Tropical Health Matters

World Malaria Day had us counting down to a future when malaria would be eliminated.  In fact in some places we have not fully begun to count up to adequate coverage of malaria interventions, so the count down in cases can begin.  The US Ambassador to the United Nations, Susan Rice, expressed this clearly:

We must do more to target programs within a handful of particularly hard-hit countries, including Nigeria, the Democratic Republic of the Congo, Uganda, Ethiopia and Tanzania, which together account for roughly half the global deaths from malaria. We must do more to deliver nets and drugs to civilians battered by conflict or housed in refugee camps. And we must do more to beat back the specter of drug-resistant strains of malaria and ultimately move toward a second-generation vaccine.

There is certainly not a lack of effort.  Numerous large contributions, for example, to the global fight against malaria include –

• $1.2 billion over five years from the US President’s Malaria Initiative
• $1.9 billion disbursed for malaria to date by the Global Fund
• $1.6 billion disbursed in Phase 1 and committed for Phase 2 of the World Bank Booster Program
• $26 million disbursed by UNITAID for ACT scale up and emergency support
• $75 million pledged for nets, medicines and research by DfID (though this does not reflect total contributions which are not posted in a single source)

Funding is not enough. Manila Bulletin reflects on the history of Roll Bank Malaria. “Aware of the challenges, African leaders assembled at an African summit in Nigeria in 2000 and resolved to initiate appropriate and sustainable actions to strengthen the health systems so that populations at risk will have access to preventive measures and prompt treatment, and declared April 25 as Africa Malaria Day.”These sustainable actions and strengthened health systems are yet to be attained, especially in the highest burden places.  Focused progress in Rwanda, Zanzibar and Ethiopia give us a glimpse of what malaria control might look like. We now need to build the systems that will use the disbursements and pledges to sustain our efforts to count malaria out.

In order to count malaria out we need to learn as much as possible about the design and management of malaria control programs, especially setting up a functional monitoring and evaluation (M&E) system from which health workers, program managers and policy makers can learn and then plan improvements.

USAID’s Global Health eLearning Center is a great free online resource for agency staff and health team members to learn about maternal and child health issues, including malaria. Registration is free, and the format does not require much bandwidth, so should be more accessible to learners in developing countries.  As of World Malaria Day – 25 April 2009 – the 29th course will be added to the curriculum, that is a six-module learning activity on malaria in pregnancy (MIP) developed by Jhpiego.  This compliments the existing general malaria course available on the site.

Global Health eLearning was originally designed to help update the knowledge of USAID health, population and nutrition staff. The website now has over 30,000 registered learners, and 80% of those are not directly affiliated with USAID. This means that the courses are filling a continuing education need for a wide variety of people.  Eventually there may be up to 50 courses, which may be organized into focused learning packages.

Another useful free eLearning site is he Open Course Ware (OCW) program of the Johns Hopkins Bloomberg School of Public Health. Lecture materials from approximately 80 of the School’s courses is available consisting of slides, handouts and other resources.  The course on Malariology …

Presents issues related to malaria as a major public health problem. Emphasizes the biology of malaria parasites and factors affecting their transmission to humans by anopheline vectors. Topics include host-parasite-vector relationships; diagnostics; parasite biology; vector biology; epidemiology; host immunity; risk factors associated with infection, human behavior, chemotherapy, and drug resistances; anti-vector measures; vaccine development; and management and policy issues.

Jhpiego has a Malaria in Pregnancy Resource Package (MRP) online.  The MRP contains all the materials needed to conduct training on malaria in pregnancy including a facilitator’s guide, sample slides, a brief tutorial, job aids and other reference documents. The training materials emphasize the M&E component of MIP service delivery.

Another key online learning resource is the Roll Back Malaria Toolbox. One can download a number of reference materials for planning and implementing M&E components to all aspects of malaria control services.

There is no excuse not to keep up-to-date on malaria control with all the free eLearning materials available online. Please share with us additional sources and links that foster eLearning on malaria.

When the Global Fund announced its Rolling Continuation Channel method for continuing the funding of existing grants a couple years ago there was hope that finally the the grant making process might become more simplified, offering a straightforward way to address the longer term disease control programming needs to countries. Again, it was hoped that the RCC might make it possible for countries to avoid the annual, time consuming and laborious circus of producing proposals for the next funding round.

These proposal development processes can distract national control programs from their duties for 3-4 months, and if they hire consultants to help so they can keep doing their normal jobs, they may be handicapped in the implementation process by not always understanding what the consultants produced.
In reality the RCC has become a super proposal development mechanism that has all the distracting qualities of the ‘normal’ procedures plus the added tension of knowing that if one fails to get an RCC grant, one must jump quickly back into the fray of applying for the regular funding cycles in order not to experience gaps in service provision. The statistics highlighted in the Global Fund Observer (GFO) prove the frustrations.

First it must be noted that, “The Rolling Continuation Channel is an invitation-only proposal process, for qualified Applicants with strong performing, existing Global Fund grants.” So here is what GFO reported about the first 5 waves of RCC funding –

• 139 expiring grants were eligible for consideration
• 33% or 46 grants (i.e. CCMs) were invited to submit a proposal
• 29% or 41 actually submitted a proposal
• 22% or 30 managed to make it through a screening by the TRP more intense than given to regular grants
• 11 of the 30 lucky ones were malaria grants, 12 were HIV and 7 were TB

Of course the ‘blame’ cannot really fall on the TRP in totality.  A major weakness of GFATM grants from the beginning has been high levels of technical assistance during the proposal writing period, followed by a dearth of guidance after the grants are awarded.  Subsequently grant performance – on which RCC invitations are based – falters.

When the RCC was first announced there had been a glimmer of hope that more attention would be paid to thinking how to support national disease control policies and strategies rather than judging specific proposals.  The TRP did note that a positive aspect of the most recent wave of proposals were in alignment with their national policies: “Proposed interventions fit within the country’s overall health policy, development framework and are consistent with international guidelines and best practice.” But this was not enough to save most of the invitees.  As mentioned later, RCC was obviously not inended to be the mechanism for building on national strategies.
The weaknesses identified by the TRP centered primarily around the grantees not providing enough DETAIL. Whether intended or not, the RCC has become just another grant proposal and application process – not a mechanism to ensure the continuation of disease control services to those in need.

At the last GFATM Board meeting (18th) the Board referred back to discussions at the 15th Board meeting regarding National Strategy Applications (NSAs).  “To learn lessons with regard to other aspects of the NSA procedure, the Board authorizes the Secretariat to bring it into operation through a phased roll-out, which shall begin with a first wave of NSAs (‘the First Learning Wave’) in a limited number of countries. The First Learning Wave shall be aimed at drawing policy and operational lessons to inform a broader roll-out of the NSA procedure.”

Maybe NSAs will become the wave of the future, and hopefully not another disappointment for those who want to eliminate malaria, HIV and TB.

Malaria in pregnancy (MIP) has often been called the neglected arm of malaria control efforts.  The challenge may not be unconnected to the fact that MIP control activities are usually organized through antenatal care, which is based in a different section of most Ministries of Health than National Malaria Control Programs.  The US President’s Malaria Initiative (PMI) has included MIP control in all its 15 country programs, but even with added attention, MIP control targets have been difficult to meet.

Jhpiego’s Malaria Core Team recently reviewed all the FY 2009 Malaria Operations Plans (MOPs) for PMI countries and found that reports of MIP indicator coverage were still low. Data were not available for Liberia, and Zanzibar has been analyzed separately from the Tanzanian Mainland as seen in the attached chart. We recognize that the 2009 MOPs would may have drawn on data that were not always up-to-date.
Coverage with a minimum of two doses of intermittent preventive treatment in pregnancy (IPTp2) ranges from a low of 3% in Angola to 60% in Zambia. While the IPTp coverage for Zambia did reach RBM’s 2005 target, it is far from PMI’s 2010 target of 85%. Likewise coverage for pregnant women sleeping under an ITN ranged from 7% in Mozambique to 51% in Zanzibar.

Some key organizational bottlenecks make achievement of these targets difficult.  Campaigns that link ITN or LLIN distribution to childhood immunization can fall short on three counts –

1. pregnant women may not be reached during these efforts
2. even when women receive nets, they do not always sleep under them, and
3. provision is not usually made to stock nets for women who become pregnant after the campaign

We reported recently from Ghana that even though clinics had good stocks of sulfadoxine-pyrmethamine (SP) to use in IPTp, IPTp coverage was low. In some clinics, not even half of those attending ANC received their first dose of IPTp.  Lack of coordination among the national health insurance scheme, the ANC clinic and the pharmacy may have been at play.  In Tanzania we found that SP stock-outs were responsible for low levels of coverage.  So even if we have the commodities, we cannot always guarantee they will reach pregnant women.

Child survival begins in pregnancy.  The pregnant woman with malaria can herself die from malaria and the anemia it causes. Even when she herself survives malaria infection, there may be resulting miscarriage or still birth.  Babies born to mothers who had malaria in pregnancy are more likely to be of low birth weight, and therefore at greater risk of dying in the neonatal period and infancy.

Malaria in pregnancy control must receive greater attention if we really want to count malaria out.

In a recent New York Times column Nicholas Kristof addressed both the needs for and difficulty in promoting family planning programs.  Even though the U.S. is more supportive of family planning services internationally, the goal is difficult.

Kristof gives the example of Haiti where there may be high unmet need for contraceptives, but low utilization rate. The experience of one Haitian woman exemplified the problem on a personal basis.

She tried injectables, but she says they caused excess bleeding that frightened her. The clinic had little counseling to explain and reassure her, so she stopped after nine months. A sexually transmitted infection at the time meant that she couldn’t use an IUD just then, and a doctor told her that the pill would be inappropriate because she has vascular problems. Reluctant to return to a clinic that seemed scornful of poor women, she drifted along with nothing.

This woman ultimately had 10 children by last count.  What are the implications of her story for millions of other women who get pregnant in malaria endemic areas?

Malaria in pregnancy is particularly dangerous for a woman, an unborn child and a newborn.  Malaria leads to anemia which in turn increases chances of maternal mortality.  When pregnant women have malaria, there is growth retardation in the fetus as well as miscarriage and stillbirth. Children are often born with low birth weight and have a poorer chance of survival in the first month and year or life.

Family planning clearly enables women to spread out and reduce the risks of malaria exposure during pregnancy, and can thus save lives. This is why one reader of Krisof’s column commented that, “You have to look at the small print of the United Nations’ Millennium Development Goal 5, ‘Improve Maternal Health,’ under Target 2, to find this language: ‘An unmet need for family planning undermines achievement of several other goals,’” which include reducing the burden of malaria in pregnancy.

Qatar’s daily, The Peninsula, reports that, “The Minister of Public Health H E Dr Sheikha Ghalia bint Mohammed Al Thani yesterday received a delegation from the Global Fund for Fighting Malaria, chaired by Princess Astrid.” The Minister expressed appreciation of the efforts of the Global Fund in fighting malaria. The delegation in turn urged Qatar to become a contributor to the Global Fund.

To date just over $13 billion has actually been contributed to the Global Fund, although over $19 billion has been pledged. 95% of this comes from countries, while the remaining comes from private or other sources (most notably the Gates Foundation at $450 million).  Among country donors, few of those sometimes termed middle income countries like Qatar have contributed.  For example, Saudi Arabia has actually given $19 million so far, South Africa has contributed $8 million, China has provided $12 million and India has given $3 million.

Delegates representing 28 donor countries and foundations just concluded a meeting in Spain to assess the Global Fund’s resource needs. The discussed “The question of how to fill an estimated funding gap of at least US$ 4 billion urgently needs to be addressed as the Global Fund’s Board will be approving a ninth round of proposals from recipient countries in November this year.”

The Global Fund’s Executive Director called on the G20 countries to step up efforts to support the Fund. Delegates “also called on the Global Fund to step up efforts to seek new government donors and attract more private sector contributions. Delegates from South Korea attended for the first time.” The visit to Qatar is in line with this stepped-up approach.

The G20 Summit did offer some hope along these lines toward the end of their lengthy statement:

We reaffirm our historic commitment to meeting the Millennium Development Goals and to achieving our respective ODA [Overseas Development Agencies] pledges, including commitments on Aid for Trade, debt relief, and the Gleneagles commitments, especially to sub-Saharan Africa.

We fully expect that the global economy will benefit when large portions of the world’s population no longer suffer loss of life and productivity from diseases like malaria.  It is in everyone’s interest to contribute.

 Jhpiego, an affiliate of the Johns Hopkins University, is planning several activities to recognize April as the month when World Malaria Day (WMD) is observed.  Jhpiego promotes the health of women, their children and their families, and will be featuring spotlights on its country efforts to protect women and children from malaria.

These spotlights will appear on a regular basis during April 2009 and will explain how Jhpiego, in keeping with the theme of this year’s WMD, is counting the efforts needed to count malaria out.  The spotlights will focus on keeping count of progress in the programs:

• Community delivery of malaria in pregnancy (MIP) control services in Nigeria
• Training the next generation of Ghanaian midwives in malaria in pregnancy control
• Scaling up in-service training on malaria to over one-third of the health facilities in Tanzania
• Improving the quality of monitoring and evaluation of MIP control in Angola leading to increased delivery of services
• Enhancing the malaria control skills of village health workers in Rwanda
• Building a strong malaria control team in Mali

In addition, Jhpiego will be hosting two noon-time seminars at its headquarters at Browns Wharf in Fells Point, Baltimore. One seminar will introduce the new e-Learning course on malaria in pregnancy that Jhpiego is developing for USAID (April 16). The second will explain the need and process of improving monitoring and evaluation of malaria control projects (April 24).