From bites to bytes

Q&A with Dr Arantxa Roca-Feltrer, Head of Monitoring and Evaluation, Malaria Consortium

20 April 2018

This interview has been edited and condensed from the audio version (Duration 11:39 [mp3 21 Mb])

Getting good data on malaria is essential. Like a puzzle, each piece fits together to help experts understand trends such as how many people are getting sick and how many have died. Through strong surveillance systems, a country can see who is most affected by the disease and where malaria control tools – like bed nets, diagnostics and medicines – are needed most. As technology has changed over the decades, so too have the approaches to collect, analyse and use malaria data. To learn about how countries gather and use this information, Dr Arantxa Roca-Feltrer, Head of Monitoring and Evaluation at Malaria Consortium, demystifies the process that countries undertake to collect vital bytes that inform policies and save lives.

Timely and accurate data on malaria directs responses and resources to where they are needed most (animated illustration)

What is a malaria surveillance system and why is it so important?

In simple terms, surveillance is considered the eyes and ears of public health. It refers to the systematic and ongoing collection, collation, analysis and interpretation of malaria and other health-related data, as well as the timely dissemination of that information to those who really need to know, so that action can be taken. A malaria surveillance system comprises different aspects – people, procedures, tools and the structures necessary to generate information on the number of malaria cases and deaths.

Surveillance is important because it provides information to guide interventions. Since surveillance directly measures what is going on within a population, it’s useful for deciding which interventions are most appropriate in particular contexts, which ones need to be targeted, as well as how these interventions are actually performing. Strengthening malaria surveillance is therefore fundamental to programme planning and implementation, and it’s a crucial contributor to accelerating malaria elimination efforts.

How is this information gathered?

In settings where malaria transmission remains very high, countries collect and report aggregated malaria data into the routine National Health Management Information System (HMIS). Data on malaria cases is usually gathered and aggregated monthly through register books, collected by either community health workers or health facility staff. That information then flows up to the central level.

HMIS data is comprehensive and not only includes malaria, but a lot of health-related data in terms of in-patient or outpatient information on births, deaths and different disease programmes like TB, malaria and HIV. However, the malaria-specific data needed for national programmes through this system is not sufficient on its own, and therefore a more comprehensive, malaria-specific surveillance system is required.

What happens with the information once collected?

It’s actually one of the weaknesses we are facing at the moment: the interpretation of information for decision making. Closing this feedback loop is currently one of the biggest challenges in malaria programmes, and it requires capacity building in interpretation and data-use aspects to guide data-to-action approaches at different levels within each country.

Can you share an example where you saw surveillance data being used to change what was actually happening on the ground?

Malaria surveillance captures information at different levels; it could be case data or other sorts of information that is related to malaria. For example, a critical element for a timely malaria response is ensuring commodities are in place. If community health workers or staff at a health facility are reporting a lack of stocks, such as antimalarial drugs, there needs to be a mechanism to trigger an alert, in a timely manner, that new stocks are required in that particular health facility. An effective surveillance system should be able to flag such issues for a continuum of care.

In a country that is close to eliminating malaria, what kind of surveillance information is needed?

The closer a country moves towards malaria elimination, the more important it becomes to follow and track every single case, so that proper action can be taken. In some instances, after conducting case investigations, it could be an imported case of malaria and an action might not be required. In other cases, it might require identifying mosquito breeding sites and deploying malaria vector control interventions.

How has malaria surveillance evolved over the years?

One of the major breakthroughs has been the transition from paper-based data collection and reporting to the use of electronic systems. Digital technology has enabled surveillance systems to be capable of faster aggregation and reporting. It has improved data quality and the visualisation of data in a much more user-friendly way, for example through dashboards. This has brought malaria intelligence to life.

If a country has a high malaria burden, does this mean the surveillance system is weak?

Unfortunately, malaria surveillance systems are usually weakest in countries with the highest burden of disease, particularly in Africa. This is mostly due to a lack of good quality data relating to malaria morbidity and mortality trends. To improve the quality of data, it’s important to identify the major problems, whether the surveillance system is performing appropriately, and what components need strengthening.

Paradoxically, when you strengthen a previously weak surveillance system, it’s quite possible – and in a way expected – that you will initially see an increase in the number of malaria cases reported. This is mostly because the system, or the ability of the system to capture more cases, has improved in terms of increased coverage or greater completeness of reporting from public health facilities. Therefore, you are seeing the true burden of malaria for the first time, and it may be higher than previously estimated.

Are there any surveillance and information-related innovations currently under development or on the horizon that excite you?

One exciting initiative under development is exploring the role that mHealth applications, using mobile phones, can play in strengthening disease surveillance systems. This is because mHealth can link the community health worker or health facility staff who are treating a patient with the wider health information system, thereby providing accurate, complete and timely malaria data to inform planning.

But before seeing what is on the horizon, it’s important to understand the big challenges that remain. Despite key improvements, there is still no single information system that currently meets the needs of a malaria elimination capable surveillance system. At the same time, it’s important to emphasize that our interpretation and use of data will only be as good as the quality of the data that is feeding into system.

A key challenge we are facing is ensuring that every single data user or malaria-related staff member is actively engaged as key players in interpreting and using data for more timely decision making. Taking this a step further would mean informing the community and ensuring that everyone is fully engaged in what is happening and the progress that is being made on malaria.

Dr Roca-Feltrer was interviewed by WHO Communications Officer, Nyka Alexander, from the Organization’s headquarters in Geneva.