Posts or Comments 17 June 2024

Monthly Archive for "September 2009"

Health Systems &Human Resources Bill Brieger | 27 Sep 2009

When health workers strike

dscn3778-sm.JPGThere are often opposing views about whether health workers should be able to strike or should be considered essential service staff who must remain on the job and resolve labor issues through other means.  It should be noted that when most people talk about health workers striking, they are talking almost exclusively about health staff in the public sector, which in many malaria endemic is the largest provider of care, especially preventive services.

IRIN News reports today on a health worker strike in Adamawa State, Nigeria that has paralyzed service delivery.  In-patients in government facilities have been discharged, and a very rudimentary out-patient service has been maintained.  The strike is now in its third month, and as IRIN reports

Most of the state’s 7,000 health workers, including nurses, specialists and administrators but not general doctors, began an indefinite strike on 25 June to protest the suspension of an improved salary structure by the state government, according to head of the health workers union.

Although private care is available, “Only a few patients who can afford high medical fees have moved to private clinics, while [most] have resigned to their homes hoping the matter is soon resolved and the strike suspended.” Of special concern is the inability of the state to respond to an impending cholera epidemic.

In Gabon earlier this year a 3-month strike “demanding premiums, pay raises and better work facilities” was reported to have cost many lives. One man told IRIN that, “He is at a loss as to what to do about his three-year-old daughter who he said has had a severe cough for two weeks. ‘I do not have the means to take her to a private hospital. My only recourse is the [public hospital], so I just do not know what to do and this saddens me deeply.'”

In Cote d’Ivoire back in February, “After talks between the medical workers’ union and the government broke down … union leaders called a strike … Unlike past strikes medical workers are maintaining minimum services – emergency care, similar to that normally provided on weekends and holidays, said the union leader.”

The relationship between health workers and government often appears contentious. As one physician told IRIN, “We do not like going on strike. We know that people are in hard times, given the situation of the country. But we have been forced to do so.” Obviously the government cannot ‘force’ people to strike, but what does this say about the overall management and priority of health in a heavily government dependent setting?

These health systems and management issues were cause for reflection by Afrol News. Health workforce problems have “been a recurring matter in most part of Ghana’s 50-year existence, especially as economic conditions worsen. While public health workers deserve good pay, like other professionals, their problems are increasingly being worsened by mounting health problems and population increases. This calls for sober and holistic reflection of the entire Ghanaian healthcare delivery system.”

Part of the problem may increased pressure on existing staff because of workforce shortages. “Sub-Sahara Africa alone needs about 1 million health workers,” reports Afrol News.  This may reflect a vicious cycle of disappointed staff, brain drain, greater staff shortages and even more disgruntled and overworked staff.

A basic principle in human resources management is that self-actualization at the worksite – being able to perform one’s duties with all the necessary resources – is more satisfying and motivating than salary, which can never be seen as enough.  Since malaria control services need to be well integrated into primary care, we need to ask whether donor programs are adequately addressing issues like skill upgrading, quality control, timely and adequate procurement and supply, and other basic health service components that will make it possible for health workers to perform their duties and gain maximum job satisfaction.

We may think we are doing enough in providing billions of dollars of malaria commodities to endemic countries, but unless we address these human resource concerns, strikes may render these malaria control services unavailable just when people need them.

Surveillance Bill Brieger | 23 Sep 2009

Keeping track of malaria where it supposedly does not exist

Non-endemic does not mean no malaria.  The Caribbean Epidemiology Centre (CAREC) explained that, Jamaica has been malaria-free for over fifty (50) years, although a number of imported malaria (Plasmodium falciparum) cases were identified each year.” That said, Rawlins and colleagues observed that there were 897 reported malaria cases in the Caribbean Epidemiology Centre (CAREC) Member Countries (CMCs) between 1980 and 2005 with Jamaica accounting for 38.4%.

Then the situation changed briefly. WHO posted information in 2007 that, “The Ministry of Health of Jamaica has confirmed 280 cases of malaria due to Plasmodium falciparum on the island between 6 November 2006 and 3 February 2007. Of these reported cases, 264 have occurred in Kingston, 12 in St Catherine, 3 in St Thomas and 1 in Clarendon. There have been no reported deaths due to malaria.”

black-river-gator.JPGWHO recommended that while “Jamaica is a non-endemic country for malaria … The occurrence of this outbreak highlights the importance of conducting surveillance in countries that are non-endemic to malaria.”

[LEFT: malaria free but not alligator free]

Likewise Rawllins et al. warned that, “All the essential malaria transmission conditions–vector, imported malaria organism and susceptible human host–now exist in most CMCs. A call is now made for enhanced surveillance, vector control and anti-malaria skills to be established in CMCs.”

We cannot turn our backs on malaria – malaria carrying mosquitoes do not mind whether they bite us in front or in back.

Advocacy &Policy Bill Brieger | 20 Sep 2009

Does ALMA spell Political Will?

Almost 10 years after the Abuja Declaration, are African leaders reasserting their political will to eliminate malaria? What will be different this time?

Coming on the heels of a visit to see African malaria success stories, “Ray Chambers, the Secretary-General’s Special Envoy for Malaria, has briefed Mr. Ban (UN Secretary General) on his recent high-level visit to Tanzania and Uganda, where he and UN World Health Organization Director-General Margaret Chan reviewed the progress being made in those two countries against the disease.”  Now leaders from these and other countries are coming to UN Headquarters to continue the discussions.

The Sunday Vision website pictures Ugandan President Yoweri Museveni at a stopover in London on his was to a scheduled meeting with other African leaders at the UN General Assembly in New York to form the African Leaders’ Malaria Alliance (ALMA) this week. UGPulse also comments that. “Twelve African countries will on September 23rd launch the African Leaders Malaria Alliance in New York City.”

According to the website of the UN’s Special Envoy for Malaria, “ALMA will provide a forum in which Heads of State can exchange ideas and articulate policy preferences, as well as anticipate, prevent and overcome obstacles on the path toward the achievement of the December-2010 goal of universal coverage.  ALMA will serve to strengthen the position of member nations in relation to global partners and in the implementation of in-country strategies.”

Apparently now is the time when “African countries promise to expand dramatically in dimension, depth and intensity.”

ALMA is associated with the word ‘bold.’ As UN spokespeople say, ALMA is to be “one of the boldest actions taken against malaria in the modern era… First, the leaders intend to have disease-prevention functions completely under control in Africa by the end of 2010. Additionally, the leaders will announce the even bolder initiative of ‘near zero deaths by malaria by 2015,'” in keeping with the Millennium Development Goals.

Compared to Abuja of 2000, the formation of ALMA 2009 is taking place in much different times. We now have major malaria funding from the Global Fund, the US President’s Malaria Initiative, the World Bank Malaria Booster Program, DfID, UNICEF and other partners.  We have numerous NGOs in both northern countries and endemic countries increasing awareness and action.

We certainly have progress on many indicators generally (though few countries reach RBM’s 80% goals for 2010), and hopes of success in places like Rwanda, parts of Ethiopia, Equatorial Guinea and Zanzibar, though these successes may not translate easily to high burden countries like Nigeria and DRC.

What we still do not have in 2009 are strong, integrated and accountable health systems that will ensure that malaria interventions are scaled up to reach all and are also sustained so that elimination efforts have a chance to succeed.

RBM was launched in 1998 on a platform of health systems reform and strengthening – that is an acknowledgment that malaria interventions cannot succeed on campaigns alone and in isolation from the health system. Unless ALMA addresses addresses health system strengthening for the sustained delivery of malaria interventions, it will simply become a faint echo of Abuja 2000.

ITNs Bill Brieger | 19 Sep 2009

Strengthening Local Net Production

netmarklogo-sm.jpgTen years have passed since USAID’s NetMark Project started, and observances of program closure were held in Washington earlier this week. The project evolved over time, but a constant theme was strengthening private sector partners – manufacturers, retailers and even advertisers – to make a sustainable contribution to international malaria targets for insecticide treated net (ITN) ownership in Africa.

netmark-countries-mapd2-copy.gifIn its earliest incarnation in Nigeria NetMark worked primarily to build the capacity of endemic country based textile and pharmaceutical companies to make and bundle bed nets and packets of insecticide that would be used by the purchaser to soak the nets.  These nets/insecticide bundles began appearing in shops, and were also available through subsidized voucher schemes in some areas.

NetMark even identified local net stitchers to ensure an ever more grassroots approach to net production and distribution. One example was a local NGO that hired poor women to make nets and generate an income. In Nigeria government and donor agencies initially jumped on the idea of locally produced nets, making sizable orders for their control programs.

Then Long Lasting Insecticide-treated Nets (LLINs) appeared on the scene and business nearly dried up for the local companies whose ITNs had to be treated every six months.

Since the advent of LLINs NetMark has partnered with the international manufacturers and endemic country wholesalers to maintain a private sector role in net distribution.  They still hope that LLIN technology will start up soon in Nigeria, thus marking a return to their original goal of boosting local production.

Nigeria, like most countries that are running up to the 2010 RMB goals of universal net coverage, has started massive distribution campaigns of free nets to achieve a two net per household coverage.  Unfortunately, local LLIN production is not currently in the picture, but there is always the ‘keep-up’ side of net programs – quickly and locally available net supplies will be needed to maintain stocks for purchase by interested people and for governments and donors to buy and give newly pregnant women.

netmark-documentary-2.jpgAn award winning video on the NetMark experience can be viewed on their website.  The documentary stresses sustainability. Medical News Today quotes Juan Manuel Urrutia, AED’s Johannesburg-based deputy director of NetMark as saying,”We worked ourselves out of a job. They don’t need us anymore, and I’m proud of that.” That would be sustainability.

In fact we still need to watch what happens. Will there be a private market in Nigeria after 60 million free nets have been distributed? Will donors and government agencies actually buy locally manufactured LLINs (once they become available) to maintain the keep-up coverage activities at maternal and child health clinics? Will households decide to buy additional nets to supplement their two free nets? Concerted effort by national malaria partners will be needed to provide positive answers to these questions.

Advocacy Bill Brieger | 18 Sep 2009

Progress, Obstacles and Advocacy in Malaria Programs

be-that-voice-2.jpgPBS Reporter Ray Suarez recently visited Bagamoyo, Tanzania, a former colonial outpost for the Omani Arabs, the Germans and the British.  Evidence of this past is crumbling, and the present finds poor people confronted with malaria.  Ironically Bagamoyo is at the forefront of work to find a malaria vaccine.

Suarez found that even though the vaccine is not yet ready and poverty pervades, the people are benefiting from national malaria control interventions.  He documented bednet use, indoor residual spraying activities and judicious use of malaria treatment combined with appropriate diagnostics.

Suarez describes the appropriate steps along the pathway to malaria elimination. We should fully implement those interventions we have to bring down mortality. Then we can implement the new technologies like vaccines when them come on line to consolidate gains and move toward elimination.

Botswana, not necessarily considered a malaria hotspot with only 14,000 cases reported last year, still needs to step up to the plate and eliminate its own share of the disease.  At a recent conference the Deputy Permanent Secretary, Health stressed the importance of bringing the public along. “He explained that implementing malaria control strategies is complex because it does not just dependent on how much they can deliver, but mainly on the acceptance by the communities. He explained that to address the obstacles, they have developed an advocacy and communication strategy to strengthen health education and community mobilisation.”

Advocacy is also at the forefront in Ghana. “Participants at a malaria advocacy forum at Apam in the Gomoa West District have appealed to the Ministry of Local Government and Rural Development to restore the one per cent contribution from the District Assemblies Common fund for malaria control initiatives in the districts.”

For the past three year the VOICES malaria advocacy program has been organizing district advocacy teams in Ghana so that the local people develop their own political voice to attack one of the most serious threats to their health and welfare. Ghana’s district advocacy guide is available online for people in other districts throughout endemic countries to use.

The experience in Ghana shows that it is not enough to have well formulated national policies and programs. These must be supported and implemented at the district and community level, so that like the people of Bagamoyo, everyone has access to the appropriate malaria control services they need.

IPTi Bill Brieger | 17 Sep 2009

Time to Give IPTi a Chance

logo_ipti.jpgEight years ago researchers in Tanzania discovered that giving a full dose of sulphadoxine-pyrimethamine (SP) to infants as intermittent preventive treatment (IPT) has similar positive effects of reduced malaria and anemia as the same process had already shown in pregnant women.  This led to the formation of the IPTi Consortium whose aim was to amass the evidence needed so that international bodies could accept and develop guidelines for this life saving intervention.

Although a variety of studies across Africa with support from UNICEF, the Gates Foundation and others have confirmed the benefits of IPTi, there has been reluctance by WHO to endorse this intervention.  This may have been based on fears of rising parasite resistance to SP.

Today the Lancet has published a meta or pooled analysis of these IPTi Confortium sponsored studies from trials that were conducted in Mozambique, Gabon, Tanzania and Ghana. IPTi Consortium reports that, “SP has a protective efficacy of 30·3% (95% Confidence Intervals 19·8–39·4, p<0·0001) against clinical malaria, in areas of low to moderate resistance to SP during the first year of life.”

Researchers from the Consortium are realistic: “IPTi is not a ‘not a magic bullet‘ and noted that SP resistance has spread to several parts of Africa, which could limit the effectiveness of the IPTi using this drug. But the intervention could prevent 6 million cases of malaria each year among those most vulnerable to the disease.”

IPTi with SP has been proven not only efficacious, but relatively easy to deliver through infant immunization campaigns and routine immunization services. IPTi has also been shown to be acceptable to the community and parents of these infants. Also IPTi is cheap – about US $0.13-0.23 per dose.

While research will continue to find replacements for SP, there is no reason not to act now using this proven intervention to save lives.  It is time for malaria partners and endemic country control programs to come together and operationalize these findings and begin saving lives until such time as a replacement medicine can be found of good efficacy and reasonable cost.

Countries must also remove SP from the shelves of shops and pharmacies where it is sold for treatment so that what remains of its efficacy can be protected until a replacement is found.

The IPTi Consortium is right that there is no magic bullet – this includes nets and treatment drugs, too. All possible and affordable strategies need to be employed to meet the 2015 Millennium Development Goals – saving children’s lives.

Advocacy Bill Brieger | 13 Sep 2009

Malaria – does the media matter?

In Nigeria, “Professor Oladele Akogun, has called on media organisations in the country to help in the implementation of the Roll-Back malaria programme,” according to This Day newspaper.  The news has different audiences, and when policy makers are targeted, we are engaging in what is known as media advocacy.

bill-on-free-medical-services-smjpg.jpgSpecifically, Prof. Akogun explains that, “the media remains the voice of the governed to the governor.”  Furthermore, “He said it was important that the media to play its role by asking policy makers questions that border on good health, roads and other issues affecting citizens’ welfare.”Prof. Akogun was focusing on Taraba State in Nigeria, and in fact it is often at the sub-national level – states, provinces, districts – where media advocacy is most needed so that national policies are actually implemented.

As an example. Jhpiego, an NGO affiliated with the Johns Hopkins University, has been working in Akwa Ibom State, Nigeria for the past three years promoting improved services to prevent malaria in pregnancy (MIP).  Jhpiego has partnered with the State’s Newspaper, the Pioneer, to draw attention of policy makers to MIP issues.

At the local government level, Jhpiego “called on local government chairmen to be more committed in the supply of routine drugs supply, provision of ante-natal cards in the primary health centres to enhance free healthcare services offered pregnant women and children under five years by the Akwa Ibom state government.”

Jhpiego also used, A conference to commemorate the 2009 World Malaria Day in Eket to “call on Akwa Ibom government to fast track a bill on free ante-natal services to all pregnant women/children under five years,” as reported in the Pioneer.  Fees for antenatal care keep women away and deny them access to MIP preventive services.

In Ghana the VOICES malaria advocacy project has been using the electronic media as follows:

  • The development of TV Spots targeting Ghanaian leaders and health providers, encouraging them to use their power to fight malaria
  • Ongoing collaboration with electronic and print media to support the use of AS + AQ as a first-line treatment for uncomplicated malaria
  • 4 TV Spots/documentaries broadcast on national TV for 3 months
  • 4 Radio Spots broadcast on community/district–based radio stations.
  • Vocal leaders appear on 6 mass media programs and 8 district level events

Examples of the TV documentaries can be viewed on the Ghana page of the VOICES website. This TV programs and media print media coverage in Nigeria should encourage malaria advocacy groups in other countries to develop their own media efforts to ensure that malaria control services reach those in need.

It is not that countries lack policies to eliminate malaria. What is often lacking is the political will, especially as sub-national and district level to implement those policies.

Equity &Treatment Bill Brieger | 12 Sep 2009

Mosquitoes bite regardless of economic status, but for treatment …

dscn3873sm.JPGIn villages of southeastern Nigeria, Uguru and colleagues found that mosquitoes do not discriminate by socio-economic status (SES), but SES does influence where people go for treatment once those bites result in malaria. “In one of the villages the most poor, very poor and poor significantly used the services of patent medicine vendors and the least poor visited hospitals.”

Expenditure to treat malaria did not vary by SES group and ranged between US$ 1 – 3, with transport costs being less than a dollar.  The difference therefore, was that the poor paid proportionately more for their treatment than co-villagers who were least poor.  Treatment options sought by each group also introduced possible differences in quality of care, too.

As the World Malaria Report of 2005 observed, “Patterns of malaria transmission and disease vary markedly between regions and even within individual countries. This diversity results from variations (in) … conditions that affect malaria transmission and socioeconomic factors, such as poverty and access to effective health care and prevention services.” Because of this, “Malaria control is increasingly recognized as playing a key role in poverty reduction in high burden countries.”

Clearly, people in the villages studied do not have access to cheap or free appropriate malaria medicines, although Enugu State, where the study occurred, has been included in the Global Fund Round 4 Malaria grant in Nigeria. Initially GFATM malaria medicines covered only children less than five years of age who attended government health facilities.

Nigeria has recognized the weakness of a strictly public sector approach and is now making malaria medicines available through both public and private sector sources, particularly the medicine shops frequented by the poor as described in Uguru’s study.

The Society for Family Health (SFH) in Nigeria, with USAID support, has spearheaded an effort to make quality prepackaged antimalarial drugs available cheaply through private sources, such as medicine shops.  Now that SFH is involved with the Global Fund grant in Nigeria, there is hope that this distribution network can be strengthened to reach more people – especially the poor who find it difficult to access formal health services in either the government or the private sector.
There is still a long way to go to achieve universal treatment coverage among the 140 million plus people in Nigeria, but a mixed sector strategy seems to be a good way to start.

Funding &Treatment Bill Brieger | 12 Sep 2009

Delays in grant signing threaten service continuity

Officials in Cape Verde have yet to sign their Global Fund Round 8 HIV grant. IRIN therefore reported that, “People living with HIV in Cape Verde are worried that the HIV/AIDS programme may be disrupted by a change in funders. The World Bank pulled out in June after supporting the programme for seven years, and a US$5.3 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria has not yet arrived.”

Major staff cuts have occurred in HIV programming, but ARVs may be sufficient until the end of the year.  Even if the grant is signed tomorrow, it is not certain how quickly procurement of HIV drugs and supplies can happen.

This HIV grant is the first and only award Cape Verde has ever received from the Global Fund. The country has not applied for a malaria grant, and WHO indicates that malaria transmission is focal: “Limited local malaria transmission exists on Sao Tiago (Santiago) island from September through November. The transmission is unstable and mainly due to Anopheles Arabiensis. Plasmodium falciparum is the main parasite. Cases imported from the continent are reported regularly.”

Gaps between funders and funding cycles is not uncommon. Ghana experienced such a near miss in its Global Fund malaria grants as one was closing out and the RCC process was not rolling smoothly nor was a new Round funding coming on board quickly either.  A clear lesson is that funding processes are far from QUICK, and countries must plan their funding pipeline far in advance.

People in Cape Verde may die if the gap in ARV procurement opens and widens.  Likewise people may die when there are delays in grant signing for malaria programs.  People will resort to ineffective malaria drugs that are still available or not seek care if private sector medicine sources are too expensive.  All GFATM applicants need to take the grant signing demands seriously, if they hope to protect the lives of their citizens.

Urban Bill Brieger | 11 Sep 2009

As Africa Becomes More Urban, What Happens to Malaria?

Africa is one of the fastest urbanizing regions of the world. Estimates are that nearly 40% of Africans live in urban areas today. This number is expected to exceed 50% by 2030. UN Habitat reports in State of the World’s Cities that African urbanization is often focused on the major cities like the capital, with major slum development, not a place where anopheles mosquitoes are comfortable.

Studies have shown that malaria is not generally an urban disease because dense, congested and dirty urban settings do not favor the breeding of anopheles mosquitoes. When malaria occurs in urban areas, it is often found in very focal transmission sites, for example, in places where urban agriculture is practiced.

luanda-sm.jpgLuanda in Angola presents a good example of the urban phenomenon as seen in the chart.  Although much of the surrounding country to the north and east are highly endemic areas, Luanda itself was found to have a prevalence of only 3.5%.  There are variations as expected with the somewhat less dense suburbs having greater, but still not high levels of prevalence.

What is important is that this city contains up to half of the country’s 16+ million inhabitants and is growing. Ironically, while prevalence is low, national strategy documents cite malaria as a cause of nearly one-quarter of child deaths in Luanda.  Clearly there are diagnostic challenges.

Unfortunately the absence of malaria in urban areas does not preclude spending money on malaria treatment, as was documented in Nairobi. We documented a similar challenge in Lagos, Nigeria where prevalence among children aged 1-6 years was only 0.9%, but community members had spent thousands of dollars in preceding weeks on antimalarial medicines to treat fevers that they suspected as being malaria.

Moving forward toward malaria elimination will require countries to account for increasing urbanization.  Increased use of diagnostic tools will be required to ensure appropriate and targeted use of anti-malarial drugs.  Vector control activities will need to be strategic and focus specifically on anopheles’ verified breeding sites.

While increasing urbanization may result in proportionately fewer people at risk from malaria, population growth generally will unfortunately guarantee that large rural populations remain at risk.  National malaria strategies need to take these varying ecologies into account if they are going to eliminate malaria.

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