logistics than technical
matters.
 Partners are not involved in
preparation of meetings and often
are informed too late.
 Some meetings among NMCP and
partners are not held on time (or not
held at all).
 There is weakness of coordination
among NMCP’s units.
DISCUSSION
The NMCP was established in 1991, but did not have its first national malaria strategy until
2002. Some 20 years after inception and 10 years after its first strategy was formulated, the
NMCP has been able to grow its staff and attract substantial donor funding. Despite national
policies and progress toward the prevention and control of malaria, gaps remain, as well as
future opportunities at community, facility, regional and national levels. This documentation is
an important reference and tool to initiate dialogue at the national level among NMCP, other
MOH directors and supporting partners including donors. The identified challenges and
strengthens afford Burkina Faso to examine the malaria program in more detail and make
strategic decisions for accelerating malaria prevention and control and attaining nationwide
coverage.
An important change over time has been seen in the area of human resources development. In
2009, major emphasis was on in-service training, not only to bring existing staff up to date on
malaria service policies and procedures, but also to make up for inadequate and out-of-date
coverage of malaria topics in the basic training offered by the ENSP. Now, not only have in-
service training materials and accompanying job aids been updated, but they have also served
as the basis for a curriculum review at the ENSP.
Progress at the community level has included reinvigoration of the CHW program. However,
challenges remain, especially in the scale-up of prevention and treatment at the community

level that depends on adequate supply of commodities, as well as eventually extending the use
of RDTs to CHWs.
Another challenge that has seen a slowly evolving solution is the use of parasitological diagnosis
using RDTs at the health facility level. In 2009–2010, RDTs were scarcely available and
training programs instilled more skepticism than acceptance. As of 2012, one can see greater
use of RDTs generally, as well as their use in rational case management. The main challenges
rest in the procurement and supply processes to better forecast need and ensure timely
supplies.
At the governmental level, there are weakness in the implementation of advocacy for and
sensitization on malaria, insufficient M&E of interventions, low proportion of trained health
workers, lack of funding for malaria control and delay in disbursements. At the
nongovernmental level, there is insufficient application of national guidelines on malaria
control, insufficient involvement of civil societies and a low proportion of health workers in the
private health sector. At the community level, there is poor utilization of ITNs and other
preventive measures, non-implementation of ACTs and insufficient motivation of CHWs. These
weaknesses in the malaria program have led to gaps in coverage of prevention and treatment of
malaria in Burkina Faso.
Even with the scale-up of LLIN coverage to households, gaps still remain in actual LLIN use by
vulnerable groups (e.g., pregnant women, children). Hopefully, the next DHS will report better
LLIN use figures. At the same time, the nets distributed during the last campaigns will soon
need replacement, and plans for this are urgently required.
Some progress has been made in the prevention and treatment of malaria in Burkina Faso over
the years. Per the Global Fund Round 7 Progress Report (GFATM 2013), the following
achievements were realized in malaria control:
 The number of children under five with uncomplicated malaria treated with ACTs in health
facilities following national guidelines has exceeded targets every quarter from mid-2008
through the end of 2011. In total, 1.7 million children were treated in October–December 2009,
and 2.5 million were treated in the peak transmission period of October–December 2011.
 The number of people over age five treated with ACTs in health facilities has also exceeded
targets: 1.5 million people received ACTs in October–December 2009 and 2.2 million people
received ACTs in October–December 2011.
 19.5 million persons reached by BCC (120% of target, October–December 2011)
However, targets were not reached for the following indicators:

 Number of persons suffering from uncomplicated malaria treated with ACTs by CHWs following
national guidelines (4% of target in January–March 2010, last reported period; targets
subsequently reduced)
 Percentage of malaria cases confirmed from cases suspected in health facilities (39% of target for
October–December 2011)
 Percentage of people who know three clinical signs of malaria and two measures for prevention
(55% of target, January-March 2010)
Overall, the best-performing areas of program management and implementation are policy
development, capacity development and training, and community involvement. Burkina Faso
has updated its policies and directives in a timely manner, and dissemination through training
has reached all districts in recent years. In addition, the MOH is in the process of

institutionalizing community involvement through the creation of the Community Health
Directorate. Other areas are challenging and bespeak of the difficulties in obtaining coverage,
particularly the inter-related areas of finance and commodities. Coordinating bodies exist on
paper. These bodies, however, are not meeting regularly, which could be part of the reason why
integration of malaria with various public health and primary care efforts are weak. (Actual
scoring of these nine elements is found in Table 5.)
Policy Formulation and Dissemination

While Burkina Faso has adopted multiple new malaria policy directives, putting those policies
into practice may not be so simple. Targeting policy dissemination at all points of care will help
to increase malaria prevention and control practices at all points of care: community, CSPS and
hospital level. Having policies in place, while a critical and necessary step, is not enough to
ensure effective malaria care. Appropriate stocks (e.g., ACTs, RDTs, SP) need to be available to
ensure clients receive correct care. Also, as Burkina Faso’s epidemiological situation changes,
monitoring and understand these changes will be important to inform how to direct resources
and prioritize malaria support.
Policy is a moving target. The transformation of IPTi by WHO’s Global Malaria Program into
seasonal malaria chemoprophylaxis in the countries of the Sahel requires updated guidelines
and action plans. Last year, the Global Malaria Program reframed the use of IPTp in countries
of moderate to high endemicity to require IPTp being offered at each ANC visit after
quickening. If there have been challenges in completing two doses of IPTp during pregnancy to
date, the future need to reach three or four doses will require more creative policies, guidelines
and action plans.
Integration with Relevant PHC Service Areas

The disproportionate impact malaria has on young children and pregnant women necessitates
ensuring appropriate integration with primary and MCH services. While realized by default at
the CSPS, coordination and collaboration at the national level is less than optimal.
Commitment from the NMCP and across directorates to improve malaria outcomes and work
together is clearly in place. However, time and resources to support effective program
coordination resulting in efficient implementation practices and non-duplicative efforts is
lacking. As well, harmonizing national-level documents among the NMCP and MCH programs
would result in more focused and targeted support to frontline providers.
An achievement score between 1 and 4 was assigned to each of the nine components found in
the analysis framework, as indicated in Table 5.

Table 5. Achievement scores for the nine analysis framework components
COMPONENT SCORE COMMENT
1. Policy Formulation 3.5  Existence of a policy, taking account of international initiatives
and Dissemination against malaria
 Key updates in 2012
 Integration of control activities against malaria at the operational
level
 Dissemination to regions and districts lags behind policy
updates
2. Integration with 2.5  Integration of the malaria control program in health district level
Relevant PHC Service activities; efforts are still needed to harmonize with other
Areas programs on MCH (e.g., IMCI, focused antenatal care,
vaccination)
3. Financial Sources and 2  Specific malaria budget line exists
Adequacy  Insufficient continued/dependable funding from all sources for
malaria activities
 No clear direction to regions and districts to consider malaria as
a priority for funding at the peripheral level
4. Community 3  Implementation of community case management; support of
Involvement, civil society positive, but attention needed to sustain the
Awareness and achievements
Education  Community case management based on syndromic treatment,
discordant with facility protocols
5. Commodities and 2  Weakness in medicine forecasting; frequent stock-outs
Procurement  Setting up a monitoring committee for the management of ACT
can improve this
6. Monitoring, Evaluation 2  NMCP maintains a database of regional level data with more
and Research malaria-specific information to conduct reviews; separate from
NHMIS; weak analysis
 Data collection tools need revision
 Data recording and reporting in facilities could use strengthening
along with clinical training
 Coordination between NMCP and Research Institutions weak
7. Capacity Building and 3  General lack of human resources in health
Training  Improvements in qualified human resources at NMCP
 Existence of an integrated training module for malaria and
national trainers; at least one provider from every facility trained
during 2011 and 2012
8. Quality Assurance 2  Existence of a national guide for supervision; low quality of
including Supervision supervision (also low level of implementation) at the health
district; lack of effective monitoring and follow-up of the
recommendations of supervision
9. Leadership, 2  Proper structuring of the NMCP with the various units as
Governance and recommended by international institutions; weak managerial
Structure capacity of the NMCP
 Delegation and division of responsibility to be strengthened
TOTAL/SCORE 22/36

RECOMMENDATIONS
Table 6. Recommendations
AREA RECOMMENDATIONS PARTNERS
RESPONSIBLE
1. Policy  Continue dissemination of malaria policy, strategic plan, NMCP
Formulation guidelines, training manuals; guide supervision at all levels
and of the health system, through training, supervision and Technical
Dissemination MOH channel assistance from
 Accelerate the review, updating, adaptation and WHO, USAID
dissemination of new policy policies and programs, such as
revised IPTp guidance, seasonal malaria chemoprophylaxis
and appropriate surveillance strategies in areas with the
potential for near-term elimination
2. Integration  Work with central departments (DSME, DPV, DCH) for Directorate of
with Relevant harmonization of guidelines for prevention and/or support Disease Control to
PHC Service for some targets (IMCI, PMTCT, IPTi) link NMCP with
Areas  Work with programs in charge of the fight against TB and other directorates
HIV as well as IMCI for better integration of strategies
against these diseases
3. Financial  Advocate for increased mobilization of resources for the MOH and partners
Sources and fight against malaria; mining companies or the booming
Adequacy mobile phone companies could make their contribution
 Explore of private sector resources and interest
4. Community  Support the new Directorate of Community Health (DCH) NMCP to
Involvement, in: coordinate input
Awareness - Development of the community health care package, from NGOs and the
and Education specifically, malaria unit DCH, as well as
- Training CHW supervisors with the right knowledge other community
and skills to effectively support CHWs service units of
ministries, such as
Agriculture
5. Commodities  Support the monitoring committee in management of ACTs NMCP, DGPML and
and to coordinate the estimated need, supply and inventory partners
Procurement tracking inputs
 Link with DCH and NMCP to ensure adequate supplies of
ITNs and SP at ANC
 Link with DELIVER, CAMEG and others to ensure adequate
supplies of RDTs
 Update and disseminate guidelines for rational use of
inputs
6. Monitoring,  Conduct a study on the epidemiology of malaria to better NMCP, research
Evaluation describe the presentation of the pathology centers and
and Research  Ensure a sharing of results of studies on malaria in partners
participants in the fight against malaria
 Build capacity at all levels of health system to better
monitor and use data for decision-making. This should be
integrated with routine training and followed up during
supervision; could also require targeted M&E training
 Review data collection system at central level to improve
efficiencies
 Capacity development of NMCP staff to analyze and use
data

AREA RECOMMENDATIONS PARTNERS
RESPONSIBLE
7. Capacity  Continue training providers targeting biomedical NMCP and partners
Building and technologists, providers of reference structures, such as
Training district hospitals (CMA), regional hospitals, health facilities
and private denominational
 Build on existing scale-up approach; also target ANC
providers to ensure effective care
 Monitor the process of revising training curricula in schools
of paramedical staff training
 Initiate a dialogue with the Training unit and Research
Health Sciences at the University of Ouagadougou for
updating training curricula
8. Quality  Develop standard tools for monitoring the implementation NMCP and partners
Assurance of the recommendations of supervision
including  Introduce quality improvement process to ensure managers
Supervision and providers have the knowledge and skills to assess their
work against performance standards, address gaps and
improve care
9. Leadership,  Support the NMCP to monitor the process of strengthening NMCP and partners
Governance its management capacity following the workshop held in
and Structure May 2012
 Reinvigorate malaria steering committee and technical sub-
working groups
 Advocate for a better positioning of NMCP within MOH

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Annex 1: Identification des Membres du PNLP
(NMCP Staff List)
N° NOM ET PRÉNOMS QUALIFICATION SERVICE/UNITÉS OBSERVATIONS
1 Dr. Combary Ali Patrice Médecin de santé Coordonnateur du PNLP Etat
publique
2 Dr. Traoré Mama Médecin de santé Responsable de l’unité de Fonds Mondial
publique prise en charge et prévention
médicamenteuse
3 M. ZEBA Idrissa Attaché de santé, Unité Prise en Charge Etat
pédiatrie
4 Mme Brigitte Sawadogo Attaché de santé, Unité Prise en Charge Etat
soins infirmiers et
obstétricaux
5 Dr. Sanon Harouna Médecin Responsable Unité Suivi Fonds Mondial
Epidémiologiste Evaluation
6 M. Kabore Moussa Attaché de santé/ Unité Suivi/Evaluation Etat
épidémiologie
7 M. Sandwidi Jean Pascal Attaché de santé/ Unité Suivi/Evaluation Etat
santé publique and
soins infirmiers et
obstétricaux
8 M. Doamba Mathias Conseiller de santé, Responsable de l’unité de la Etat
soins infirmiers et lutte antivectorielle
obstétricaux
9 Mme. Sawadogo Attaché de Unité de la lutte antivectorielle Etat
Monique santé/soins infirmiers
et obstétricaux
10 M. Kabore Raymond Technicien du Génie Unité de la lutte antivectorielle Etat
sanitaire
11 Mme. Konseibo Béatrice Attaché de Responsable de l’unité de Etat
santé/soins infirmiers plaidoyer, information,
et obstétricaux éducation, communication et
mobilisation sociale
12 Mme. Lalle Aissétou Attaché de Unité de plaidoyer, information, Etat
santé/soins infirmiers éducation, communication et
et obstétricaux mobilisation sociale
13 M. Kabore Noel Communicateur Unité de plaidoyer, information, Fonds Mondial
éducation, communication et
mobilisation sociale
14 Dr. Moussa Ouedraogo Pharmacien Responsable de l’unité Fonds Mondial
l’approvisionnement et
logistique
15 M. Sia Moïse Préparateurs d’Etat Unité approvisionnement et Etat
en Pharmacie logistique
16 Gnankine Ibrahim Administrateur des Responsable de l’unité Etat
Hôpitaux et services l’administration et finances
de santé

N° NOM ET PRÉNOMS QUALIFICATION SERVICE/UNITÉS OBSERVATIONS
17 Gouba T. Serge Comptable Unité administration et Fonds Mondial
finances
18 Sawadogo Mady Comptable Unité administration et Fonds Mondial
finances
19 M. Zongo Vincent Chauffeur Personnel d’appui Etat
20 M. Yra Adama Chauffeur Personnel d’appui Etat
21 M. Kagambega Ousséni Chauffeur Personnel d’appui Etat
22 Sanou Adama Chauffeur Personnel d’appui Fonds Mondial
23 Liliou Sampana Chauffeur Personnel d’appui Fonds Mondial

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A Documentation of Malaria

© Jhpiego Corporation, 2013. All rights reserved.

A Documentation of Malaria Program Implementation in Burkina Faso iii

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Figure 1. Malaria-endemic zones in Burkina Faso

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Morbidity and Mortality

Malaria and HIV Interactions

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Progress on Malaria Indicators

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Table 2. Malaria indicators obtained through routine monitoring and evaluation

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The desk review was followed by in-depth

The final phase of the review shared the

STRATEGY AND POLICY DEVELOPMENT

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CURRENT LEVELS OF SUPPORT

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Table 3. Sources of financial support to NMCP in FCFA

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In terms of treatment of MIP, national case management guidelines in 2010 recommended:

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Table 4. Malaria case management by health service level

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INTERMITTENT PREVENTIVE TREATMENT

In 2001, the MOH conducted an evaluation to determine coverage of chloroquine

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According to a study conducted by Centre National de Recherche et de Formation sur le

Indoor Residual Spraying

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MANAGEMENT OF SUPPLY OF COMMODITIES AGAINST MALARIA

ADVOCACY, INFORMATION, EDUCATION, COMMUNICATION AND SOCIAL

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Epidemiological Surveillance, Monitoring, Evaluation and Research

NMCP PROGRAM MANAGEMENT AND COORDINATION

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MAJOR FINDINGS CHALLENGES AND BOTTLENECKS STRENGTHS AND BEST PRACTICES

INTEGRATION AND COORDINATION WITH RELEVANT PRIMARY HEALTH

Reproductive and Maternal Health

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HIV and AIDS

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MAJOR FINDINGS CHALLENGES AND BOTTLENECKS STRENGTHS AND BEST PRACTICES

FINANCIAL SOURCES AND ADEQUACY

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MAJOR FINDINGS CHALLENGES AND BOTTLENECKS STRENGTHS AND BEST PRACTICES

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ASCs have now been incorporated with the

Each SR has hired a district supervisor and

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