Posts or Comments 28 September 2021

Monthly Archive for "August 2010"



Procurement Supply Management Bill Brieger | 30 Aug 2010

Infrastructure needed for economic growth … and health

world-bank-logistics-performance-index-africa-sm.jpgDr Ngozi Okonjo-Iweala, the World Bank managing director, addressed the need for well functioning transport and trade facilitation to boost economic growth. She was quoted in the Monitor as adding that, “You can’t trade without the means to get goods offshore.”

Concerning Africa, Dr Okonjo-Iweala explained that …

We know better logistics are strongly associated with trade expansion, export diversification, the ability to attract foreign direct investments, and economic growth. Yet the 2010 Logistics Performance Indicators (see figure to right) showed that Sub-Saharan Africa is home to the 10 lowest performing countries in the survey. This is a cause for concern. Simplified customs and export procedures to quickly move goods across borders are also important. Yet the World Bank Group’s latest Doing Business report indicates that the average number of days to export from sub-Saharan Africa is 33. This can range from 75 days in Chad, 37 days in Uganda, and 23 in Mozambique.

While these infrastructural weaknesses hinder export and trade, they also hinder procurement and supply management for importing and distributing malaria commodities needed to meet Roll Back Malaria and Millennium Development Goals.

According to Roll Back Malaria, “Controlling malaria through universal coverage is not only about increasing spending and the delivery of malaria interventions. It also requires building, expanding and continuously improving health systems supporting all interventions.” This includes infrastructure such as transport, logistics, and communication.

The ongoing national LLIN distribution effort in Nigeria has been able to document some of the logistical challenges facing malaria program roll out efforts. In one state the reconciliation of LLINs supplied and those received at local government level delayed the implementation of the campaign. A ship containing nets balance had arrived at Lagos port however, due to congestion had not docked. Imbalance in LLINs supplied to local governments required shifting of supplies.

Logistics innovations to address such problems in Nigeria included training staff in use of waybills and stock sheets to help track LLINs. Another helpful factor was identification of appropriate storage facilities in all local governments.

Malaria No More and partners recently conducted Logistics Training to help countries learn from challenges and best practices, like seen in the Nigerian experience. Some of the key steps in Logistics planning that were outlined in the training include –

  • Customs clearances (selection of agent, Tax/Vat exoneration)
  • Security (personnel, transport and storage)
  • Storage (calculate storage volume, storage plan), negotiate with local government, partners and area facilities, physical location and accessibility
  • Transport (based on strategy) transport from entry points to the districts (macro) and from district to DPs (micro), identity available resources, develop transport plan
  • Micro-planning logistics (micro-planning guide document)
  • Tools and control mechanisms and follow-up of the LLINs (tracking)
  • Standardized templates in planning (storage, transport,budgets)

Infrastructure improvements will enhance economic growth and enable families in the long term to afford malaria prevention and treatment, but right now, extra effort is needed to overcome infrastructural and logistics challenges to Universal Coverage so that a healthier, malaria-free populations can contribute to their nations’ growth.

Epidemic &Health Systems Bill Brieger | 28 Aug 2010

Malaria – another challenge for Pakistan

who-syed-haider-pakistan-flood2.jpgLike other diseases, malaria takes advantage of natural and human disasters. Pakistan may be the latest example. UN Radio reports that, “Cases of suspected malaria are increasing in the flood-affected provinces of Sindh and Balochistan in Pakistan, according to the World Health Organization (WHO). The agency says malaria is adding to the already increasing trends of water and vector-borne diseases, especially in Sindh and Punjab provinces.”

While WHO is providing treatment kits with artemisinin-based combination therapy (ACT) medicines, a bigger challenge may be destruction of infrastructure, including health services. Jhpiego explains that, “In 2005, northern Pakistan was struck by a massive earthquake, destroying 80% of the structures in that region and reducing the quality of, and access to, primary health care services.” Similar problems are expected because of the floods.

After the 2005 quake, USAID funded Primary Healthcare Revitalization, Integration and Decentralization in Earthquake-affected areas  or the PRIDE Project for 2006-10, which involved improving primary health care services at 94 health care facilities.

Pakistan experiences both P. falciparum and P. vivax malaria. The Demographic and Health Survey reports that the transmission pattern is a combination of stable and unstable malaria with low to moderate endemicity, with epidemic breakouts in Punjab and Sindh provinces. “The disease is now emerging as a prominent health problem in Balochistan and the Federally Administered Tribal Areas (FATA).” That 2006-07 DHS showed very low utilization of insecticide-treated bednets and low uptake of malaria medicines by children and pregnant women.

Pakistan has received three rounds of malaria grants from the Global Fund. A combination of Global Fund and government support was trying to address the 30 most highly endemic districts in the country. Although the latest grant performance report gave Pakistan an ‘A2’ grade, other news reports paint a different picture.

According to IRIN, “Pakistan’s Roll Back Malaria (RBM) strategy is lagging far behind the international goal of reducing the disease worldwide by 50 percent by 2010, mainly because of a lack of skilled staff and a shortage of funding.” A health official explained that “existing surveillance system is the major challenge at the moment, since we do not have accurate data.” This information pre-dated the flooding, and consequently the health system is in even less of a position to respond to malaria challenges now.

Pakistan needs appropriate emergency response to a potential malaria epidemic, but eyes should also be focused on the longer term need for reconstruction and strengthening of the health system. Otherwise malaria cannot be eliminated.

ITNs &Private Sector &Universal Coverage Bill Brieger | 17 Aug 2010

Net readiness

dscn9200a.JPGEndemic countries are working hard to reach universal coverage (UC) by 31 December 2010.  With many countries relying on the small number of LLIN manufacturers, there is a big challenge and much competition among countries to get this done. Burkina Faso is a case in point.

For understanding of the situation the country ‘road map’ toward UC in 2010 presents the following information:

  • 8,487,000 needed for 2010
  • 1,581,000 currently in use
  • 7,466,134 expected from Global Fund
  • 1,020,866 gap

The actual dates for the mass distribution have been steadily pushed back as Global Fund supplied nets have not arrived and challenges remain to find a donor to fill the gap.

This has not stopped the National Malaria Control Program from getting the process rolling. A national launch was held on 12 July at Nanoro, about 85 km from Ouagadougou. It was expected thereafter that from region to district to health facility level effort would be made to count houses and residents in order to get a good estimate of where nets need to go. It seems that without nets physically present, district level preparations are on hold.

burkina-faso-nets-on-sale-along-the-road-2a.JPGAn interesting prospect in the wider net picture is the widespread availability non-treated nets for sale along the roadside. This implies that there must be some level of demand, for which people are willing to pay.

Two questions arise. First, will mass campaigns drive local entrepreneurs out of business? Secondly, if the local businesses persist, what role can they play in keeping up with gaps in net supplies.  Though not as technologically advanced as LLINs, these commercial nets might fill a gap if supplies of longer lasting insecticide packets were also sold.

As the end of December approaches, we come to suspect that UC may occur in waves over the next two years as supplies become available. In the meantime there needs to be research into the local net markets to learn about what is driving demand, the extent of this demand and the potential for the private sector to fill gaps now and as we need to keep up supplies into the future.

Integration Bill Brieger | 17 Aug 2010

Malaria Integrated into Secretary Clinton’s Address

With the greater emphasis on maternal and child health evidenced in the U.S. Global Health Initiative, the Gates Foundation, the G8 Summit and DfID, one might question whether health development assistance is veering away from diseases like malaria.  Secretary Hillary Clinton set that concern to rest today in her speech at the Johns Hopkins University’s School of Advanced International Studies.

Below are some excerpts that refer to malaria in a variety of contexts and show the continued commitment of the US Government to malaria control and elimination:

  • I’ve met … children in Angola who wake up every morning under bed nets and then head off to school eager to learn, unafflicted by malaria
  • We help prevent and treat malaria for more than 50 million people every year
  • We want to align our efforts with that of other donor countries and multilateral organizations, many of which do outstanding work to improve global health. Let me just mention one in particular: the Global Fund to Fight AIDS, Tuberculosis, and Malaria
  • Consider the life of a woman in one of our partner countries … Sometimes health services come right to her door, in the form of health volunteers bringing bed nets to protect her family from malaria
  • angola-children-get-nets-an-child-welfare-clinic-sm.JPGWe are taking the investments our country has made in PEPFAR, the President’s Malaria Initiative, maternal and child health, family planning, neglected tropical diseases, and other critical health areas – building on the work of agencies across the federal government, such as the Centers for Disease Control – and expanding their reach by improving the overall environment in which health services are delivered

This last quote shows clearly that the US Government aid effort sees malaria as part of the broader health development picture. We encourage all partners not to lose sight of the need to reduce child and maternal morbidity and mortality by integrating malaria control into all MCH efforts.

Advocacy Bill Brieger | 16 Aug 2010

African Union commits to maternal and child health and malaria

Guest Blog by Kathryn Bertram, VOICES Project

African leaders attending the 15th African Union Summit from 19th to the 27th July in Kampala agreed to extend the Abuja call towards accelerating universal access to HIV/AIDS, TB and malaria services in Africa, and called on the Global Fund to create a new window to fund maternal, newborn and child health.

auchair.JPGAccording to the AU declaration: “We appeal to development partners and donors for the replenishment of The Global Fund during its October 2010 meeting and to ensure that the new pledges are earmarked for Maternal Newborn and Child Health.”

This year’s AU Summit carried the theme of maternal, newborn and child heath in order to fill a gap that critics say existed in the African Union’s health strategies. At least 35 heads of state attended the event, despite the recent Al-Shabaab bombings that killed scores in Kampala the week before.

African Heads of State participated in at least two maternal, newborn and child health events, one of which—a maternal and child health-themed advocacy gala—was jointly sponsored by the VOICES project at Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs (JHU-CCP) and 10 other global health organizations.

Organizations called on heads of state to increase commitments to improve the health of women and children in Africa and achieve the Millennium Development Goals (MDGs).

mus_speech.JPGDemonstrating that global health organizations with disparate agendas can integrate their calls to action effectively,  partners included JHU-CCP, United Against Malaria, African Leaders Malaria Alliance, UNAIDS, StopTB Partnership, Roll Back Malaria Partnership, UNITAID, The Partnership for Maternal, Newborn and Child Health, and the United Nations Foundation in addition to The Global Fund to Fight AIDS, Tuberculosis and Malaria, Friends Africa, and the Global Alliance for Vaccines and Immunization.

Maternal, newborn, and child health and development is an important issue for malaria prevention advocates as malaria heavily impacts pregnant women and children. Although recent surveys show that fewer children under-five years in Africa are dying from malaria—and ITN use by children rose 20% over 8 years across 26 African nations—malaria is still a major killer of this age group, accounting for one quarter of all deaths.

Fifty million pregnant women are also affected by malaria, accounting for ten percent of maternal mortality annually.

yvonne_presidents.JPGUganda President H.E. Yoweri Museveni reminded other African heads of state that health investments are development investments. “We know that when we focus our resources, we have measurable impact,” he said, pointing to successes relating to maternal and child health. “For instance, 10% more children and 9% more women [in Uganda] now sleep under nets compared with six years ago.”

United Against Malaria Ambassador and African singing sensation, Yvonne Chaka Chaka, said, “So much progress has been made to stop the under-fives dying from malaria, to prevent children being orphaned by TB and HIV/AIDS…and to curb preventable diseases with widespread immunization efforts. We must continue and ramp up efforts for women and children in recognition of their importance for Africa’s future.”

According to the AU Commissioner for Social Affairs, Bience Gawanas, the summit was “historic.” She said, “[W]e have been asking about political will and leadership and there is no doubt that the AU heads of states and governments have shown the political will to promote maternal and child health on the continent.”

More information about the joint health advocacy events and the AU assembly declaration is available at the VOICES website.

Photos are of Uganda President H.E. Yoweri Museveni, AU Chair H.E. Bingu wa Mutharika, President of Malawi, and Yvonne Chaka Chaka with President Kikiwete of Tanzania.

Drug Quality &Treatment Bill Brieger | 14 Aug 2010

No unqualified acceptance for prequalified medicines

According to the World Health Organization, its “Prequalification Programme aims to make quality priority medicines available for the benefit of those in need.” The results is a “list of prequalified medicinal products used for HIV/AIDS, malaria, tuberculosis and for reproductive health.” The list is supposed to guide purchasing decisions of all UN and development partner agencies.

dscn0689a.JPGThe Global Fund is one of the international agencies that encourages its recipient countries to buy from the prequalified list, and through the Affordable Medicines Facility, malaria (AMFm) intends that not only good quality is promoted, but reduced prices. Interestingly, this development has raised concern in Nigeria, the biggest market for malaria drugs in Africa.  As Soyombo Opeyemi explains in the Daily Independent

The proposed intervention by The Global Fund to drastically reduce prices of Artemisinin Combined Therapies (ACTs) through its Affordable Medicines for Malaria programme (AMFm), which will see ACTs from six foreign companies sell from September 2010 at a monitored price regime of between N60 and N70 a dose [between US $ 0.40-0.47], as against the current average price of N350 for most ACTs produced or marketed in Nigeria, has generated a rumpus in the last few weeks in the media.

The controversy arises over two competing development goals – making high quality medicines available to those in need at affordable prices vs strengthening local industrial capacity. As seen in the Table below, many of the manufacturing sites are in ‘developing’ countries, but as Abdullahi Mohammed points out in This Day …

(These manufacturers) also have access to cheap credit, enjoy tax reliefs and export incentives, among other forms of official assistance. All this makes it difficult for Nigerian manufacturers, who currently have practically no access to bank credit and are stuck with providing their own infrastructural requirements, to compete with their foreign counterparts.

Companies Producing WHO Prequalified Anti-Malaria Drugs

Amodiaquine + Artesunate

·         Ipca Laboratories Limited

Dadra and Nagar Haveli (U.T.), India

·         Guilin Pharmaceutical Co. Ltd

Guilin, Guangxi, China

·         Cipla Ltd

Patalganga, India; Goa, India

·         Sanofi-Aventis Group

MAPHAR Laboratories, Casablanca, Morocco

Artemether + Lumefantrine

·         Novartis Pharma

Beijing, China; Suffern, USA

·         Ajanta Pharma Ltd

Paithan, Aurangabad, Maharashtra, India

·         Ipca Laboratories Ltd

Dadra and Nagar Haveli (U.T.), India

·         Cipla Ltd

Patalganga, India; Himachal Pradesh, India

The Nigerian malaria drug market is vast. There are dozens of Arthemeter-Lumefantine ACTs approved for sale and over 100 Artesunate-Amodiaquine formulations. Some of these are produced by actual Nigerian manufacturers while others are imported by a Nigerian Company from India and elsewhere. It would be important to identify the actual indigenous manufacturers who are losing out to the six big international pharmaceutical producers.

dscn1575a.JPGIt is not clear whether there are actual foreign assistance efforts aimed at building the capacity of malaria endemic countries in Africa to produce their own pharmaceutical products.  If such a longer term project were started in parallel with efforts like AMFm, there may be more acceptance for temporary set backs in the local market, knowing that in good faith, the international community is trying to strengthen countries’ abilities to fight malaria into the future.

the challenge though is which aid program can address the infrastructural problems facing Nigerian manufacturers – lack of reliable electricity, water supply and roads – as well as a legal framework that protects intellectual property and gives the local companies a fair chance to compete.