Tropical Health Matters

Front line clinics in Kenya, such as the one pictured here, carry four different dosage packs of Coartem to cover all age groups. In addition, coartem is given for free to all patients, and people over five years of age are generally tested before this artesunate-based combination therapy (ACT) drug is prescribed. This comprehensive approach means that there is no discrimination in providing care.

In other countries free ACTs that have been provided through donor support are intended only for children less than five years of age. ACTs for the remainder of the population have not been bought by health authorities based on concerns for cost. Sometimes then, the free ACTs from donor programs have been used inappropriately for older patients. Kenya appears to be avoiding this problem.

The lesson is even larger than that of the need for drug forecasting and adequate procurement. The Kenyan Ministry of Health recognizes that ACT has a preventive effect as reported by Sutherland and colleagues whose “results suggest that co-artemether has specific activity against immature sequestered gametocytes, and has the capacity to minimize transmission of drug-resistant parasites,” though this can be modest in some settings. If only a portion of the population is treated, this benefit of reducing transmission is missed.

Another benefit is economic. The Kenyan Ministry of Health also recognizes that if a parent is sick with malaria and misses work, the whole family will be affected. Just as WHO is calling for free nets for all, there also needs to be free ACTs for all who are infected with malaria. To do this we need continued donor and country support as well as a wider range of WHO pre-qualified ACTs to create competition and bring ACT prices down.

Last week WHO’s Global Malaria Program (GMP) launched its new guidance for Insecticide Treated Nets. Two key features of the guidance is the stress on providing free nets and the need to achieve total population coverage in endemic areas. The position paper begins by stating that the three primary interventions to be scaled up for effective malaria control include:

• diagnosis of malaria cases and treatment with effective medicines;
• distribution of insecticide-treated nets (ITNs), more specifically long-lasting insecticidal nets (LLINs), to achieve full coverage of populations at risk of malaria; and
• indoor residual spraying (IRS) to reduce and eliminate malaria transmission.

Nowhere in the document, let alone in this highly visible opening paragraph, is there mention of Intermittent Preventive Treatment/Therapy for pregnant women (IPTp). Thus, once again the GMP misses an important opportunity to stress a crucial and well proven intervention to protect the lives of pregnant women, their unborn babies and newborn infants from morbidity and mortality from the most dangerous form of malaria, P. falciparum.

A recent review by ter Kuile et al., has shown once again, that even in areas where there is up to 50% resistance to sulfadoxine-pyrimethamine (SP) in small children, IPTp with SP is still efficacious in controlling maternal malaria and reducing both maternal anemia and low birthweight in newborns.

We are not sure why the GMP itself has high levels of resistance to acknowledging the lifesaving effects of IPTp, and regret the poor example being set by a leader in world health. Fortunately other major development partners who actually have money to spend are still willing to help countries that suffer from malaria by supporting IPTp.

Thursday the 16^th of August 2007 marked a dual launching of two related malaria documents in Nairobi. WHO released its new guidance on insecticide-treated bed nets, and the Ministry of Health (MOH) in Kenya shared its impact report on malaria control interventions. Both stressed the importance of mass distribution of free Long Lasting Insecticidal Nets to achieve coverage of vulnerable populations. WHO explained that Kenyan evidence on net distribution modalities and improvements in malaria morbidity and mortality reinforced the need eventually to cover the entire population in endemic areas to achieve maximum health and economic benefits.

The Washington Post reported that the WHO guidance may put to rest the argument between proponents of free nets and those who believe that, “people who spend their own money on them are more likely to value them and use them properly.” Both documents indicated that equity in reaching the poorest portion of the population was best achieved by providing free nets, but that highly subsidized nets through clinic voucher programs and social marketing may play some role in improving access to LLINs in the poorer segment of society.

Data from the Kenya document seen in the attached picture show that over the past three years the gap between the higher and lower income quintiles of the population has been narrowing. This is an indication of how malaria control can contribute the goal of reducing health inequalities enshrined in Kenya’s National Health Sector Strategic Plan for 2005-10.

WHO also commended Kenya for implementing its national malaria strategy through a broad based international partnerships including DfID, UNICEF, USAID, GFATM, WHO and the Wellcome Trust among others. As the Times reported, donor funding helped make it possible for Kenya to give free nets.

The Kenyan MOH reported that the donor partnership has made one-quarter of a million US dollars available for malaria control since 2002. This amount should be viewed in the light of estimated budgetary needs of US $105 million for the current year alone. The fight against malaria in Kenya requires not only continued donor support, but also greater Kenyan government contributions and wise management of donor support to achieve the greatest health and equity impacts.

Recent discussions with people in countries that have received Global Fund to Fight AIDS, TB and Malaria (GFATM) grants has shown that most people, either in government agencies or in civil society are aware of the great wealth of information about the global fund generally or about their own country’s programs specifically that can be accessed on the GFATM website.

For example, if people are critical of the composition and performance of their country’s Central Coordinating Mechanism, they could download a copy of the CCM guidelines. When they complain about lack of civil society participation as grant recipients, they could download GFATM Board decisions that call for inclusion of NGOs as principal recipients. With such information in hand they can advocate with government, donors and the CCM itself to bring about improvements. Ironically, sometimes improvements may have already been made and described on the GFATM website, but people have not accessed the site to learn about the latest developments.

Another common complaint concerns disbursement of funds. NGOs in particular may wonder why they have not received recent installments of grant money. They are likely to blame the GFATM first, although a basic principle of the Fund in timely and efficient distribution of funds. A look at a particular country’s page on the GFATM website can provide access to the most recent progress reports on each grant wherein one can see the amount of funds pledged, the amount disbursed by the Global Fund and the amount expended by the principal recipient (PR). If a PR is running behind on expending funds received, the Global Fund will not send more. Therefore advocacy again may be needed to ensure accountability on the part of the PR, CCM and even the Local Funds Agency who is supposed to audit expenditure and implementation progress.

Clearly this situation reflects the digital divide. It is not enough for international organizations like the GFATM in professing openness to simply provide open access information on its website. People who need this information often do not have easy access to the internet, or if they do have access, they may have no idea that such a wealth of information exists. The GFATM does not have offices in countries and is therefore in a poor position to communicate about itself to those who need information. Partners like Roll Back Malaria, UNAIDS, and USAID among others, are providing technical assistance to countries for their Global Fund activities. Maybe these international partners can also help educate and link the potential and actual Global Fund partners in country via more accessible print and electronic media to the valuable advocacy resources available online.

Advocacy efforts are needed at the district and community levels to ensure that national policies for a malaria free future are actually implemented. Emmanuel Fiagbey of Voices Ghana contributes this report on development of District Malaria Advocacy Teams (DMATs)

Working in close collaboration with the National Malaria Control Program, the District Health Management Team (DHMT), the District Assembly and other stakeholders, Voices Ghana has succeeded in laying the foundations for vigorously promoting malaria advocacy at the district level.

 DMATs have become functional in Asuogyaman and Keta Districts. The process was set in motion with a meeting of key stakeholders including traditional leaders, religious leaders and leaders of public and private sector organizations who discussed the malaria situation, ITN distribution and use, acceptance and use of the new malaria drug, availability of resources for malaria control programs, and developing effective partnerships for malaria control.

DMATs were formed with the goal of effecting change in malaria programming, policy implementation and improving resource mobilization for malaria control efforts. Membership includes members of the District Assembly, DHMT, NGOs, other key public sector departments, chiefs, religious leaders, private sector representatives, the media and the Police Service.

So far the DMATs have defined their roles and responsibilities and formulated their advocacy action plans for implementation. Examples of activities include

• Mothers and Fathers clubs for malaria control in 30 communities in the Asuogyaman
• Sensitization durbars in selected communities on the new malaria drug policy
• Private sector fund raising with organizations such as the Volta River Authority, Akosombo Textiles Ltd. Akosombo Volta Hotel, and Keta Salt and Fishing Industry
• Labor union mobilization for malaria control in the work place

• Malaria free clubs in schools
• Consultative meetings with Parent Teacher Associations on strengthening early treatment and referral systems in schools

• Ensuring all health facilities are equipped with ITNs
• Create seed funds for Artesunate+Amodiaquine and SP to prevent stock-out

• Consultative meetings with District Council of Chiefs and religious leaders
• Creation of special ITNs funds to serve the needy
• Malaria prevention and treatment education with women’s and men’s associations.

Kiszewski et al. paint a stark picture of the potential funding gaps for malaria control programming in endemic countries. Based on data available between 2000-03, the authors found that only 4.6% of approximately $1.4 billion of projected annual funding needs were available from domestic sources in African countries. With notable exceptions including Cameroon, Malawi and South Africa, most countries could contribute less than 2-3% of the total malaria programming needs, e.g. 0.1% in Kenya, 0.5% in Mozambique, 1.1% in Nigeria and 2.6% in Mali. Even if domestic contribution (which includes out-of-pocket expenditure) doubles, triples or quadruples, the gap will remain.

Obviously there are large scale donor programs addressing this gap but none can do it alone. Recently around 55% of support from the Global Fund to Fight against AIDS, TB and Malaria has gone to sub-Saharan Africa and roughly a quarter of total GFATM funding has been allocated for malaria projects. This needs to be viewed in light of the fact that $7.7 billion has been committed by GFATM over the six annual rounds of funding to date. GFATM hopes to more than double its annual commitments, but this will not meet the malaria resource gap.

The US President’s Malaria Initiative hopes to work up to a $300 million annual contribution to 15 sub-Saharan countries. The World Bank’s Malaria Booster Program is targeting specific countries with good size grants, such as $180 million for Nigeria over 5 years. The Bill and Melinda Gates Foundation is funding major malaria research and expand use of existing tools. UNICEF has mobilized funds and bilateral donors to make a major contribution to meeting needs for insecticide-treated nets. NGOs in industrialized countries have been supporting this with net fund raising campaigns. An innovative taxation on air travel has brought UNITAID into the malaria arena. But is this enough?

The big challenge is sustaining funding levels. Although the GFATM is developing mechanisms for a rolling continuation of grants with good performance, grants that don’t perform or are mismanaged can be canceled. A key factor in determining performance is the strength of the health system. Kiszewski and colleagues do acknowledge that ‘program costs’ such as training, communications, monitoring and infrastructure account for 14.1% of the malaria funding needs.
The GFATM itself stresses health system strengthening (HSS) through monitoring and evaluation tools and that “funding for HSS activities can and should be applied for as part of disease components.”

Some HSS problems are deep and chronic as pointed out by MSF who has documented the health worker crises in many African countries. Therefore the question remains, will donors commit not only to addressing the malaria resource gap on a sustainable basis, but also to strengthening the underlying health system which is crucial for managing those malaria resources?