Posts or Comments 28 January 2023

Monthly Archive for "December 2008"

Research Bill Brieger | 13 Dec 2008

Malaria elimination also requires research

While universal coverage of existing malaria control tools is necessary to achieve 2010 and 2015 targets, moving beyond such scale-up toward elimination requires a thorough examination and reappraisal of these tools and the way they are applied. A special supplement to Malaria Journal addresses these concerns.

In his introductory editorial to the special supplement, Marcel Hommel warns that, “The move from control to elimination is actually a quantum leap. If it were once possible to state that all the tools for control were available and that no further research was required, it is doubtful whether elimination could be achieved with those same tools. There is now a need to define a new research agenda and to identify the differences between control and elimination.”  The ten review articles included show that this research agenda includes both basic and applied or operational research. A few highlights follow.

Galinski and Barnwell point out that, “Plasmodium vivax, which has long been neglected and mistakenly considered inconsequential, is now entering into the strategic debates taking place on malaria epidemiology and control, drug  resistance, pathogenesis and vaccines. Thus, contrary to the past, the malaria research community is becoming more aware and concerned about the widespread spectrum of illness and death caused by up to a couple of hundred million cases of vivax malaria each year. ”

Ann Mills and colleagues discuss the economic, financial and institutional challenges that face the renewed call for eradication and intensified control. They point out that some of the key issues requiring research include 1) allocative efficiency of malaria eradication, 2) costs and consequences of the various tools and mixes, 3) extension of coverage of interventions and service delivery approaches, 4) processes of formulating and implementing malaria control and eradication policies, and 5) research on financing issues. They are concerned about equity and decision making at both national and international levels.

Brabin et al. look at the role of monitoring and evaluation in malaria in pregnancy (MIP) control and conclude that, “Large-scale operational research is required to further evaluate the validity of currently proposed (MIP) indicators, and in order to clarify the breadth and scale of implementation to be deployed.” This is especially urgent because MIP interventions currently vary by the type and stability of malaria transmission, which itself may be changing due to large scale intervention to date.

Other reviews address malaria research issues surrounding global warming, vaccines, ACT deployment, the role of drugs in elimination, diagnostics, and integrated vector management.

Finally, the Executive Director of the Roll Back Malaria Partnership calls attention to the research agenda inherent in the newly adopted ‘Global Malaria Action Plan.’ As she explains …

Armed with the Plan’s globally agreed research agenda, partners and advocates can now bring more investment to malaria research and foster further dialogue and innovation. The Global Plan requires a long-term commitment: continued funding is essential in both country implementation and R&D to prevent a re-emergence of malaria. However, the investment is worthwhile.

Leadership &Partnership Bill Brieger | 12 Dec 2008

A job with a difference


WHO is recruiting for the position of Director Global Malaria Programme (GMP). The Director is expected 1) to provide strategic and technical direction, 2) to undertake resource mobilization and management and 3) to facilitate Partnerships and Coordination.

Overall the GMP “is responsible for malaria surveillance, monitoring and evaluation, policy and strategy formulation, technical assistance, and coordination of WHO’s global efforts to fight malaria.” While WHO and its GMP are among the partners in the Roll Back Malaria partnership, some partners might be perceived as more equal than others – in part because WHO sees itself as “the foremost global authority on health.”

The GMP is a major source of the latest technical knowledge on all aspects of malaria ranging from case management to insecticides.  The position of Director is such a group certainly demands wide ranging technical expertise, but even more, it requires skills in leadership.  Since malaria control, elimination and eventual eradication requires the broad ranging collaboration among donors, technical agencies and civil society organizations as embodied in RBM, the Director of the GMP needs to exercise his/her leadership role in a special way.

A spirit of collegiality and inclusion is essential for the new Director, since no one agency or person has all the answers to the problem of malaria. Not surprisingly the job posting stresses a “Commitment to collaborate effectively with other key partners.”  We encourage all those with such a commitment to apply.

Health Systems &Human Resources Bill Brieger | 10 Dec 2008

Training – as important as commodities

dscn1179sm.JPGNew tools are said to be the answer to the question of malaria eradication. Even with the not so new tools available – ACTs, RDTs, IRS, LLINs, IPTp, IPTi – progress toward elimination can be made if health workers are trained in their appropriate use. Ssekabira and colleagues found that training improved some aspects of malaria case management such as reduced treatment of people testing negative in the lab, but they also pointed out that there needs to be integrated ‘team based’ training around all these tools in order to achieve success.

In their focus on training for improved malaria case management SSekabira’s group learned that ‘integrated’ means getting all clinical and laboratory staff on board as well as ensuring adequate procurement/supply of drugs, equipment and supplies, supportive supervision and especially adequate human resources to be trained, deliver services and supervise. This is a tall order, but alternative is bleak.

The advent of large scale donor funding of malaria control in the past six or so years began with a focus on malaria commodities. Concern was expressed to achieve coverage targets – 60% in 2005, 80% in 2010 – which was thought to be possible only if enough drugs, supplies and materials were made available to endemic countries.  In this context, countries were reluctant to ‘waste’ their donor dollars and euros on health systems strengthening, human resource development and operations research.  SSekabira’s efforts show these seeming peripheral elements actually provide a crucial framework without which all the malaria commodities in the world will really go to waste in storerooms and warehouses.

The use of Rapid Diagnostic Tests (RDTs) provide a simple example of the commodity vs. integrated approach.  Harvey et al. reported that, “Manufacturer’s instructions like those provided with the RDTs … are insufficient to ensure safe and accurate use by CHWs. However, well-designed instructions plus training can ensure high performance.”

Training resources exist, as for example Jhpiego’s Malaria in Pregnancy Resource Package, which is freely available online. Management Sciences for Health has training tools for the procurement and supply management. Greater use of such tools is needed so that the billions of dollars and euros spent on commodities will actually save lives.

HIV Bill Brieger | 01 Dec 2008

Malaria and HIV/AIDS service integration

20081027_poster_140.jpgToday is the 20th anniversary of World AIDS Day. This is a good time to think about two diseases that have received some of the largest disease-specific funding in history.  The question is whether program planners for these two diseases not only recognize the effect each disease has on the other in overlapping areas of endemicity, but whether they maximize efforts to achieve synergies in joint programming.

According to Unicef, “In Africa, the HIV pandemic has been superimposed on the longstanding malaria pandemic, where P. falciparum malaria is consistently one of the major causes of infant and child mortality. The high prevalence of both HIV and malaria infection in Africa means that even small interactions between the two could have substantial effects on populations.” Some key points include –

  • HIV infection increases the incidence and severity of clinical malaria
  • Acute malaria infection increases HIV viral load

Korenromp and colleagues conclude that “Across 41 countries in sub-Saharan Africa, the HIV-1 epidemic may have increased the incidence of clinical malaria by 1.3% (95% CI 0.6%–7.9%) and malaria deaths by 4.9% (95% CI 3.1%–17.1%) in 2004.”

WHO has offered guidance on health systems response to the interaction of two diseases as follows:

  • integrating services for prevention, treatment and care for malaria and HIV within the framework of maternal and child health services, is vital for reducing the burden of both diseases
  • establishing mechanisms for collaboration and joint programming at various levels
  • strengthening health systems and capacity for equitable service delivery, to address the needs of poorer ommunities
    that are most at risk of these diseases

Hopefully joint planning will receive greater emphasis today and in the future from the major partners who support efforts to fund and control both diseases including the Global Fund, Unicef, WHO, The Clinton Foundation and the US Government (PEPFAR and PMI).

PS – if you haven’t signed the HIV-Malaria petition yet, today would be a good day to do so - to sign the petition click:

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