Posts or Comments 17 June 2024

Monthly Archive for "January 2008"

Funding &Health Systems Bill Brieger | 31 Jan 2008

Lancet Praises PMI, Systems Still Need Strengthening

Back in December, an editorial in The Lancet praised the first two operational years of the US President’s Malaria Initiative (PMI). Various supporters and critics were quoted as favoring the approach that was heavy on basic malaria control interventions and light on consultants.

At the same time, PMI leaders themselves recognized that many national health systems with which PMI works are weak and need strengthening. There was also recognition that PMI must work with the broader health system in order for its interventions to have the broadest effect on maternal, child and even national health. Clearly there is little value pouring funds and commodities into national health systems that cannot absorb or manage them.

The editorial did point out that the current US effort includes support for procurement, supply, education and monitoring, which are essential components of efforts to strengthen a health system. Although sometimes criticized for selecting countries that already have other international malaria support, PMI views this also in the context of systems strengthening. For example, countries have the option of including health systems strengthening components in their Global Fund proposals (though this aspect need MUCH more attention).

Spending all money on high priced consultants is certainly a problem. Spending some money on reasonably priced consultants that can address health systems bottlenecks is a good investment.

ITNs &Partnership Bill Brieger | 23 Jan 2008

‘ROADS’ to health and development in East and Central Africa

The USAID Regional office for East Africa launched a transport corridor program in 2005 called the Regional Outreach Addressing AIDS through Development Strategies (ROADS) based on the premise that mobile populations such as long distance truck drivers may also be ‘drivers’ of the HIV epidemic along the routes they travel. One transport corridor starts in Mombasa, Kenya and moves west to and through Uganda on to Southern Sudan or Rwanda, Burundi and the Democratic Republic of Congo. Another corridor starts at the port of Dar es Salaam in Tanzania, as does one that starts in Djibouti and passes through Ethiopia.

Along the way the ROADS project is establishing Safe-T-Stops for truckers where they can find HIV education, recreation that keeps them away from bars, and services like counseling and testing (CT). The project also works in the towns surrounding truck stops and has formed clusters of women (including sex workers), youth, and people living with HIV/AIDS CBOs. These groups not only engage in peer education and community theater, but also promote CT, ARV adherence, home based care and nutrition activities that support AIDS patients and vulnerable groups like orphans.

Economic development is a growing component of the ROADS portfolio with businesses and farms being set up in and by local communities. Integration of family planning services is underway at some sites and throughout the 26 current ROADS communities there is capacity building for public, NGO and private health care providers.

women-cluster-in-kenya-sensitizing-community-on-malaria.jpgAn example of further integration was a pilot project for malaria control in ROADS communities of Malaba and Busia that span the Kenya-Uganda boarder. WHO reported that it “developed project activities with the District Health Management Teams of Tororo and Teso districts as well as with the Truck Drivers Associations on both the Kenya and Uganda… The project enhanced access to ITNs to the target populations in both the Kenya and Uganda by procuring a total of 6,145 ITNs and distributing them to the cluster members. 1,711 of the old crop of ITNs were re-treated. Of the new ITNs given to the clusters, 800 were set aside for income generating activities. The cluster members were trained on ITNs use and re-treatment.”

This project demonstrated the value of integration malaria control into a strong community participation and multi-sectoral health and development model. Based on this experience WHO has decided to use this approach as a ‘best practice.’

Resistance &Treatment Bill Brieger | 22 Jan 2008

Chloroquine in 2008?

pharmakina-cq.JPGComing into the immigration office in Bukavu, Democratic Republic of Congo, one is welcomed by a 2008 calendar that features chloroquine products made by Pharmakina, a company that has set up production in DRC. Another copy of the calendar is seen in the provincial office of the national AIDS coordinating agency. According to the company “PHARMAKINA combats malaria supplying drugs of natural origin. PHARMAKINA cultivates 1,200 hectares of quinquina that guarantees the stocks of barks for a LONG-TERM production.”

While it is admirable that local botanical production is being promoted, the sale of chloroquine when drug resistance is rendering this anti-malaria drug useless in most of Africa is questionable. [see comment for correction] The East African Network for Monitoring Antimalarial Treatment observed that “Between 1998 and 2001, Kenya, Uganda, Tanzania, Zanzibar, Rwanda and Burundi changed antimalarial drug policy, in the face of widespread chloroquine resistance.” Specifically in DRC researchers reported that CQ is no longer efficacious in the treatment of malaria.

Furthermore DRC’s malaria grant from the Global Fund remarks on the change of national malaria drug policy to use artesunate-amodiaquine as first line treatment. The August 2007 progress report on that grant observed that there was, “Concern with the impact of the switch from chloroquine to ACTs on the program’s Phase 2 targets on the Principal Recipient’s ability to purchase sufficient drugs to enable it to reach targets and the CCM’s proposal in the Phase 2 request to reduce the program’s timeline from 5 to 4 years.” Maybe this is why CQ is still popular?

Local production of malaria drugs does have the potential to reduce costs and increase access. Just as Pharmakina is promoting local cultivation of quinine, other companies and countries are promoting growing of artemisinin. The principle is the same, but the drugs are not. The challenge is producing the most efficacious drugs that come in combination form. Following WHO malaria treatment guidelines is a good place to start.

Health Rights Bill Brieger | 13 Jan 2008

Human Rights, Corporate Responsibility and Access to Medicines

We are in the midst of observing the 60th Anniversary of the Universal Declaration of Human Rights. Article 25 of the Declaration states that, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

udhrpage-sm.jpgAs we have noted before, The UN has appointed a Special Rapporteur of the Commission on Human Rights on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. One of the issues being pursued is that of access to medicines, including medicines for malaria, and to that end guidelines are being developed for pharmaceutical companies.

In an introductory note the draft guidelines observe that, “Almost 2 billion people lack access to essential medicines. Improving access to existing medicines could save 10 million lives each year, 4 million of them in Africa and South-East Asia. Access to medicines is characterised by profound global inequity. 15% of the world’s population consumes over 90% of the world’s pharmaceuticals.”

The suggested guidance encourages pharmaceutical companies to address human rights in their mission statements and actually act on those statements as part of corporate responsibility. One particular concern is that companies refrain from discouraging or working against country policies that are working to improve access to medicines by citizens. What comes to mind of course is efforts by countries to buy or produce generic HIV or malaria medicines in order to ensure the greatest coverage of affected people. Other issues addressed in the draft include ethics, quality, technology transfer and pricing.

What would be most helpful in the malaria arena is if more alternative and generic medicines could become available and those made available at the cheapest possible prices. For example, one possible unintended consequence of WHO’s pre-qualification process seems to be putting all our eggs in the one basket of artemether-lumefantrine, which does not make sense epidemiologically or economically. International and national based pharmaceutical companies have a role to play in rolling back malaria. They need to do this in a responsible manner that saves the most lives.

Health Rights Bill Brieger | 05 Jan 2008

Kenyans should hate malaria, not each other

The continuing post-election saga of violence, killing and intimidation in Kenya has far reaching health impacts beyond the immediate sorrow of unnecessary deaths. News reports today indicate that food aid for displaced persons cannot reach those in need because of insecurity.

Robyn Dixon reports in the Baltimore Sun that, “Up to 100,000 Kenyans face starvation in western Kenya because of election-related tribal violence, the World Food Program warned yesterday, as rivals in last week’s disputed presidential vote showed no willingness to talk.” In addition, “More than 180,000 Kenyans have fled their homes because of tribal violence, the United Nations reported, and 500,000 will need aid in the coming month.” According to the BBC, “Food rations in many homes outside Nairobi are running short as most shops remain closed.”

It will not take long before increased susceptibility to diseases, including malaria, will plague the displaced and homeless. The situation is particularly sad because Kenya was held up as a model of success by the WHO’s Global Malaria Program in August. According to the BBC public transportation has nearly shut down. Displaced people will now have little or no access to life saving malaria interventions including prompt treatment with ACTs and ITNs/LLINs. Women will miss antenatal appointments and an opportunity to receive IPTp.

In an attempt to preserve or gain their own power, political leaders actually give more power to devastating diseases and hunger. The people of Kenya deserve better.

Partnership Bill Brieger | 04 Jan 2008

Roll Back Malaria Partnership: 10th Anniversary in 2008

According to RBM’s website, “To provide a coordinated global approach to fighting malaria, the Roll Back Malaria (RBM) Partnership was launched in 1998 by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank. The RBM Partnership has expanded exponentially since its launch and is now made up of a wide range of partners — including malaria-endemic countries, their bilateral and multilateral development partners, the private sector, nongovernmental and community-based organizations, foundations, and research and academic institutions — who bring a formidable assembly of expertise, infrastructure and funds into the fight against the disease.”

Randall Packard in his new book, “The Making of a Tropical Disease: a short history of malaria.” He described the conditions that led to the founding of RBM which included a resurgence of the disease after failed efforts at eradication, declining efficacy of drugs and pesticides, program policy and management failures, collapsing health systems, and global debt burden among others. Clearly the RBM Partnership had a huge task ahead of itself.

rbmlogo2.gifOne of the very first RBM activities was to provide technical assistance to endemic countries to conduct needs assessments which in turn could form the basis of plans and proposals to raise fund to implement control activities. The Partnership then would help link the countries with donors to support these plans and thus achieve one of the main objectives of RBM, “the scaling up of interventions at country level to ensure wide spread coverage, particularly to population groups most vulnerable.” The ability of countries to do this has been greatly enhanced when organizations like the Global Fund became part of the partnership, giving countries the means to achieve scale up.

pretesting-rbm-needs-assessment-instruments-in-1998.jpgThe results of adding financial partners into the mix of technical and national partners has been, according to the Executive Director of the Global Fund, Michel Kazatchkine, reduction in malaria deaths in Zamzibar, Eritrea, Kenya and Zambia. The RBM Partnership has continued to mobilize technical assistance in developing proposals and helped achieve major funding increases for malaria grants from the Global Fund. According to the Global Fund Observer, ” In Round 7, an unusually high 62% of malaria proposals were approved, up from 32% in Round 6.”

The VOA reported that Dr Kazatchkine “warns against complacency. He says more than one million people still die each year from malaria. He notes many areas in Africa such as Nigeria and the Democratic Republic of Congo do not have access to bed nets.” RBM is not being complacent, but is planning updated country assessments and additional assistance for strengthening GFATM Round 8 proposals.

RBM is unique in that its “strength lies in its ability to form effective partnerships both globally and nationally.” While involvement of international donor, non-governmental organization and private sector partners are crucial, it is the national partners who hold the key to success and sustainability. Hopefully we will see in the coming months more documentation of RBM’s 10 years of success.

Environment &Epidemiology Bill Brieger | 03 Jan 2008

Rains in Africa

us-national-weather-service.jpgThe Cape Times has issues a warning that greatr than normal malaria transmission is expected during the current rainy season in southern Africa. They quote a WHO official as syaing, “Malaria transmission from November 2007 to May 2008 is expected to be above normal in most parts of southern Africa. In East Africa, October to May is an important part of the rainy season, when malaria transmission and epidemics can occur. In southern Africa, the heavy rains and likelihood of flooding in certain areas from December may lead to an increase in malaria transmission.” This prediction links with US Weather Service reports for early December that state, “In southern Africa, consistent with the current moderate La Nina episode, rainfall was overall above average across much of southern Africa.”

Jones et al., (2007) tested a model for understanding forecasting malaria in the highlands of Tanzania, Such highland areas, like much of southern Africa are subject to epidemics as opposed to the year round transmission found in the lowlands of much of Africa. They addressed the issue of Malaria Early Warning Systems (MEWS) based on climate variations that have been proposed to warn ministries of health of the potential of increased risk of malaria epidemics and drew attention to the The El Niño Southern Oscillation cycle. this builds on suggestions for creating such a system by Thomson and Connor (2001).

Jones et al., found that “malaria incidence is positively correlated with rainfall during the first season (Oct-Mar). For the second season (Apr-Sep), high malaria incidence was associated with increased rainfall, but also with high maximum temperature during the first rainy season.” Chaves and Pascual (2007) built on the malaria early warning experience to propose and discuss early warning systems for other neglected tropical diseases. They concluded that, “EWS are a feasible ecological application for neglected tropical diseases,” and recommended that “Forecasts can be useful in planning services for the populations affected, allowing estimates of approximate number of hospital beds, vaccine shots, drug doses and vector control measures.”

The increasing ability to understand weather and climate and their effects on malaria, especially in epidemic regions of the world is extremely helpful for planning timely deployment of malaria treatment and prevention interventions. This presents a big challenge to countries dependent on large scale donor project funds, which are not always dispersed in a timely manner or on a regular schedule and are thus, not always in tune with general national health and development planning cycles.

Development &Funding Bill Brieger | 02 Jan 2008

Continuing to look at aid

More critical thought about the wisdom of large scale major disease focused international assistance continues to emerge. An article in the Baltimore Sun by Charles Piller contrasted the big disease programs with smaller comprehensive health efforts.

The NGO Partners in Health “partners with governments in Africa, Haiti , South America and Russia to improve public-sector health care. It uses grants far smaller than the billions of dollars that foundations give to fight malaria or AIDS, and it treats patients broadly for whatever problems they have. It also links medical services to food, work and self-reliance for the poor. Partners in Health, or PIH, founded by renowned physician Paul Farmer two decades ago in Haiti , regards the approach as both common-sense and a Hippocratic responsibility.” According to a staff member, “Diseases are all intermingled. I could just focus on HIV, but we’re the only physicians around for a nine-hour walk.”

An Op Ed piece in the Baltimore Sun also takes a broader view and questions whether US foreign aid is really addressing the problems of poverty that serve as a foundation for success in preventing disease. The author, Jim Kolbe, observes that, “From the work of celebrities such as Bono to large charities such as the Gates Foundation, unprecedented global attention has been focused recently on reducing poverty in Africa. While images of Africa are effective in raising awareness of the issue, little attention has been paid to the problems in our current efforts to alleviate poverty. It is increasingly apparent that our aid – and trade – policies are not really supporting economic growth in impoverished countries.”

Monsters and Critics.Com specifically looks at the ‘war on malaria.’ They warn that, “… experts are wary about oversimplifying the struggle against a disease with a history of resistance to drugs, pesticides and good intentions,” and quote Jasson Urbach of Africa Fighting Malaria as saying that, “Having a grand goal such as eradication in mind is good, but we can and should learn from history and previous efforts at eradication before we get our hopes too high.” “Malaria was essentially a development issue,” Urbach argued. “As countries became wealthier they were more likely they were to drain soggy land and build houses with better protection from mosquitoes.” The article also expressed concern about the economic resources needed to sustain an eradication effort.

village-huts-sm.jpgA recent article in the American Journal of Tropical Medicine and Hygiene looks more closely at the connections between malaria and poverty by exploring the “dual causation between malaria and socioeconomic status” at the household level, noting that the negative macroeconomic effects of malaria have been established. The authors report that, “Malaria prevalence was measured by parasitemia, and household socioeconomic status was measured using an asset based index. Results from an instrumental variable probit model suggest that socioeconomic status is negatively associated with malaria parasitemia.”

So whether improved economic status provides the ability to reduce malaria or malaria prevalence decreases household economic status, there is a clear link between malaria and poverty. While there is need to ensure a more comprehensive and coherent approach to international development assistance that addresses poverty and broader public health needs, there is still room to address malaria control as part of an integrated development strategy.