Posts or Comments 25 February 2021

Monthly Archive for "December 2009"



Environment &Epidemiology Bill Brieger | 31 Dec 2009

Facing Malaria on Mount Kenya

The recently concluded climate change summit on Copenhagen did not stress health, let alone malaria, as much as other consequences of climate change.  The Inter-governmental Panel on Climate Change has let us know a reason why attention to malaria in the climate debate may be somewhat confused:

Climate change may “have mixed effects on malaria; in some places the geographical range will contract, elsewhere the geographical range will expand and the transmission season may be changed.”

Kenya is one of those areas that has been reporting increases in the geographical range of malaria – particularly into the highlands.

Li and colleagues have been examining the Western Highlands over the period 2003-05 and documented variability of mosquito breeding sites by season and year.  Their findings point to ways to improve larval habitat modifications as an important part of integrated vector management in such areas of seasonal and focal mosquito breeding.

An integrated approach to malaria control also is credited for a “pronounced reduction and possible interruption of malaria transmission in 2 highland areas of Kenya for a 1-year period and provides evidence that interruption of transmission was related to widespread annual IRS insecticide treatment and use of ACT as first-line treatment for uncomplicated malaria. Although both areas remain at risk for recurrence of malaria epidemics, our study provides evidence that interruption and eventual elimination of malaria in areas of unstable transmission may be achievable.”

dscn6330-sm.JPGThe Mount Kenya highlands have been studied by Chen et al. who were concerned about possible increases in malaria cases reported over the past 10-20 years there. They found that, “Local malaria transmission on the Mount Kenya highlands is possible due to the presence of An. arabiensis. Land use pattern and land cover might be the key factors affecting the vector population dynamics and the highland malaria transmission in the region.” Human factors appear to play an important role –

On the Mount Kenyan highlands, the population has increased at least 25% over the past 20 years. Population density in Karatina and Naro Moru areas is estimated at 530 persons per square km, much higher than those in the further north areas, e.g., only 81 persons per square km in Nanyuki. With the increasing population on the highlands, enhanced human activities including deforestation, farming and livestock rearing could create more vector habitats. For example, at the site northwest to Karatina, hundreds of anopheline larvae were found in ditches holding spring water for crops in a field. The vectors emerging from this kind of habitat can play an important role in local malaria transmission.

More recently researchers from the Kenya Medical Research Institute with support from DfID “found that the average temperature in the Kenyan Central Highlands had risen from 17C in 1989 to 19C today.” Specifically the group reported that …

Before the 1990s malaria was absent from the region because the parasite that causes it can mature only above 18C. However, malaria epidemics began among the population as average temperatures went over the 18C tipping point. The number of people contracting malaria during these epidemics has increased seven-fold in the past decade. In 2005, malaria-carrying anopheles mosquitoes were discovered in Naru Moro, more than 6,175ft (1,900m) above sea level.

Climate change may partly explain malaria increases in Kenya’s highlands, as may more local human activities. The important lesson is that such epidemic-prone areas need to be closely monitored. A timely mix of control interventions can then be judiciously applied. As Noor and colleagues recommend:

As malaria interventions go to scale effectively tracking epidemiological changes of risk demands a rigorous effort to document infection prevalence intime and space to remodel risks and redefine intervention priorities over the next 10-15 years .

Health Systems &Integration Bill Brieger | 29 Dec 2009

One Billion and Counting

As 2009 comes to an end, The Guardian lets us know that, “The baby’s name and nationality are not known. The child will grow up innocent of having a place in history. But somewhere, this year, that child became the billionth person in Africa, the continent with the fastest growing population in the world.”

With 45% of Africa’s current population living in urban areas, the billionth child was as likely to be born in Lagos or Nairobi as in a village. This paints an epidemiological picture where, “Deaths from smoking or car crashes will be a factor as much as the more familiar health issues of malnutrition, malaria and Aids. These citizens will also be vulnerable to droughts, floods and desertification caused by climate change.”

And while the population keeps growing, African children born in 2009 face the highest under 5 year old child mortality rates in the world. Afghanistan and Burma were the only non-African countries among those 38 with rates of 100 child deaths per 1000 live births or greater.

The life expectancy of that child is 55 years – 14 years younger than the world average. It could even be ten years less if the child was born in some of the areas highly endemic for HIV.

So what are we offering the cohort of children born in Africa during 2009? Many countries like Nigeria are in the midst of working toward universal coverage of insecticide treated nets, and just reported a successful campaign in Ogun State where 1.6 million of the proposed 63 million national total were just distributed.

africa-population-growth2.jpgWe have noted that the process of making appropriate malaria medications for children and intermittent preventive treatment for pregnant women (to protect the next cohort of African children as well as the mothers) is well below target. One-off Campaigns to get nets out to households are somewhat ‘easier’ than ensuring an integrated and functioning public, private and non-governmental health system that is needed to provide other routine preventive and treatment services.

We wish that when this one billionth child has a birthday in 2010, she or he will be fully protected from malaria with a net and have ongoing access to the services needed to keep malaria at bay.

Migration Bill Brieger | 28 Dec 2009

Migration and Malaria

cross-border-initiatives-sm.jpgMalaria – a disease without borders. That was the theme of World Malaria Day in 2008.  What does this mean in practical terms?  There are definitely countries that share mosquito breeding sites on their borders, but it is the human movement across borders that has caused concern recently in Malaysia.

The New Straits Times reports from KUALA LUMPUR that, “Migrant workers, many of whom are here illegally, are the source of the spread of malaria in six states.” The Health minister is quoted as complaining that, “‘In some of these states, the increase in cases is due to migrant workers, many of whom are illegal, coming from countries where malaria is still endemic …’ In addition, he said, these workers were mobile and posed a challenge to the ministry’s efforts to ensure they completed their treatment.”

A different aspect of migration also threatens our ability to control malaria – brain drain. AllAfrica.com shares a story from Burkina Faso: “UNESCO is expanding a scheme that aims to slow the brain drain of African and Arab researchers by giving them access to global scientific networks and computing power.” Additionally, “UNESCO and Hewlett-Packard say they plan to include 100 more universities in the scheme by the end of 2011, with help from additional partners.”

Although the article does not address malaria directly, similar efforts by the international research community to strengthen endemic country research capacity hope to enable African researchers to contribute directly on the ground to solving their countries’ malaria problems. For example, see the work of the Malaria in Pregnancy Consortium.

The timing of these migration concerns – whether illegal migrants entering a country or high level brainpower departing – coincide with the observance this month of the tenth International Migrants Day. This observance recognizes the “human rights and fundamental freedoms of migrants.”

Migration is a basic reality of human existence. We should not blame migrants for the challenges posed by malaria but acknowledge, if we are to eliminate malaria world-wide, that migrants need access to basic malaria control services, whether they come to Malaysia, Guyana or Kazakhstan.

We should also realize that the issue of migration and malaria shows how intertwined the control of the disease is with national development. By improving employment opportunities, health systems and research capacity in malaria endemic countries, we might stem the tide of some migration and enable all levels of the national workforce to contribute in their own ways to controlling malaria at home.

Leadership &Malaria in Pregnancy Bill Brieger | 26 Dec 2009

USAID – new director confirmed

The US Senate has given the development community a holiday gift. The indo-Asian News Service reports, “The Senate unanimously on Thursday confirmed the nomination of Shah, 36, and some three dozen other officials nominated by President Barack Obama before taking its Christmas break.”

Rajiv Shah has training in medicine and economics and has worked with the US Department of Agriculture. This gives him a broad development perspective and hopefully will ensure nutrition issues are not forgotten, “having championed Obama’s global food security initiative.”

Shah has also worked with the private and the NGO sectors, important partners in USAID’s work.

When Shah was nominated, President Obama said, “Rajiv brings fresh ideas and the dedication and impressive background necessary to help guide USAID as it works to achieve this important goal.”

There are those who are worried that fresh ideas alone may not be enough to guide an agency with such wide scope. NationalJournal.com remarked that, “Then there is the question of seasoning. While development junkies trade war stories of remote missions and malaria like currency, Shah has almost zero field experience. He may be the smartest guy in the room, but he doesn’t have that wellspring to draw on.”

During confirmation hearings Senator Richard G. Lugar posed a question about the future of the successful disease control programs initiated by the US Government in recent years. Shah explained that …

The welcome increase in funding for health assistance since 2000, particularly for combating HIV and malaria, has largely been targeted to African countries where disease and overall poor health conditions have had substantial socio-economic impact. That said, there are still tremendous unmet health and development needs in these countries. The Administration is committed to a broad Global Health Initiative that takes account of the range of health and development needs and, if confirmed, I look forward to working with Congress on this important issue.

The United Nations Foundations congratulated the President on Shah’s nomination and reiterated its own priorities which address both disease control and strengthening maternal and child health (MCH) services:

The United Nations Foundation is particularly focused on development goals related to global health, including our efforts to eradicate polio, reduce measles mortality, and eliminate malaria worldwide. In light of the unmet need in the world for maternal health and family planning, I hope that USAID’s new leadership will keep women’s health and international family planning a priority.

A good example of the nexus between malaria control and MCH is the challenge of preventing and treating malaria in pregnancy (MIP). Pregnant women bear a disproportionate burden of malaria that threatens their survival and that of the fetus and the newborn child.  Without strong a antenatal and reproductive health foundation, MIP control cannot reach those in need.

If Shah does have this bigger picture of malaria control in mind, we can hope for a broadening of malaria intervention into MCH programs that go beyond the limits of the 15 countries that constrained the potential impact of the President’s Malaria Initiative.

Coordination &ITNs &Private Sector Bill Brieger | 25 Dec 2009

Keeping up with nets

With the big push to achieve universal coverage of long lasting insecticide-treated nets (LLINs) by the end of 2010, most countries are relying on procurement from a few big companies, most not located in endemic regions. As the Roll Back Malaria Partnership explains:

Rapidly scaling up to universal coverage for populations at risk is critical to achieve the targets of 50% mortality and morbidity reduction by 2010 and a 75% reduction in morbidity and near zero mortality by 2015. The principle of scale-up has been promoted since 2005 by the RBM Partnership. This commitment has been reaffirmed by the UN Secretary-General’s call on World Malaria Day in April 2008 to “put a stop to malaria deaths by ensuring universal coverage by the end of 2010” through the use of vector control and case management tools and strengthening of community-level efforts.

Because most country coverage figures show a major gap in net ownership AND use, the term ‘catch up‘ has been used to describe this massive scale up. For example, the recently released 2008 Nigeria Demographic and Health Survey shows

  • 17% of households have any kind of bed net, treated or not
  • 12% of children under 5 years of age slept under any net
  • 11% of these children slept under an ITN
  • 12% of pregnant women also slept under any net

Kenya’s newly launched national malaria strategy documents that in 2007 40% of pregnant women slept under an ITN, as did 50% of children under 5 year old.

These figures are well below the 2010 RBM coverage target of 80%. As the UN concedes, “Nigeria and Kenya (are) two nations which together account for one third of the estimated 1 million deaths worldwide from the deadly disease.” While Nigeria alone is in the process of distributing more than 60 million LLINs by the end of 2010, this feat aby itself will not guarantee achieving the MDGs.  As RBM explains

Even if parasite prevalence falls to low levels, malaria control will not eliminate the mosquito vector, the parasite, or the favorable environmental conditions for transmission in many locations. To keep malaria at bay, countries need to maintain high levels of coverage even in the absence of a large number of cases. Relaxation of control—whether because of the decline in political will, decrease in funding, or some other reason—could lead to resurgence in transmission and to epidemics.

dscn0009sm.JPGThe maintenance phase of intervention is known also as ‘keep up.’ This means replacing LLINs that are damaged or lose their insecticide strength or to provide nets to new members of a population.

RBM has estimated a 4-5 year life-span for LLINs. As Stephen Smith from CDC reminds us, “Long-lasting nets don’t last forever.”  Smith cites data from Laos and Ghana that show in field conditions nets may be effective for only 1-3 years. This in part stems from the fact that manufacturers do not guarantee the strength of the insecticide beyond 20 washings. Behavior change to prevent frequent washings has not been easy. Nets are also damaged with holes and tears, and while this does not affect the insecticide potency, it may expose the sleeping person to mosquito bites.

So where are the continuous net supplies coming from to keep up? The New Times of Kigali provides one answer. “Rwanda’s manufacturing giant, Utexrwa has entered into a partnership with German chemical and pharmaceutical giant, Bayer to produce over 70, 000 anti-malaria bed nets.”

This brings another partner to the continent to join A to Z Textile Mills in Tanzania who through and agreement with Sumitomo Chemical have been producing long lasting nets since about 2003.  Local production has so far not been able to meet the bulk of the scale up needs for malaria control.

Hopefully local production will be positioned to address the keep up/maintenance needs for nets. This will require coordination between manufacturers, national malaria control programs and the private commercial sector to guarantee a market for nets.  This also assumes that WHO’s pesticide evaluation processes is scaled.

Local production is often made synonymous with capacity building. Without a realistic business plan and collaboration among malaria partners, local production may become a disappointment.

Performance &Procurement Supply Management Bill Brieger | 23 Dec 2009

Procurement bottlenecks – whose fault and can they be fixed?

Roger Bate and colleagues (Tren, Hess and Bate, 2009) are again challenging us to face up to problems with the procurement, supply and quality of malaria control medicines and commodities. Their article that appeared yesterday in Malaria Journal questions whether efforts to get supplies from the lowest price bidder pay off in the end.

Kenya and the Global Fund are the major focus of this analysis. Kenya’s Round 4 Malaria grant from GFATM has not had easy sailing and currently is rated at B2 – which means “Inadequate but potential demonstrated.” The grantee was plagued with considerable procurement and supply management (PSM) problems during Phase 1, when the Global Fund observed that, “Overall performance of this program has not been satisfactory to date.”

Prior to receiving approval for Phase 2 the Fund did note change: “The PR (had) considerably improved the PSM plan which was a CP (Conditions Precedent) for this disbursement and overall the revisions to the PSM plan address the majority of concerns raised at Phase 2 signature.” An innovation at address PSM was a ‘procurement consortium’ that would enable the Kenyan program to collaborate with experienced agencies and learn.  An observation by Amin et al., shows how this process was complicated by the way the Round 4 Malaria grant was set up initially.

The main challenge centered on how to manage the financial flows to make sure funds were availed in time for orders to be placed and processed. Theoretically, funds would flow from the GFATM, to the principal recipient (Ministry of Finance), then to the MoH (sub-recipient). The MoH would, after consultation with the national procurement consortium established to manage the tendering and ordering of commodities purchased with GFATM funds, place an order with WHO to forward the order to the supplier (Novartis Pharma AG in Switzerland).

dscn5837.JPGThis lengthy process was also highlighted by the Global Fund. “The PR (principal recipient) should also disburse directly to the Consortium, rather than through SRs (sub-recipients), in order to avoid excess bureaucracy and speed up the procurement cycle.”

The specific concern of Tren et al., is a recent effort by the Global Fund to ask some grant recipients to use international competitive bidding processes for certain drug purchases. In the case of Kenya “After awarding the tender for its annual supply of the anti-malarial artemether-lumefantrine to the lowest bidder, Ajanta Pharma, Kenya experienced wide stock-outs in part due to the company’s inability to supply the order in full and on time.”
psm-guide-front-page_page_01.jpgThe Global Fund itself states that, “The central objective of Global Fund procurement policies is to procure quality-assured products at the lowest price and in accordance with national and international law. Procurement must be conducted in a transparent fashion.” ‘Competitive procurement’ is mentioned in these guidelines, and WHO’s pre-qualification process for ensuring drug quality is stressed, though as Tren et al., point out, exceptions to the latter can be made.

Back to Kenya – Tren et al. have shown that delays in procurement have occurred with the Ajanta contract starting in 2008, but delays and stock-outs have been a common occurrence since the start of Global Fund malaria programming in Kenya.

One of the major procurement delays and inefficiencies, sending money into a country, converting it to local currency and then procuring from an outside source requiring re-conversion of the money, has been addressed partially by GFATM’s Voluntary Pooled Procurement (VPP). It was hoped that the labyrinthine procurement process among PRs, SRs and others in Kenya could have been ameliorated by VPP, but apparently this was not to be.

In the meantime Kenya has been turned down by the GFATM for all subsequent malaria grant applications since Round 4, in part due to poor performance linked with these procurement challenges.  Kenya’s only current GFATM malaria grant expires in less than 14 months. Somebody better get the procurement process right before then.

Equity &Funding Bill Brieger | 22 Dec 2009

User Fees – a potential threat to malaria elimination?

A nutrition clinic during 2009 in Côte d’Ivoire saw only 33% of the number of clients it helped in 2007.  IRIN reports that staff believe this was not due to decreases in malnutrition, but to the introduction of user fees.Under the hospital’s cost-recovery scheme, each family must pay 5,000 CFA francs (US$10.80) per child requiring intensive therapeutic feeding.”

Médecins Sans Frontières used to run the nutrition clinic, but fees were needed to run the service after the NGO left in 2008. “Many women who come in cannot afford to pay, Konan (who runs the clinic) said. ‘Two out of six new cases we have now could not pay… Sustaining these activities is hard … MSF wanted us to make the treatment free but we need more money to do so.'”

Cost recovery schemes have been touted, at least since the 1987 Bamako Initiative, as a way to guarantee that primary care services are sustainable. Mali, where the Bamako Initiative was penned, has been running a cost recovery system for many years that involves the community in decisions about the costs of medicines in the community health center, but ethical issues continually arise when malaria medicines are supposedly free through money from sources like the Global Fund.

A study in Burkina Faso on fees in a Bamako Initiative style program found that, “The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the  community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay.”

Our experience in Akwa Ibom State, Nigeria, attest to the negative impact of fees. Each local government decides on its own scale of registration fees for antenatal care.  While ANC registration in southern Nigeria is generally high, we found that only about 20% of pregnant women were coming to government run ANC clinics in Akwa Ibom.

After introducing a program to enhance malaria in pregnancy control services in selected local governments, we found that attendance still remained low.  The community distributors we had trained were expected to refer pregnant women to ANC, but the process was thwarted when the women were asked to pay between 200-300 Naira (upwards to US $2) to register.

Fortunately the women were able to receive their Intermittent Preventive Treatment (IPT), health education and some bednets through the trained community distributors, but the goal of linking them to improved quality comprehensive ANC services could not easily be met.

bill-on-free-medical-services-for-pregnant-women2.jpgAdvocacy efforts continue with each of the local government chairpersons and councils in the project area, but they are reluctant to relinquish these small fees. The state health services, such as secondary level district hospitals, offer free ANC, but this bypasses the primary care system. At any rate there are not enough state hospitals to make up for the need.
The State Legislature continues to debate whether to make health care for women and children free throughout all local governments. In the meantime, women in the state are effectively denied the means to protect themselves and their unborn children from the risks of malaria.

Much work is still needed to overcome the barriers to universal coverage of malaria interventions. The goals of sustaining a health system and eliminating malaria appear at odds at times, but delivery of malaria services depends on a strong primary health care system.  There are certainly better sources of revenue for health services than charging fees to poor pregnant women in communities where people earn less than a dollar a day.

Peace/Conflict Bill Brieger | 21 Dec 2009

No honors being on MSF’s top 10 list

For the past 12 years Doctors Without Borders/Médecins Sans Frontières (MSF) have produced a list of the top 10 humanitarian crises of the year. In 2009 the shame manifested in three distinct patterns:

  1. governments blocked lifesaving assistance to trapped populations, including in Sri Lanka, Pakistan, and Sudan, where aid groups—including some MSF teams—were expelled from Darfur
  2. respect for civilian safety and neutral humanitarian action further eroded, such as in Yemen, Afghanistan, Pakistan, DRC, and Somalia, where people—and in some cases aid workers—were either indiscriminately or directly attacked
  3. people suffering from a host of largely ignored diseases were again neglected by the international community, and those living with HIV/AIDS saw their chances of receiving life extending therapy further diminished

Though malaria is not specifically singled out as a top 10 crisis, it is intricately related to several of the problem locations identified –

  • In the malaria endemic eastern DR Congo, “Throughout 2009, the civilians suffered continuous violence from different armed groups in eastern Congo. Hundreds of people were killed, thousands of women, children, and, sometimes, men were raped and hundreds of thousands of people fled their homes.” Displacement and poor or no access health services increased exposure to malaria morbidity and mortality.
  • Southern Sudan is experiencing renewed violence. “Nearly five years after the Comprehensive Peace Agreement (CPA) ended a brutal, decades-long civil war, medical needs throughout southern Sudan remain at urgent levels, and escalating tensions are creating a precarious security situation.” Again, displaced people are at greater risk of malaria. As AlertNet reminds us, “political and social upheaval which moves populations into endemic areas,” is a key factor exposing people to malaria.
  • MSF also notes a general shortfall in funding for HIV, TB and Malaria as well as neglected diseases. “MSF is calling for governments to fulfill their commitments to provide access to life-saving AIDS treatment for every person in need and to fully fund the fight against AIDS, including through the Global Fund to Fight AIDS, TB, and Malaria.” The timing of the shortfall also could not be worse for malaria programs that are trying to achieve universal coverage in 2010.

The Humanitarian Practice Network points out several conditions where malaria becomes a humanitarian crisis –

  • Severe weather events and changes produce epidemics in areas where malaria transmission is unstable. For example, “In Ethiopia, a malaria epidemic in 2003 is estimated to have affected 21.9 million people in 38 zones, resulting in (at a conservative estimate) 8.7 million cases, with 263,000 deaths.”
  • “Complex emergencies created by war or civil unrest undermine efforts to improve malaria control. In 1984, when Burundi was politically stable, the number of malaria cases each year was 200,000. In 2000, following a period of internal violence and instability, reported annual malaria cases in Burundi were over 3 million. In the late 1970s, the authorities in Afghanistan reported around 300,000 malaria cases annually. By the 1990s, this had risen to 2–3 million cases a year – one of the highest malaria burdens outside Africa.”

Mentor, another malaria partner, wants health workers to be prepared to handle malaria in a humanitarian crisis. After training these health workers should “Be able to prepare and plan for effective priority interventions for the acute emergency context and modify programme approaches according to changes in the situation as the situation moves towards post emergency phase to reconstruction.”

Clearly an emergency response by agencies like MSF and Mentor is needed to save lives from malaria.  The bigger question is what can we do to prevent these humanitarian crises that arise not only from neglect but from outright oppression of peoples? Malaria elimination will never be achieved if such crises continue to create ideal disease breeding grounds.

Communication &Surveillance Bill Brieger | 20 Dec 2009

Malaria Messaging

cellphone-mango.JPGCell phones are being used for more than calls and text messages.  A variety of applications to help treat and control malaria have been tested over the past few years. A few examples from Africa follow.

1. Diagnostics and Patient Monitoring

Gizmodo explained that, “Scientists at UCLA modded an ordinary phone into a portable blood analyzer that can detect diseases at a very low cost … Blood analysis usually requires either large and expensive equipment or a trained technician to manually examine the material. Both are out of reach for many remote areas, especially in parts of Africa where HIV and malaria are rampant.”

Indian Express notes that this, “Lensless Ultra-wide-field Cell monitoring Array platform based on Shadow imaging has now been successfully installed in both a cell phone and a webcam. Both devices acquire an image in the same way as using a short wavelength blue light to illuminate a blood, saliva or other fluid sample.”

Fletcher and colleagues determined that, “A telemedicine system for global healthcare via mobile phone – offering inexpensive brightfield and fluorescence microscopy integrated with automated image analysis – to provide an important tool for disease diagnosis and screening, particularly in the developing world and rural areas where laboratory facilities are scarce but mobile phone infrastructure is extensive.”

Global Envision explained that Fletcher’s team “has been able to reliably identify pathogens from two of the most prominent diseases in the underdeveloped world — malaria and tuberculosis.”

2. Surveillance and Program Monitoring

Cellular News reported that, “University of Florida researchers at work on a malaria elimination study in Africa have become the first to predict the spread of the disease using cell phone records.”

The study by Tatem et al., found that, “Anonymous mobile phone records provide valuable information on human movement patterns in areas that are typically data-sparse. Estimates of human movement patterns from Zanzibar to mainland Tanzania suggest that imported malaria risk from this group is heterogeneously distributed.”

In 2008, Unicef pioneered a new text message based system for data transmission called RapidSMS. It has been used recently in Nigeria to track distribution of ITNs during massive state-wide campaigns and in Malawi as part of an Integrated Nutrition and Food Security Surveillance System.

As Unicef observes, “Without accurate and timely data, it is very difficult to make decisions, see where there are problems, respond quickly, and allocate resources effectively. RapidSMS is a powerful suite of tools that directly address this problem improving coordination and impact.”

3. Health Communication

Unicef is also collaborating with local telecoms to spread the work about health programs. This past July, “To highlight Zambia’s Child Health Week activities, which this year focus on preventing polio, the Ministry of Health and UNICEF have joined together with two of the country’s leading mobile phone companies, ZAIN and MTN, to spread the message about vaccinations and other key intervention.”

Richard Lester and co-researchers are testing the applicability of cell phones to communicate with patients and improve compliance with anti-retroviral treatment. They hope to, “test the effectiveness of the described intervention protocol, but will instruct further development of the use of mobile telephony to improve health management in resource limited settings.”

While there are still a number of cost, coverage and regulatory issues to be addressed, cell phones are poised to become an invaluable technology for controlling malaria and saving lives.

Health Systems &Human Resources &Migration Bill Brieger | 19 Dec 2009

Health worker migration – push or pull?

The New Vision of Uganda reports that according to the 2009 Human Development Report, “THE majority of Ugandans who migrate to other countries are among the higher educated group. And those who migrate, whether within their own country or abroad, are doing better in terms of income, education and health than those who stayed where they were born.”

dscn3845a.JPGHealth workers are among those educated emigrants, but the factors behind their movement are complex.

Citing the case of health workers deserting Africa, (the World Development Report) explains that this is being caused by poor staffing levels and poor public health conditions. “Migration is more accurately portrayed as a symptom, not a cause, of failing health systems.”  It notes that improving working conditions at home might be a better strategy to stop the brain-drain than restricting emigration.

The Canadian Medical Association Journal explains the problem thus:

You can’t force someone to stay and attempt to work in a place that  is lacking even minimum provisions for them to do their job. “If you tell them they can only hand out band-aids and aspirin, no  one will stay,” says Dr. Otmar Kloiber, secretary general of the  World Medical Association. “People should have the privilege to  migrate. For medical workers it’s important to have exchanges in  order to learn and to work. You can’t put someone on a dead end road and ask them to build a health care system.”

WHO also reminds us that health workforce maldistribution and migration occurs within countries, too. “Approximately one half of the global population lives in rural areas, but these  people are served by only 38% of the total nursing workforce and by less than a  quarter of the total physicians’ workforce.” Health workers locate in urban centers to gain greater economic, educational and social opportunities for themselves and their families.”

The loss of health workers is a major impediment in implementing malaria coverage targets and making progress toward disease elimination even when malaria commodities are provided in adequate amounts. More generally, WHO notes that, “Without available, competent, and motivated health workers, the potential for  achieving the Millennium Development Goals, and for effective, efficient use of  the financial and other resources committed to achieving the Goals, remains  extremely limited.”

The solution, according to the comments above is not simply finding more people to deliver malaria services in isolation, but ensuring that malaria control services are integrated into a well functioning health system. Donors who provide malaria and other health and development support are also cautioned to become aware of how their own programs, policies and activities can disrupt the health workforce in the countries receiving aid.

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