Posts or Comments 19 June 2024

Monthly Archive for "May 2009"

Peace/Conflict Bill Brieger | 30 May 2009

Is there less malaria in Darfur today because of the genocide?

Back in 2004 the independent Sudan Tribune reported that, “Malaria has broken out among Sudanese in Darfur who lack clean water and latrines in squalid refugee camps, aid agencies said.” Things have gotten unimaginably worse since then.

In Darfur children don’t live long enough to die from malaria.  Bob Herbert in the New York Times quotes a woman who was attacked by soldiers in Darfur –

They said to us: ‘If you have a baby on your back, let us see it.’ The soldiers looked at the babies and if it was a boy, they killed it on the spot [by shooting him]. If it was a girl, they dropped or threw it on the ground. If the girl died, she died. If she didn’t die, the mothers were allowed to pick it up and keep it.

Physicians for Human Rights is publishing a report of women who escaped Darfur only to suffer further in camps. The women “spoke candidly and openly about their lives in Darfur, the horrific attacks that drove them from their villages, their harrowing flight to Chad, and the struggles of their daily lives in the camp.”

The Editors of The New Republic (TNR) remind us of campaign speeches on the horrors of Darfur, but explain that, “Obama is now president, and Darfur is still a mess. What is taking place there today is not simple to describe. People are no longer being killed at the alarming rate of 2003 and 2004. Yet the region continues to attract the world’s attention because two million people remain housed in camps where they live on the brink of disease and starvation, with little hope of returning home in the near future.”

TNR also notes that past genocides have stopped when the perpetrators were driven from power. The editors declare that if building rapport with the regime in Sudan … “is truly going to be the administration’s strategy, then it is deeply wrongheaded.” They quote the Genocide Intervention Network who wrote, “[T]he Sudanese government responds much more directly to pressures than they do to incentives.”

Donors have side stepped the problem by pretending there are two Sudans.  The Global Fund recognizes a special CCM for the south: “The Sub-CCM in Southern Sudan was created in 15th May 2003 to represent the then SPLM/A controlled areas from the then Health Advisory Counsel for Southern Sudan (HAC). HAC acted as advisor to the then Health Secretary (SOH) and had elected members from different Health agencies operating in Southern Sudan.” USAID is providing food aid in Sudan, including Darfur, but also has a major Southern Sudan strategy.

Time has more than run out – where is the leadership needed to bring the Darfur horrors to an end?

Corruption &Funding &Performance Bill Brieger | 29 May 2009

Has Zambia joined the ‘club’?

Just last November IRIN/PlusNews published a list of countries who are “Falling foul of the Fund.” What distinguishes this ‘club’ of 10 countries on the list is poor performance that resulted in cancellation or suspension of their Global Fund grants.  For example, in Pakistan the, “Fund discontinued support for (its) malaria projects because of weak project implementation, slow procurement of health products, poor data quality, and slow spending of project funds.” Uganda was one of the worst case scenarios according to PlusNews:

In 2005, the Global Fund temporarily suspended all five of its grants after a review by PricewaterhouseCoopers of one of the grants revealed evidence of “serious mismanagement” by the Project Management Unit in the Ministry of Health. The grants were worth a total of $201 million over two years, of which $45.4 million had already been disbursed. The health minister and his two deputies lost their positions and are on trial with several other government officials for charges relating to the misuse of Global Fund money.

Now there are reports out of Lusaka, Zambia that the Ugandan ‘model’ may be repeated, but only to the tune of $2million. “The governments of the Netherlands and Sweden announced they had suspended aid after a whistleblower alerted Zambia’s Anti-Corruption Commission [ACC] to the embezzlement of over US$2 million from the health ministry by top government officials.”

In Zambia, like many malaria-endemic countries, “most of the national health budget is donor-funded.” The report highlights the suffering of people affected by the HIV, malaria and TB when the misbehavior of public officials threatens the funds that keep those suffering alive.

While this experience may feed into the recent debate on the value or danger of foreign aid, the reality is that the massive efforts to control major diseases requires support from the global community – support that recognizes our common humanity.  A positive example is Rwanda where the national health account shows that in 2006 donor support accountred for 53% of total health expenditure.  Rwanda has become the poster child for the benefits to malaria control and eventual elimination, but just a slight step to the dark side, as it were, could jeopardize all the gains in a minute.

Clearly if we want to eliminate malaria the solution is not to withdraw or withhold funds from endemic countries. The question is do we have accountable mechanisms for using the funds? Do we put all our funds in one basket, or do we spread them among public, private and civil society sectors?  Without viable answers to these questions, malaria will never be eliminated.

Epidemiology &Health Systems &Performance Bill Brieger | 29 May 2009

No man is an island – and neither are parasites and mosquitoes

The American Journal of Tropical Medicine and Hygiene is announcing as ‘good news’ the ‘remarkable malaria control progress and benefits on the island of Bioko in Equatorial Guinea over the last 4 years.’  Kleinschmidt and colleagues report –

  • spraying IRS every 6 months in typically > 80% of households
  • achieving 73% LLIN use (not just ownership) in households through house-to-house distribution with instruction and education
  • achieving significant reductions in parasite prevalence, anemia and fever
  • falling under five mortality from 152 per 1,000 births to 55 per 1,000

Steketee commends the strong public-private partnership that enabled this progress and recommends case containment and other strategies to solidify and sustain the gains toward elimination from the island.

Only one key component of the control strategy did not show progress – by 2008 coverage of pregnant women with two doses of intermittent preventive treatment (IPTp) was only 19%.  This component is not campaign based and requires strengthening the basic MCH services – so one wonders is the program to date has really strengthened the local health system to maintain the achievements. Then there is the Equatorial Guinea mainland to consider

Bioku Island is in the middle of the off shore oil fields, headquarters for the oil companies and an important tourist destination.  the benefits of controlling malaria in this powerful setting definitely have international economic ramifications for the local economy.

Apparently the poor people on the mainland are not being forgotten – in “2006, the partners secured Global Fund resources to expand the work to mainland Equitorial Guinea.”  The mainland is still a relatively small territory – and if Rwanda as a nation can make and achieve a commitment to control malaria, an oil rich nation like Equatorial Guinea should be up to the task of helping all its population.

eqg-indicators-200904.jpgThe most recent Global Fund Malaria Grant performance information (April 2009) shows the Equatorial Guinea project performing at the B2 level.  This is at the bottom rung of acceptable performance.  There is mixed achievement on indicators as seen in the chart – IPTp seems better than on Bioku, but not everyone is sleeping under distributed nets. ACT case management training has started but no data are available to show if people have been treated. According to the Global Fund, “The program has faced significant delays due to long procurement process and treatment protocol approval but is now on track as drugs have been delivered.”

The Global Fund project has two more years to go – hopefully all partners – public, private, NGO, etc. – will pull together and help the mainland just as they have been willing to protect their interersts on the island.

Treatment Bill Brieger | 26 May 2009

Are there enough antimalarial drugs?

An article in Nigeria’s Daily Trust on Sunday casts doubts about the availability of adequate treatment for malaria in the country with a headline that asks, “What Happened to Funds Sunk Into Anti-Malaria Projects?”  It is true that with Nigeria having the highest burden of malaria on the continent there may not yet be enough money, medicines, nets and other resources – the Minister for Health estimates that the country needs $1.3 billion – but that does not mean that current funds are being squandered as the headline implies.

In fact an irony may be that there are too many different types of drugs. Nigeria’s National Agency for Food Drug Administration and Control (NAFDAC) has registered the following Artemether-Lumafantrine ACTs:

  • Actimax
  • Actpro
  • Arcofan
  • Artemef
  • Artrin
  • Atmal
  • Coartem
  • Fanterm
  • Lonart
  • Lumether
  • Malagard
  • Ogamal

Nearly 100 Artesunate-Amodiaquine ACTs have been registered. Few of these ACTs are prequalified by WHO. Some monotherapy artesunate drugs, which WHO disapproves and whose NAFDAC registration won’t expire until 2012, are still for sale and available in shops.  There are at least 5 Artesunate-Mefloquine brands.  Artesunate-SP is registered in up to 10 brands.

malmeds-sm.jpgAside from the above, chloroquine is still common as is sulphadoxine-pyrimethamine, both of which exhibit resistance and are no longer recommended for first line treatment in Nigeria. There is of course quinine needed for treatment of malaria in pregnancy. Overall over 325 different brands of antimalarial drugs are registered.

While there may not be enough free or reduced price pre-qualified antimalarial drugs at the front line primary health care facilities, there is a plethora of questionable drugs on the market. One wonders how anyone could test, let along maintain pharmaco-vigilance, on all these medicines.

We hope Nigeria is successful in getting its Global Fund Round 8 malaria grant signed and has a positive experience in applying for the Affordable Medicines Facility for malaria to strengthen quality and supply of inexpensive drugs in the public and private sectors.  In the meantime, partners at national, state and local levels need to consider how the consumer – which includes local and state government medical stores – can make sense of all the antimalarial drugs out there.  Maybe one day NAFDAC and the National Malaria Control Program can truly work in partnership to ensure rational pharmaceutical practices.

Peace/Conflict Bill Brieger | 25 May 2009

Aid workers can’t reach IDPs, but mosquitoes can

dscn0190sm.JPGWar still rages in Nigeria’s oil rich Niger Delta states.  IRIN reports that, “Aid agencies are unable to access an area in the Niger Delta where more than 2,000 people are believed to be hiding in the bush after a military offensive against militants forced families to flee their homes.”  These southern riverine areas have some of the highest levels of malaria transmission in the country. Those hiding in the ‘bush’ may avoid the rebels and the Nigerian military, but they cannot avoid mosquitoes.

BBC shows that the conflict is escalating. “The Movement for the Emancipation of the Niger Delta (Mend) said it had attacked pipes for a Chevron facility in response to a military offensive.”

Even in the best of times few aid agencies reach these populations many of whose settlements are accessible only by boat. One effort was made by Médecins Sans Frontières a few years ago to bring the then new artemisinin-based combination therapy drugs to the remote villages of Bayelsa State. At the time (2002) “In Southern Ijaw, in Bayelsa, MSF resistance studies involving these front-line malaria treatments have shown 40% resistance to chloroquine and 45% resistance to SP,” but the state and federal governments were still three years away from making ACT the drug of choice.

Today three Nigeria Delta states with the greatest problems of violence are on the books of major donor programs. Rivers State is being supported by the World Bank Malaria Booster Program, and Bayelsa and Delta States are covered under the Round 4 malaria grant from the Global Fund.  Even in areas where there is not direct fighting the problem of kidnapping makes these states less than hospitable to people who hope to deliver malaria interventions.  According to the BBC, from “2006 January onwards – Militants in the Niger Delta attack pipelines and other oil facilities and kidnap foreign oil workers. The rebels demand more control over the region’s oil wealth.”

Recently the New York Times observed that, “The violence in past years has hampered the ability of companies like Shell to pump or export oil, and helped push up global oil prices. Nigeria’s oil production currently averages around 1.6 million barrels a day, up from a low of 1.2 million barrels a day in April. That’s still significantly lower than the country’s capacity, much of which remains shut down.”
Not even reduced oil production and spikes in world oil prices due to the violence in Nigeria seem enough to lead parties to find a solution that not only protects lives from human violence but also from the violence wrought by mosquitoes.

Corruption &Funding &Health Systems Bill Brieger | 25 May 2009

to aid or not to aid

While Cheney and Obama are debating approaches to national security in the US, the international community is still debating whether development aid should continue or not.  In the latest salvo, Jeffrey Sachs wonders at the fact that critics of aid themselves have benefited from such aid … “I certainly don’t begrudge any of them the help that they got. Far from it. I believe in this kind of help. And I’d find Moyo’s views cruel and mistaken even she did not get the scholarships that have been reported … I begrudge them trying to pull up the ladder for those still left behind.”

According to the Zambian EconomistDambisa (Moyo) is tired and frustrated by the aid apparatus that has not only come to “trap” poor and indebted African states but is, in her view, the root cause of poverty.”  It is unlikely though that the huge apparatus of international development aid is going to disappear at the wishes of doubters like Moyo.  But is aid doing what it is supposed to do without the unintended consequences critics note?

Moyo’s views do touch a chord.  A colleague from Africa wrote to me today, “I often think that countries like (mine) do not really deserve any aid in view of the magnitude of corruption among their leaders. I never read any good news about my country. It is one case (or another) of a leader carting billions of dollars away .”  We have certainly witnessed embezzlement of GFATM money, but should we throw up our hands and admit that aid is defeated?

In the case of malaria, progress seen in places like Rwanda, Zanzibar, and Ethiopia would not have been possible without GFATM, PMI and other aid programs.  One can still ask if such progress is sustainable.  Watching donor disease control efforts over the years – guinea worm, onchocerciasis – one feels some dis-ease about whether such programs, no matter how much they contribute to human development, are really wanted. What are national priorities – do governments tolerate big infusions of money for special projects simply because they are big?

Is this aid by fad, and can donor fatigue be prevented until the big diseases are eliminated? And does aid corrupt and large aid corrupt absolutely?  Does aid build systems or simply help with cash flow?  Where is there accountability – not just can recipients account to donors – but also can donors account to the people they are trying to serve?  Aid that does not enable a voice for people and communities is really nothing more than well intentioned cash flow.

It would be tempting during these economic hard times to let the aid naysayers win the day.  The challenge therefore is to build a system that not only uses aid in a way that helps people now but ultimately sets the stage for generating new local and appropriate resources that may one day replace that aid.

HIV &Malaria in Pregnancy Bill Brieger | 23 May 2009

PMTCT, malaria in pregnancy share common problem

dscn3784a.JPGPartners “too often fail to coordinate programs to help promote more integrated, comprehensive health care for women,” and governments are “often unable or unwilling to initiate or sustain health care programs and reforms that would improve women’s access to services.” according to a new report from the International Treatment Preparedness Coalition.

If we did not know the source of this information we could assume it applies equally well to controlling malaria in pregnancy as it does to preventing mother-to-child transmission of HIV.  Both services are supposed to be part of integrated focused antenatal care (ANC).  Neither appear as regularly as needed to save the lives of mothers and newborns. This is not because women in developing countries fail to attend ANC.

Nearly 95 percent of pregnant women (in Uganda) attend antenatal care (ANC) services at least once during their pregnancy. They do not necessarily have access to comprehensive prevention of vertical transmission services, however, because just 43 percent of all health facilities that provide ANC and delivery services have integrated prevention of vertical. transmission.

Omo-Aghoja and colleagues point out that, “Part of the reasons for the low uptake of measures for malaria prevention in pregnant women in many African countries is the lack of proper integration of the recommended interventions into antenatal care (ANC) offered in health institutions.”

In a recent New York Times article on maternal mortality Dr. Massawe, a Tanzanian clinician asks, ““Why don’t we have a global fund for maternal health, like the one for TB, malaria and AIDS?”  Until the question of why women, including pregnant women, are not offered comprehensive and integrated services is answered, inequity and death of mothers and children will continue to be an unacceptable reality.

Human Resources &Malaria in Pregnancy Bill Brieger | 21 May 2009

Malaria Training Trounced by Transfers

dscn1689-sm.JPGIn an effort to ensure the human capacity to deliver malaria services, partners are embarking on in-service and pre-service training throughout endemic countries.  Such training is not something that can be accomplished quickly. Most partners plan training in a phased approach that eventually covers all districts and facilities, but quality training cannot be rushed.

Jhpiego has a 35 year history of capacity building of the health workforce in maternal and reproductive health, including the issue of malaria in pregnancy. Jhpiego has been working in Akwa Ibom State, Nigeria for the past 2 years to test the concept of community-clinic collaboration in the delivery of malaria in pregnancy control services.  The effort began by developing a core team of trainers at the state level, who in turn trained another core among staff of seven of the states 31 local government areas (LGA).

These LGA teams then embarked on training front line health facility staff in both malaria in pregnancy control and outreach through community directed interventions.  The actual service delivery of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) took off in July 2008 after both health workers and community selected and directed volunteers were trained.  Nearly 10,000 pregnant women have received two doses of IPTp since then.

Now the Pioneer Newspaper reports that many of those trained have been transferred to other LGAs, and this could disrupt the smooth delivery of MIP control services.  The challenge in Nigeria is that while the State Ministry of Health provides technical guidance to LGA health staff, and the LGA itself provides the facilities and supplies to run the services, most of the actual health workers are employed by another entity – the State Local Government Service Commission.  Transfers and repostings occur as frequently as every two years or only as often as every 5 years.  Often a transfer is the only way a health worker can move into a higher grade position – in effect get a promotion.

So while the system may benefit the individual employee, it makes it difficult to offer continuity in service and to build strong community relations needed to deliver public health care.  Eventually the State will have the resources through the World Bank Malaria Booster Program to train health staff in all LGAs on malaria. In the short term the efforts to prove that LGA health facilities can improve the quality and reach of malaria in pregnancy control services may be jeopardized.

The ultimate irony is that the bulk of health workers on the front line in Nigeria are not part of a system that could provide coordinated human resource planning for health.  Instead, they are transfered by a non-health bureaucracy like any other LGA civil servant, whether she be a clerk, accountant, secretary or in this case a nurse.  When Nigerian health planners are able to train and update all health staff in malaria, such transfers may not disrupt services.  For now, these planners need to examine the effects of a system that treats health staff like civil service pawns.

ITNs Bill Brieger | 18 May 2009

Universal Coverage of LLINs Kicks off in Kano

kanogate1-sm.JPGNigeria’ drive to achieve universal net coverage campaign – two per household – just wrapped up its first effort with over 2 million LLINs for 21 of the 44 local government areas (LGAs) in Kano State. Distribution in the remaining LGAs will occur later. All the partners were on board, and many lessons were learned – some quite unexpected.  This is the first step in distributing 22 million nets in 12 states before the end of 2009 and 60 million in all states by the end of 2010.

The scheme started at the household level with the provision of two net vouchers. People were told to present these at one of the 2-4 distribution points in their ward over the upcoming two weeks.  UNICEF introduced a unique SMS tracking system to monitor the net distribution that provided clues where there more or less vouchers than expected and where efforts to increase or shift commodities were needed.  This system apparently worked well in the rural areas, but complications arose in the urban communities.

There was a rush for nets at some distribution points with people fearing that supplies of something free would not be adequate, so the sooner one claimed his/her nets the better.  In addition some people, variously termed traders and hooligans thought that this would be an ideal way to make a profit and raided distribution points, stealing the nets they could carry away.  Some obverses termed what happened as a ‘riot’ or a ‘stampede’, while others spoke of teargas. Unconfirmed injuries were also rumored. Security was not adequate for this unexpected ‘net-frenzy.’

At a point the exercise was suspended for a couple days. Additional police were provided, and eventually those with vouchers were served.  The LLINs were packaged kust like those already on sale in some shops, and so a suggestion for future distributions that would reduce the enticement of theft would be branding of those nets provided free by the malaria partners.  Another suggestion is to use the community directed approach to distribute the nets by local volunteers right to the households.  If vouchers can be distributed to the household, so can LLINs, and that way distributors would see the actual house and its inhabitants and could engage immediately in education on proper net use.

Net use is the big remaining question. People certainly rushed to get the nets, whether for legitimate needs or not. The question is whether a few months for now one will see these nets hanging on beds in the various households and see vulnerable groups – small children and pregnant women, actually sleeping under them.

Anambra State is gearing up to distribute nearly 1.8 million nets in June. Hopefully Anambra will have adequate community involvement, good distributor training, detailed supervision, strong security and culturally relevant health education to prevent ‘stampedes’ and ensure real universal coverage.

Funding &Partnership Bill Brieger | 18 May 2009

Flying against malaria – more partners in the fight (and flight)

When it comes to malaria, mosquitoes are not the only things flying.  British Airways announced recently in Lagos that some of the funds earned for UNICEF for the ‘Change for Good’ program will be used to provide ITNs in Nigeria.

Africa News reported that, “According to Andrew Crawley, the Airline’s Director of sales in Nigeria in a visit to health centers in Lagos during the World Malaria day says ‘We have made this commitment to support help reduce the suffering of people plagued by this ailment’ Speaking on BA’s collaboration with UNICEF, Crawley says ‘On behalf of everyone at the British Airways, I would like to thank all our customers who have donated their spare currency to the Change for Good program. Without them the funding of this program would not have been possible’ says BA sales director.”

Change for Good has been operating for around 15 years and has raised over 26million pounds for UNICEF projects in 60 countries.  “The Airline donated mosquito nets to remote villages in Lagos, where the breeding of mosquitoes is provoked by poor environment.”

Other airlines have been flying against malaria for several years to support UNITAID. The work of UNITAID has focused largely around affordable drugs for malaria.  Partner countries and airlines are many as seen below.

UNITAID receives its funds through airline ticket taxes or regular budget contributions. Countries implementing the airline tax as of the end of 2008 include Chile, Côte d’Ivoire, Democratic Republic of Congo, France, Madagascar, Mauritius, Niger and the Republic of Korea. Norway allocates part of its tax on carbon dioxide emissions from air travel to UNITAID. Jordan joined UNITAID in late 2008 and declared its intention of introducing the air tax. In addition, two African countries – Kenya and Burkina-Faso – pledged their intention of introducing the air tax in the near future to support UNITAID.

More innovative funding and awareness mechanisms are needed to reach our targets

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