Posts or Comments 15 June 2024

Monthly Archive for "January 2009"

Advocacy &Funding Bill Brieger | 30 Jan 2009

Economic downturn – is anyone bailing out the people who suffer from malaria?

Jeffrey Sachs, director of the Earth Institute at Columbia University and special adviser to the U.N. Secretary General, was reported by the Seattle Times as expressing concern that, “While U.S. bailout funds will help pay $18 billion in holiday bonuses for Wall Street executives, the U.S. has broken its promise to fund a global health program that saves millions of lives.” He rightly believes that such monies would be a better investment in addressing the $5 billion funding gap faced by the Global Fund.

Peter Chernin, president of News Corp. and chairman of Malaria No More added his voice in the Seattle Times report: “Malaria control is an example of a good return on investment, Chernin said.Programs are showing real results such as a 66 percent drop in malaria-related deaths in Rwanda in one year following increased use of bednets to prevent bites and treatment with effective medicine.”

According to the Seattle Times, “Chernin will join with Exxon Mobil and Standard Charter Bank to launch a campaign to raise $100 million from private companies, primarily for malaria programs funded through the Global Fund. The campaign will also ask companies to provide technical and business assistance, such as logistics for bed net delivery and marketing efforts to increase the use of bed nets.” These corporate interventions are crucial but do not absolve rich countries of the need to support the Global Fund and similar efforts.

An EU Parliamentary monitor observes that, “The decision (to cut Global Fund support), announced on Thursday at the World Economic Forum in Davos, was criticised by Van Lancker, a member of parliament.” The Parliamentarian complained that, “… potentially lifesaving treatment for people suffering from these and other diseases is now being jeopardised by this cut in funding.  Basically, donor governments and other bodies are not living up to the commitment they set back in 2001 when the (Global) fund was launched.”

These are surely frustrating times compared to the Davos of 2005 where celebrities, NGOs and industry leaders made a pledge to fight malaria.  Then as now there was recognition of the economic benefits of investment in malaria control. All partners – government and private – need to reaffirm their commitment to Roll Back Malaria and Millennium Development Goals and make that investment a reality.

Agriculture &Coordination &Mosquitoes Bill Brieger | 30 Jan 2009

Creating malaria … and drug shortages

Malaria control rests heavily on support from or activities of other development sectors besides health.  Power supply and agriculture provide two current examples.

Yewhalaw and colleagues explore the ramifications of dam construction for electricity supply in Ethiopia and see how human activity can increase mosquito breeding and the spread of malaria. Their work concludes –

This study indicates that children living in close proximity to a man-made reservoir in Ethiopia are at higher risk of malaria compared to those living farther away. It is recommended that sound prevention and control programme be designed and implemented around the reservoir to reduce the prevalence of malaria. In this respect, in localities near large dams, health impact assessment through periodic survey of potential vectors and periodic medical screening is warranted. Moreover, strategies to mitigate predicted negative health outcomes should be integral parts in the preparation, construction and operational phases of future water resource development and management projects.

At the same time Médecins Sans Frontières (MSF) has issued a warning about how agricultural market dynamics may have negative bearing on artemisinin supplies in the very near future. MSF explain that –

Current best estimates, based on available stocks and current planting efforts, demonstrate that there will be a shortfall of about 40 tons of artesiminin starting material in 2010 to produce the expected 240 million treatments needed. Taking into account that it takes about 14 months from the planting of Artemisia annua to the availability of the finished product, the availability in 2010 depends on what is being planted by farmers in the next weeks and months. We believe that market forces will not resolve the short-term artemisinin supply problem. Because it is extracted from plants, the supply of artemisinin is impacted by the highly volatile market of food crops which affect farmers’ decisions of whether or not to plant Artemisia annua.

These are two examples of how human actions exacerbate the scourge of malaria.  Such human influences are common throughout the history of malaria control. Intersectoral planning and surveillance is needed since malaria is not just a health affair.

Community Bill Brieger | 29 Jan 2009

Sustaining Intervention with the Right Kind of Health Education

District health officials in Ghana know that the life saving benefits of malaria interventions cannot be sustained without the community. GNA reports that, “Sunyani Municipal Health Directorate has concluded its 2008 review meeting with a call on mothers to continue to use insecticide treated mosquito bed nets for their children.”

Reported malaria deaths in the district have droped by around 4% in both 2007 and 2008. “The statement attributed the achievement to the intensification of health education on malaria (emphasis added), distribution of insecticide treated bed nets to children and improvement in case management of the disease.’

Health education, if properly done, is not just about posters, radio spots and messages, though these have their place. The right kind of health education involves people in understanding health issues in the context of their own culture and enables them to make decisions and take actions that will keep them healthy.  Health education is a discovery process – it is voluntary. Simplifying things to behavior change leaves the door open to coercive methods, benign (and often ineffective) information provision or active engagement – we need to be careful not just with terminology, but also with intentions.

The best of health education is an enabling process. The community directed interventions (CDI) approach, spearheaded by the African Program for Onchocerciasis Control and lately applied successfully to malaria interventions, engages the community in providing their own malaria control services with supportive supervision from the health system.  Other models exist such as community coalitions used by the COMPASS Project in Nigeria. Readers are encouraged to share their own experiences.

The key point is that unless the community is actually engaged, people will not obtain the correct malaria medicines and take the full course. They may get free nets, but may not use them regularly and correctly. It is ultimately the community that decides if malaria interventions will be effective. CDI involves communities all along the road, and even beyond the end of the road, in managing their own health programs. We need more community efforts to ensure that malaria elimination is in the hands of the community people who are affected and who ultimately make the difference.

Procurement Supply Management &Treatment Bill Brieger | 27 Jan 2009

Can children actually get their malaria drugs?

The Wall Street Journal quotes Novartis Chief Executive Daniel L. Vasella as saying, “In the end the only drug that matters is the drug that is swallowed.” The article goes on to explain how Novartis has developed a form of Coartem that is “Dispersible, that is small, cherry-flavored and dissolves easily,” as a way to ensure that the dispensed medicine is actually swallowed. The article also addresses other flavors that may be tried.

Much progress has been made in packaging malaria drugs for different age groups, especially children, when before there were only standard adult doses than had to be divided – a challenging task for many parents. The alternatives for children were more expensive syrups that were not always stable in tropical climates.

The article also addresses other challenges to ensuring children get their drugs. “But efficient channels to distribute the products are rare, giving rise to what health workers call ‘pile-up’ of drugs trying to reach villages and health clinics.” Efficient distribution is essential since artemisinin based medications have a relatively short shelf life and can expire within 18 months of arriving in a country.

Another challenge is cost. Medicines bought through Global Fund Grants are generally made available free for children in public or NGO clinics. Pilot programs are underway to see how subsidized price antimalarials can be made available through the private sector which may actually account for 50% or more of actual malaria treatments provided.

Three challenges that are not mentioned in the article include –

  • For one, when drugs are made available for free or at reduced cost only for children, there will be leakage into wider use as health workers or medicine shop keepers will provide multiple packets of the child drugs to satisfy their adult clients/customers.
  • A second unmentioned challenge is the tendency to overprescribe malaria drugs, especially among adults.  The answer to this is case management that includes diagnosis using a laboratory, but more likely rapid diagnostic tests, which can be used at the primary care level
  • Finally there is the issue of compliance.  Artemisinin-based combination therapy generally is taken twice a day for three days. If medicine providers do not counsel clients on the need for full compliance children may swallow only a few doses and not only fail to be cured but also contribute to drug resistance.

Malaria case management is a complicated process that begins with the drug manufacturer and ends in the home. All partners along the way must be vigilent if children’s lives are to be saved.

Advocacy &Mortality Bill Brieger | 20 Jan 2009

Silent Deaths – Raise a Voice

Nigeria Health Watch raises a point that could apply equally to malaria in children and pregnant women: “Maybe because they do not die in aircraft crashes, in gruesome fires following oil spills or in similar tragic circumstances no voice is raised in anguish about the Nigerian children that die from vaccine preventable diseases everyday.” They note that money is not the issue, because in the case of immunization, as funding increased in the 1990s the coverage rates decreased.

Nigeria Health Watch links us to the NIGERIA PARTNERSHIP FOR HEALTH 2008 November Conference in London to learn about why the health system has not stopped the deaths from preventable childhood diseases. Prof. Adetokunbo Lucas traced the history of the Nigerian Health Services and explained how it was initially established to protect colonial personnel, and one the side some locals might have been helped. Does that mentality persist – do only the elite get proper care? Prof. Lucas suggests several things that went wrong with the health system post-independence –

  • PHC concept misunderstood: Primary care alone, Cheap, poor services
  • Ignoring role of communities
  • Federal, State Local government roles poorly defined
  • Cost-effective interventions overlooked
  • Failure of implementation

Another presentation by Fola Laoye of Hygeia (a community health insurance project) observed that malaria is the most common clinical diagnosis in Nigerian clinics. Hygeia believes that it is Necessary to seek alternative sources of financing and access to health care, shifting to demand-based and output driven schemes.” Such alternative health system models are important, but can they be taken to scale?

Finally Dr Abdulsalami Nasidi showed that malaria accounts for 24% of under-five child mortality in Nigeria. Unfortunately he did not think that the Nigerian health system had made appreciable progress since the return to democracy ten years ago and casts doubt on achieving the Millenium Development Goals. Dr Nasidi concludes as follows: “Nigeria continues to face several challenges in the efforts to deliver primary health care and child survival programmes includng routine immunization and polio eradication.” His reasons for this include –

  1. Inadequate level of financing
  2. Weak management and institutional structure
  3. Lack of integration of various components of health well being
  4. Poor coordination of various Stakeholders
  5. Low level access and utilization of health facilities
  6. Poor resource allocation and management
  7. Low level of community efforts
  8. Inadequate monitoring and evaluation

From the foregoing we have the diagnosis and some prescriptions for Nigeria’s health system. What we need is the political will to make the health system work to deliver malaria and other life saving and health promoting interventions.

Indoor Residual Spraying Bill Brieger | 19 Jan 2009

Where is IRS most feasible?

In Nigeria’s Rivers State the State’s Malaria Control Coordinator reports on “efforts to roll back malaria in Rivers State, (in which) the state government says it would carry out indoor residual spraying (IRS) to terminate mosquitoes, the causative agent as from this quarter.”

The Coordinator has set up a timeline: “According to her, plans were already underway to purchase and distribute chemicals that would be used for the house-to-house spraying. She also said that if done every six months in the next three years, Rivers State would be free from malaria.”

WHO explains that, “The application of IRS consistently over time in large areas has altered the vector distribution and subsequently the epidemiological pattern of malaria in Botswana, Namibia, South Africa, Swaziland and Zimbabwe.” These are countries with large areas of unstable or epidemic malaria where annual spraying is effective.  Rivers State, Nigeria, as its Malaria Coordinator notes, requires twice a year spraying since it is an area of stable, intense and year-round transmission.

When the US President’s Malaria Inititive planned IRS in Ghana it chose districts in the Northern part of the country where malaria transmission is more seasonal and IRS can be cost-effective when used only once a year. For most of the country PMI is planning to distribute more than a million long lasting insecticide-treated nets as the appropriate strategy.

The Rivers State effort, while recognizing the need to adapt IRS timing to its ecological/epidemiological setting will still face huge challenges including –

  • dispersed, nearly inaccessible riverine communities
  • coordination among neighboring states where mosquito control efforts may not be as strong
  • ongoing civil disorder wherein “Militants in the Niger Delta attack pipelines and other oil facilities and kidnap foreign oil workers.”

Apparently the State is also relying on the bednet option, and “government had distributed four million insecticide treated bednets during the last immunisation campaign in the state. But this spraying option would ensure that even those who fail to clean their areas get the needed cover.” Nets can be distributed and monitored through a variety of community channels and last for 5 years if used properly.  This might be a safer and more viable vector control option for such a high transmission areas.

Drug Quality Bill Brieger | 16 Jan 2009

Tanzania: a history of counterfeit drugs

Fake anti-malarial drugs have long been a problem and are of even more concern now that the prices of first-line drugs are so much higher than the standard ones of 10 years ago.  Tanzania is one of the countries trying to confront this problem.

Today IRIN News quotes the president of Tanzania’s Medical Association as saying, “People are interested in getting a profit, but this is a human rights issue. The consequences of this business are really immense. Take, for example, a person with severe malaria: if he or she cannot access the genuine drug, then it means they may die.”

IRIN found that, “fake drugs will generate US$75 billion in revenues by 2010, nearly double that of 2005. Global counterfeit syndicates use evolving consumer technologies that make it ever easier to imitate legitimate drugs.” In addition “The CTI (Confederation of Tanzania Industries) estimates between 15 and 20 percent of all merchandise circulating in the country is counterfeit, earning Tanzania a reputation as a dumping ground for imitation goods, including fake drugs. Officials say suppliers from China, India, Europe and the USA have used the country as a gateway into Africa.”

The challenge arises because, “It is difficult to punish the vendors of fake drugs in Tanzania, because fakes are so hard to identify. In Dar es Salaam, one pharmacist pointed to receipts showing where he sourced the medicines in his shop, and insisted he only purchased drugs from wholesalers that worked with the Tanzania Pharmacy Board,” according to IRIN.

IPP Media traces that this has been a long standing problem –

  • In August 1999, fake Metakelfin labeled as a genuine product from the original manufacturer, Pharmacia and Upjohn, was found in circulation in some pharmacies in the country
  • Laboratory analysis confirmed that the counterfeit Metakelfin actually contained paracetamol and the public was
    alerted. In May 2000, counterfeit Ampicillin capsules (250mg) were found circulating in some retail pharmacies
  • Laboratory analysis confirmed the capsules contained potato starch. In June 2001, expired Chloroquine Injection (from an unregistered Indian company) was relabeled as Quinine Dihydrochloride Injection 600mg/2ml from a company in Cyprus
  • In January 2005, fake Gentrisone Cream (a product of Shin Poong, South Korea) was reported. In this case, the active ingredient was replaced with hand and body lotion
  • (November 2007) Jacob Hassan was diagnosed with malaria. The medic prescribed three tablets of Metakelfin to be taken at once and three others after a week – as the medical facility had ran out of the tablets then, the patient decided to purchase the dose from a pharmacy in the vicinity – little did he know that the purported medicine he had bought was actually paracetamol

The in October 2008 Interpol reported that, “In Tanzania 191 locations, including pharmacies, warehouses and illicit markets, were inspected resulting in the seizure of some 100 types of products. Among the confiscated drugs were anti-malarial, cardiac, anti-fungal, multivitamin, hormonal and skin medicines. Police closed four pharmacies and 18 drug shops (known as Duka la Dawa Baridis) found to be in breach of the law. A total of 44 police cases were opened.”

With special effort to involve the private sector in achieving malaria treatment coverage targets, there is need also to involve then – industry, private medical clinics, medicine shops and all – in the process of ensuring drug quality, safety and surveillance.

Corruption Bill Brieger | 12 Jan 2009

Speaking out on Missing Global Funds

The Daily Nation in Nairobi calls the inability to trace missing money from the country’s Global Fund Grants the “Shame of reaping from the sick and dying.” Although Government had set up a task force three months ago, the current Public Health Minister, “pompously announced that no funds were misappropriated after all, despite her Medical Services counterpart Anyang’ Nyong’o’s and her own earlier admission that the money had been stolen. Perhaps in their preposterous belief that Kenyans are such a forgetful lot, the two ministers that owe Kenyans an explanation over the Global Fund’s saga have resumed business as usual.”

The article provides details on other money that has disappeared from government coffers:

  • Sh19.3 million from the joint Kenya Medical Research Institute (KEMRI)/US Centres for Disease Control bank account in Kisumu
  • Last month, Kemri’s entire pension fund amounting to Sh 537 million went missing

The ramifications of the Global Fund problem are starkly highlighted by the Nation – literally children dying from malaria and AIDS patients dying from tuberculosis and lack of food.

Not only was Kenya denied Round 8 funding from the Global Fund, but application for Round 9 funds was put on hold until the task force resolved the problems.  Apparently officials believe that the task force is no longer needed since the Minister “insisted the Government would apply (for Round 9), after all.”

The Global Fund and its contributors are persistent and will not be as ‘forgetful’ as Kenyan citizens are thought to be.  In fact advocacy from Kenyan citizens to save their own lives will probably go a long way to solve the problem, if they are not muzzled by the new media law or caught up in political uncertainties persisting after the last botched elections. Government’s openness and accountability, it seems, are actually preconditions for the health of its citizens.

Health Systems Bill Brieger | 05 Jan 2009

Is there ‘enough’ government to eliminate malaria?

Fareed Zakaria in today’s Washington Post quoted, “Samuel P. Huntington, the greatest political scientist of the past half-century, who died on Christmas Eve,” as saying, “‘the most important political distinction among countries concerns not their form of government but their degree of government.'” The implication, therefore is that …

So many of the world’s problems — from terrorists in Waziristan to the AIDS epidemic to piracy in Somalia — are made worse by governments that are unable to exercise real authority over their lands or people.

Money does not solve the problem. Sue Lloyd-Roberts of the BBC reported that, “Oil has provided hundreds of billions of pounds in revenue for the government since it was discovered in the Nigerian Delta 50 years ago and yet the country boasts some of the poorest communities in West Africa. Elections are rigged by money and guns and corruption pervades society from the top down.” People she interviewed explained that it is not just the billions of dollars embezzeled by government leaders over time but that, “The idea that there is a huge pot of black gold out there for the taking has distorted everyone’s values.”

‘Smaller’ pots of money may have a similar effect. When it became likely that Kenya might not secure Round 8 Global Fund support, “A Kenyan official (said) the government will investigate allegations of corruption in programs funded by a U.N.-backed agency to treat patients with AIDS, malaria or tuberculosis.” The Medical Services Minister said that, “The Geneva-based Global Fund to fight AIDS, Tuberculosis and Malaria said it suspects that some lists of patients treated in earlier programs were fictitious.”

Larger trends may be at work. The Washington Post looked at the world’s demographic future and explained that, “Sub-Saharan Africa — which is afflicted with the world’s highest fertility rates and ravaged by AIDS — will still be racked by large youth bulges … In recent years, most of these countries have demonstrated the correlation between extreme youth and violence. If that correlation endures, chronic unrest and state failure could persist through the 2020s — or even longer if fertility fails to drop.”

Failing states cannot eliminate malaria.  Cholera and now likely malaria are killing people in Zimbabwe. Refugees in the continuing crisis in eastern Democratic Republic of Congo are exposed malaria and other diseases, and in the Niger Delta of Nigeria poverty, unemployment and instability amidst great oil wealth threaten health and social infrastructure.

Greater attention to poverty alleviation and youth employment will be crucial for stabilizing and strengthening governments so that they can address poverty-associated endemic diseases like malaria.

Community &Health Systems Bill Brieger | 04 Jan 2009

Hospitals, hospitals, hospitals – but can they conquer malaria?

Nigeria Health Watch calls our attention to numerous news headlines highlighting hospital construction …

… and makes the observation that, “While all these are important to some extent … no building has ever saved a life. However … it is convenient for politicians to brag about these.”

Although hospital emergency/casualty wards are often used for treatment of severe malaria, it is at the primary health care (PHC) level where the main attacks against malaria take place.  What role do buildings play in the PHC process?

When PHC was getting off the ground as official health policy in Nigeria in the late 1970s, the effort had three main components – infrastructure, personnel and community.  Infrastructure for the local government (district) level consisted of a web of facilities ranging from comprehensive health centers and health centers to health clinics and health posts. Personnel needs for PHC were to be met by new cadres of staff whose titles, though varying over time, all contained the word ‘community’ – community health officers, community health assistants, community health supervisors, community health extension workers.

These new cadres of staff, while linked to or based in the facilities, were expected to work in and with community members. The formation of village, district, ward and other levels of health and development committees that included both a representative selection of community members and leaders as well as health workers and staff from other sectors, formalized, in theory, the link between the front line staff and the community.

Many new PHC health facilities were built over the past 30 years, especially in the more rural and underserved sections of Nigeria’s 774 local governments. These new buildings alone did not guarantee services.  For example, several new PHC structures in the more remote rural areas of Oyo State mainly provided shelter for goats and sheep for their first 10-15 years.

Eventually as more trainees graduated from the community health worker courses, there were attempts to staff the facilities, as few professional nurses would not work there.  Ultimately local governments found that these community health workers were in fact a cheaper substitutes for nurses, pharmacists and other professionals, and thus, the community side of their work was often not fully realized.

With the advent of major malaria financing in Nigeria from the Global Fund, DfID, USAID, the World Bank and some NGOs, it may be possible to see the PHC system spring to life and ensure that the combination of facilities, personnel and community actually deliver malaria treatment and prevention services at the grassroots as hoped for 30 years ago.

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