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Monthly Archive for "December 2010"

Health Systems Bill Brieger | 31 Dec 2010

Health systems in World Malaria Report 2010

[This posting was developed for and simultaneously appears in’s blog today]

Since the World Malaria Report 2010 was published, the main news reports have focused on the numbers – including increases in malaria programme financing, numbers of people protected by malaria interventions, number of cases confirmed through parasitological diagnosis, and number of artemisinin combination therapies (ACTs) procured.

wmd-2010-cover.jpgKey reductions were reported in the number of confirmed malaria cases and malaria mortality and burden. There is a recognition that not all locations experienced the positive trends. Quoting the report: “There was evidence of an increase in malaria cases in three countries in 2009 (Rwanda, Sao Tome and Principe, and Zambia). The reasons for such resurgences are not known with certainty. The increases in malaria cases highlight the fragility of malaria control and the need to maintain control programmes, even if numbers of cases have been reduced substantially.” The report stressed the importance of surveillance systems in detecting these challenges.

These contrasting findings show that we need to identify the factors responsible for fragility or strength in health systems in order make malaria control progress possible. The 2010 World Malaria Report differs little from its predecessors in that it does not provide much of substance to document which health systems interventions have made gains possible and retreats unfortunate.

For example, the report lets us know generically that, “Much of the support for malaria control activities derives from existing health systems in countries. This is true especially for the treatment of acute disease – where health workers, hospitals, clinics and other infrastructure are typically provided by the national governments or supported by non-governmental organizations.” We also find statements such as, “The monetary value of such benefits (from increased diagnostic testing) is uncertain, but there is consensus that these are worthwhile objectives for health systems”.

Concerning country case studies, we are told that, “…they reflect the burden that malaria places on the health system. Changes in the numbers of cases and deaths reported by countries do not, however, necessarily reflect changes in the incidence of disease in the general population, because …” of inadequacies in health information systems. It would be most helpful to share examples and evidence of health information systems that actually work to help countries target interventions more effectively.

Again the obvious is stated … “Policies may vary according to the epidemiological setting, socioeconomic factors and the capacity of the national malaria programme or country health system. Adoption of policies does not necessarily imply immediate implementation, nor does it indicate full, continuous implementation nationwide.”

We would love to see evidence of successfully implemented policies that have made a difference.

We have a belief that health systems reform and health systems strengthening are important aspects of achieving universal coverage of malaria interventions. We would really like to have our belief backed by evidence presented in future World Malaria Reports.

Partnership &Peace/Conflict Bill Brieger | 31 Dec 2010

Can Southern Sudan Vote for Independence from Malaria?

As the New York Times in describing preparations for the independence vote in Southern Sudan points out today, “With little more than a week to go until the vote, ballots have been printed, voters registered and campaign rallies held. A countdown clock is posted in the capital, Juba, and foreign officials are flying in for the occasion.”

According to the Times The United Nations Development Program (UNDP), which is responsible for demobilizing various armed forces in the area,may have ” grossly mismanaging the money and may have even intentionally misled donors as to the program’s success.”

The UNDP is also responsible for the Global Fund Round 7 Malaria Grant in Northern Sudan. It may be doing a better job with its malaria assignment. The most recent grant progress report rated them well with a ‘B1’, but raised the concern that, “The cash absorption rate during this reporting period is only 56% of the budget. This is attributed to delays in procurements.”

sdn_mean-ss-line-2.jpgThe North has a mix of malaria transmission situations, while the South is squarely in the endemic zone (as seen in map to right). When the South votes soon for Independence, what will be their own chances of becoming independent from malaria?

The Round 7 Malaria Grant in the South is managed by PSI. The Grant started 2 years ago and currently also rates a ‘B1’. At the most recent grant progress report dated October 2010, the following were achieved:

  • 86% of ITNs had been distributed
  • 10 BCC media campaigns had been implemented and over 6000 community organization staff had been trained, exceeding targets
  • Only 17% of targeted children had been treated with ACTs in the community
  • Health facilities exceeded expectations in terms of maintaining ACT stocks

The progress report concludes that, “Strengthening the capacity of the health system to
deliver health services including malaria interventions have fallen behind set targets, due to late SR selection and contracting, and the PR focusing on the LLIN mass distribution campaign. Nevertheless, results seem to be gaining on set targets.”

Southern Sudan is not without malaria partners. For example, PSI has been working Southern Sudan since “January 2005, distributing Serena long-lasting insecticide-treated nets (LLIN) through the commercial sector … (and providing) support to the Ministry of Health (MOH), Government of Southern Sudan, and county health departments to prevent and treat malaria.” The IRC has trained “villagers to recognize and treat young children for malaria, diarrhea and pneumonia has helped to reduce child deaths by 81 percent in one area of Southern Sudan.”

USAID is also working to help tackle the malaria problem in Southern Sudan. The area has been one of three ‘non-focus’ countries – that is not formally under the US President’s Malaria Initiative (PMI). Two of these countries, Nigeria and Democratic Republic of the Congo, have been added to the formal PMI roster. One wonders whether the fate of malaria control in Southern Sudan rests on the election outcomes.

The BBC quotes a Southern Sudanese nurse who compares the upcoming referendum, “.. as a mother giving birth to twins – once the labour pains are over, the two children can grow up as friends .” We know that malaria during ‘pregnancy’ and during ‘infancy and young childhood’ are threats to survival. We hope that all donors will continue to work for the survival of these Sudanese ‘children’ and bring about a true independence from malaria.

Universal Coverage Bill Brieger | 30 Dec 2010

Universal Coverage – if not now, when?

In the waning hours of 2010 several public health goals and targets come to mind –

  • Access to clean water and sanitation by 1990
  • Guinea worm eradication by 1995
  • Health for all by 2000
  • Polio eradication by 2005
  • Universal Coverage of malaria interventions by 2010
  • Millennium Development goals by 2015

As of October 2010 Nigeria had distributed long lasting insecticide-treated nets (LLINs) 14 of the 36 states and the Federal Capital Territory and about 40% of the targeted 60 million plus nets. A key challenge was, “The lack of operational funds to support campaigns in 22 states significantly resulting in undue delays in the delivery of LLINs.” More progress was made during the remaining months of the year.

road-map-progress-2.jpgWhere are we on 31st December 2010? The Roll Back Malaria Partnership’s most recent report on progress toward targets (the country road maps) is seen in the chart to the right. Intervention coverage progress is based on the number of countries that are actually implementing nets, medicines and spraying.

As can be seen the best progress comes with treatment and preventive medicines (ACTs and IPTp respectively).  Only 64% of countries have distributed at nets to at least 80% of the targets. The biggest gap in in the area of rapid diagnostic testing.

Distribution of an intervention does not mean actual coverage has been achieved. A recently reported study from Nigeria shows the challenges once nets reach the household.

Oyeyemi and colleagues found that 95.2% of households has received a net after a campaign. Unfortunately progress went downhill from there: “87.3% of the LLINs received were present in the households during the survey and 52.1% of households hung their LLINs … (and) utilization rate of a LLIN among the sampled population was 59% the previous night before the survey.”

Recent Demographic and Health and Malaria Indicator Surveys from places like Liberia, Senegal and Nigeria show that possession of a net by a household is not a guarantee that it will be used.

From the chart above we can see that efforts to attain universal coverage – or more accurately universal distribution – will have to proceed into 2011.  Distribution goals require health systems strengthening. The coverage goals will require more intensive community outreach and education to ensure these interventions are actually used.

We are achieving outputs – commodities distributed; we are struggling with outcomes – commodities used. What will we see in terms of impact by 2015 – the latest on the list of public health targets where we started this posting?

Funding &Treatment &Universal Coverage Bill Brieger | 30 Dec 2010

Prepaid mechanisms can promote Malaria treatment and save lives

Tarry Asoka, a medical doctor and health development consultant, provides us a perspective on why health insurance is needed to meet malaria treatment gaps. Tarry is  Publisher/Editor of Health Insurance Affairs and Malaria Bytes

All across sub-Saharan Africa the poor utilization of modern health services usually reverses and begins to improve, reaching a tipping point as soon as there is confirmed indication that ‘treatment charges’ in health facilities have been removed. And politicians in the sub region are very quick to take good note of this phenomenon – often taking full advantage to develop populist ‘free health campaigns’ that are often not sustainable.

waiting-for-free-medical-treatment-rivers-state.jpgThe lack of continuity is not usually the result of faulty design but due to poor execution as many of these are mostly ad hoc initiatives rather than enduring programmes. But the fact that these campaigns continue to be popular especially among poorer citizens despite their lack of permanence and irrespective of who is organising it – government, NGOs or private – should give health planners some worry that something is not quite right.

Curiously, malaria is still the most common condition recorded by health professionals during such health jamborees. A recent free medical check-up drive to promote a new community-based health care programme in a high density area in Port Harcourt, Rivers State, Nigeria – noted that close to 30% of those who were seen had classical symptoms and signs of malaria that have not been treated for at least 2 days.

So what could have happened to such persons especially children if this event did not take place at that particular point in time? Your guess is as good mine.

But one fact is clear – the payments that are needed to be made at the point of accessing health services prevent large majority of the population from seeking medical care. A recent survey in Kenya, for example, found that “61.5% of individuals who did not seek (malaria) treatment reported that cash shortage was the main barrier.” Others coped by borrowing, selling household possessions, or buying cheap drugs from shops.

Therefore, any mechanism that enables people to access care ‘free at the point of delivery’ will improve treatment for life-threatening conditions such as malaria and save lives.

This is ‘no-brainier’, and does not require elaborate plans to be put in place. Apart from informal and community-based health insurance, which has been quite challenging to set up, other approaches such as vouchers and coupons have also proved to be useful alternatives.

The task now is to scale-up these options to achieve universal coverage.

Peace/Conflict Bill Brieger | 29 Dec 2010

Politics and malaria elimination do not mix

The New York Times reported this week that …

Malaria cases jumped 25 percent in Sri Lanka from 2009 to 2010, the country’s ministry of health is reporting. And while this year’s total is still small, at 580, the trend is unsettling to experts. Sri Lanka is a bellwether for the dream of malaria eradication — and Exhibit A for the argument that politics affects the disease more than climate or public health measures do.

Major strides had been made during the first malaria eradication effort when cases fell from half a million to 18 (in 1963).  Unfortunately, “Malaria persisted, with cases highest in the north and east, where the Tamil Tiger insurgency was strongest.”

malaria-operational-plan-unhcr2.jpgConflict scenarios that inhibit malaria control progress are more common that we often acknowledge.

Côte d’Ivoire is in a precarious position again. Researchers reviewed “household data that were collected before and after an armed conflict in a rural part of western Côte d’Ivoire, and investigated the dynamics of socioeconomic risk factors for neglected tropical diseases (NTDs) and malaria. We identified a worsening of the sanitation infrastructure, decreasing use of protective measures against mosquito bites, and increasing difficulties to reach public health care infrastructure.”

East Timor was luckier than most. “Although the political crisis affected malaria programs there were no outbreaks of malaria.” What may have saved the day was a focus on malaria services on camps of internally displaced persons (IDPs). The experience gave rise to policy changes to ACT medicines and rapid diagnostic testing.

East Timor may also have experienced a fortunate juxtaposition of factors including previously decreasing prevalence from interventions prior to the conflict, IDP camps were located close to service organizations, and the timing occurred at the end of the rainy season when incidence normally decreases. The authors note that other conflict locations like the Democratic Republic of the Congo have not faced such a positive scenario.

Researchers have rightly pointed out the challenges to understanding disease dynamics in conflict situations: “Situational constraints and methodological obstacles are inherent in conflict settings and hamper conflict-related socioeconomic research.”

Charles Mgone observed that conflict zones within countries often receive less funding and of course research capacity development to help understand the nature of the problem and potential solutions. He therefore recommended “Special attention should also be given to those with more acute capacity needs and high disease burden, such as communities in conflict-affected regions.”

Paul Spiegel and colleagues give a wake up call. Less that half of national strategic plans (NSPs) and Global Fund proposals for HIV and malaria address the needs of refugees and IDPs. They conclude that, “For NSPs, strong and concerted advocacy at global, regional and country levels needs to occur to successfully ensure that affected populations are included in their plans. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals.”

Corruption &Learning/Training Bill Brieger | 26 Dec 2010

Global Fund – timely oversight or trigger happy

In the past year the Global Fund to fight AIDS, TB and Malaria (GFATM) has suspended grants in Mauritania, The Philippines, Zambia, and Mali. In fact one grant to Mali was terminated. Efforts to identify high risk grants are underway.
Some are saying that the Office of the Inspector General (OIG) of GFATM is finally showing some teeth, while others worry that actions to suspend and terminate will harm the very persons that the Global Fund was set up to help. At the recent 22nd GFATM Board Meeting the Executive Director provided the following comments based on OIG work:

  • Based on recent OIG findings in a number of countries, activities involving cash transfers for training events and associated costs, including per diems, travel, meal and expense payments, are in many cases posing a high risk of misuse
  • The OIG has identified five countries where measures to protect Global Fund-financed drug shipments from theft need to be implemented
  • The Secretariat and OIG agree that LFAs have not been sufficiently focused on the identification of fraud risks and actual fraud in Global Fund-financed programs, and may not currently have the capacity to address these risks

Prior to the recent Board meeting, one wonders whether the communication between the Secretariat, the Executive Director and the Office of the Inspector General were clear and efficient. A 6th December 2010 memo entitled “Joint communication on Inspector General matters” mentioned that, “The Inspector General and the Executive Director of the Global Fund have initiated sincere effort towards collaboration to follow up on recent findings by the Inspector General as well as to take steps to permanently strengthen grant oversight.”

The memo concluded that, “The Global Fund, by nature of its mandate, sometimes has to work with entities with weak programmatic and financial capacity, and to operate in environments where there may be a paucity of financial controls and lack of oversight systems. The Global Fund’s risk management systems are constantly improving. Recently discovered fraud has made the Secretariat determined to redouble its efforts to improve these systems.”

In some cases of suspended grants the Global Fund is looking for alternative Principal Recipients to manage the funds or find alternatives to ensure services to those in need do not cease to be served.  The concern about the Local Fund Agents is valid since the Global Fund, unlike other international agencies, does not have country offices or provide technical assistance.

Several years ago I worked with a team in Nigeria to design and deliver adolescent and youth peer education on reproductive health through community based organizations (CBOs). The initial effort focused on how to organize and train peer educators and the technical aspects of reproductive health. Eventually it became obvious when one CBO leader was using her personal bank account to keep project funds that the local CBOs needed as much technical assistance in establishing and maintaining proper financial and accounting procedures as they did in organizing peer based reproductive health education.

The Global Fund operates in a scale thousands of times larger that our small peer education projects, but the basic principle remains. Don’t condemn local organizations for poor financial performance if you did not try to help them develop better financial and accountability procedures in the first place.

Currently 22% of grants are considered to be poor performers. Too much is at stake in reaching 2015 and beyond to simply say to poor performers, “sorry, your funds are suspended.”

Diagnosis &Research &Treatment Bill Brieger | 26 Dec 2010

Malaria Treatment Guidelines – are health workers aware?

Malaria Journal published a few days ago an article comparing the costs of treating children and adults for malaria at a Nigerian hospital based on clinical diagnosis versus treating only when microscopy was positive for parasites. Normally we would pass abstracts from such articles on to members of our listserve (see link at right), but comments from a colleague in Nigeria gave pause.

He rightly pointed out that normally any research that helps us consider the factors involved in proper malaria diagnosis and treatment is welcome as we move toward universal coverage and elimination. His concern was that the researchers, who conducted their study in 2009, had not followed national malaria treatment policy and guidelines, which had been promulgated in 2005 based on the alarming growth of resistance of malaria parasites to the common, though cheap, antimalarials such as chloroquine and sulphadoxine-pyrimethamine (SP).

First the cost findings from the team at Bowen University Teaching Hospital (aka Baptist Medical Center, Ogbomosho) –

  • For children, testing all but treating only Giemsa positives was $6.04/child
  • Empiric treatment of all children clinically diagnosed was $4.49/child
  • For adults, treating only Giemsa positives was $4.84/adult for treatment option one and $4.97/adult for option two
  • Empiric treatment for adults was $4.14/adult for option one and $4.63/adult for option 2

In spite of the cost findings, the researchers did point out the drawbacks of empirical or clinical diagnosis in terms of accuracy and potentials for promoting drug resistance and called for scale up of rapid diagnostic tests (RDTs) to address these concerns.

The treatment regimens in this study included …

  • Pediatric patients: artesunate (6-9 tablets of 3 mg/kg on day one and 1.5 mg/kg for the next four days) plus amodiaquine (10 mg/kg on days one to two and 5 mg/kg on day three in suspension)
  • Adult option one: four and one-half 50 mg artesunate tablets on day one and nine additional artesunate tablets over the next four days, plus three 500 mg sulphadoxine/25 mg pyrimethamine tablets
  • Adult option two: four and one-half 50 mg artesunate tablets on day one and nine additional artesunate tablets for the next four days plus nine 200 mg tablets of amodiaquine at a dose of 10 mg/kg on day one to two and 5 mg/kg on day three

National treatment guidelines specifically stress use of artemisinin-based combination therapy (ACT) for basic, uncomplicated malaria treatment.These guidelines are undergoing further revision with a stronger emphasis on ACT use based on RDTs and microscopy where available and recognition of the dangers of monotherapy drugs like chloroquine, SP and even artesunate itself.

The researchers from Ogbomosho are rightly concerned about cost issues, and being a private/NGO university and hospital, they do witness the direct effects of medication costs on patients that health staff in the public sector may not see.

This is still no excuse for not following national treatment guidelines when these drugs were available for their procurement in 2009. Now with the advent of the Affordable Medicine Facility malaria (AMFm) in Nigeria all health facilities, especially NGO hospitals like Ogbomosho, have no reason not to buy and dispense the correct medicines.

To re-emphasize this point, a press release from November 2010 clearly states –

“The Federal Government has directed all medical doctors and other health officials in the country to henceforth start using Artemisinin-based Combined Therapy (ACT) for the treatment of malaria disease in the country. Minister of Health, Prof. Onyebuchi Chukwu, gave the directive yesterday in Abuja during the ministerial press briefing on Affordable Medicines Facility (AMF) for malaria programme. According to the minister, the spread of malaria had become so critical that everyone in the country was now involved.”

We hope health workers in all sectors get the word! Hopefully national authorities will step up their efforts to disseminate guidelines to all front line health workers whether in public, private or NGO sectors.

Agriculture &ITNs Bill Brieger | 23 Dec 2010

Malaria, Farms and Mobility

Whether overnight stays in farming huts poses a risk of malaria infection is a question being asked by researchers in Laos. Daisuke Nonaka and colleagues determined that “staying overnight in farming huts was not associated with an increased risk of malaria infection in the setting where ITNs were widely used in farming huts.”

Net use was greater in the rainy reason than dry in both farm huts (95% vs 66%) and main residences (82% vs 86%), and there were fewer nets on average in huts in the dry (1.1) and rainy seasons (2.3). The average number in main residences decreased from 3.1 in the dry to 2.1 in the rainy seasons.  This implies some movement of both people and nets between residences and seasons.

Another interesting finding was that there was higher prevalence of malaria when 5 or more people shared a net. Though the findings do not specify whether these sharing practices vary by residence or season, one might suspect a bit more crowding in the farm huts, and this should be explored.

village-huts-sm.jpgEnsuring adequate number of ITNs to achieve universal coverage when people have one residence is a big challenge. In fact most procurement estimates are based on population, not residences.  Are there enough nets to cover all sleeping spaces, even if this means extra nets for a family?

Researchers in Tanzania when net supplies were not as large as today found that, “The household’s location at the time of interview (whether at their farm or village homes) was associated with parasitemia, and those residing at their farms were more likely to be parasitemic than those at their village houses, all other things held constant.”

Likewise, we found that mobility between farm and town settlements affected availability and use of cloth filters to prevent guinea worm.  Absence from the farm settlement at the time of ivermectin distribution is an important factor that affects coverage in onchocerciasis prevention efforts.

Unlike bednets, cloth filters for guinea worm can be more easily carried from one residence to another, and ivermectin pills can be kept easily until a mobile villager comes back.  Bednets by themselves pose challenges of hanging in even one residence, but ultimately we need to address the challenge of matching bednet supplies with the fact that rural people can have more than one residence in order to eliminate the disease.

Integration &Mosquitoes Bill Brieger | 21 Dec 2010

Two for One – ivermectin and mosquitoes

Suppose that when mosquitoes bit you, they died. The possibility that a human blood meal can kill mosquitoes sounds far fetched, but has been observed as a by-product of mass community mass drug administration (MDA) of ivermectin for lymphatic filariasis in Senegal.

Researchers in Senegal compared villages where MDA was performed with a control set of villages and concluded that, “Ivermectin MDA significantly reduced the survivorship of An. gambiae s.s. for six days past the date of the MDA, which is sufficient to temporarily reduce malaria transmission. Repeated IVM MDAs could be a novel and integrative malaria control tool in areas with seasonal transmission, and which would have simultaneous impacts on neglected tropical diseases in the same villages.”

This is not the only time links have been made between malaria and lymphatic filariasis. A good example was community distribution of insecticide treated nets were provided in Nigeria, which curtailed the mosquitoes that carried both diseases.

In MDA programs for filariasis control “The goal is to treat 80% of the eligible, at risk population yearly, for at least 5 years, in order to interrupt transmission and prevent children from becoming infected.” The window of opportunity for collaboration between MDA and malaria control programs is therefor, very focused.

A smaller scale study reported in July of this year found that, “In mosquitoes feeding on volunteers given ivermectin the previous day, mean survival was 2.3 days, compared with 5.5 days in the control group (P < .001, by log-lank test). Mosquito mortality was 73%, 84%, and 89% on days 2, 3, and 4 in the ivermectin group." Since ivermectin started as a drug for veterinary parasites, it is useful to note that similar results on mosquitoes were found after cattle were given ivermectin. Researchers from Michigan State University* reported that, "Most (90%) of the An. gambiae s.s. that fed on the ivermectin-treated cattle within 2 weeks of treatment failed to survive more than 10 days post-bloodmeal. No eggs were deposited by An. gambiae s.s. that fed on ivermectin-treated cattle within 10 days of treatment." The authors concluded that, "Treatment of cattle with ivermectin could be used, as part of an integrated control programme, to reduce the zoophilic vector populations that contribute to the transmission of the parasites responsible for human malaria." community-ivermectin-distribution-in-buea-cameroon.jpgIvermectin distribution of course has been the major strategy of the the African Program for Onchocerciasis Control (APOC) for the past 15 years.  APOC’s efforts will continue much longer than those of lymphatic filariasis in over 100,000 communities throughout the continent.

More attention to joint planning and coordinating of malaria and other disease control efforts should be synergistic and mutually beneficial for the populations, who according to APOC, live beyond the end of the road.


Monitoring &Surveillance Bill Brieger | 20 Dec 2010

Lessons from 3 Rounds of Malaria Indicator Surveys in Zambia

mis-2010-report-cover-2.JPGTodd Jennings of MACEPA (Malaria Control and Evaluation Partnership in Africa, PATH)
and the National Malaria Control Centre, Lusaka, provides us with an update on the newly completed Malaria Indicator Survey from Zambia.

Earlier this month Zambia’s Ministry of Health released results from their 2010 National Malaria Indicator Survey (MIS).  The full report, summary and technical brief are available on the National Malaria Control Center website.

Zambia is the first African country to have conducted three of these surveys, continuing a trend in benchmarking progress and providing evidence for decision makers to guide malaria control needs.  First the good news:

  • The use of insecticide-treated mosquito nets increased for children under the age of five increased to 50%, and to over 60% in household that owned nets in 2010.
  • Over 70 percent of Zambian households are now covered by at least one treated mosquito net or recent indoor residual spraying.  This represents a 69 percent increase since the 2006 survey.
  • Pregnant women are more protected from malaria with 70% receiving at least two doses of preventive anti-malarial medicine during pregnancy.
  • Among children using anti-malarials for treating fever, more children are receiving Coartem®, the first line treatment for malaria, rising from 30% in 2008 to 76% this year.

progress-in-itn-use-in-zambian-children-under.jpgThese figures are among the best in Africa. Better diagnostics nationwide, especially with rapid tests to confirm malaria parasitemia, mean fewer patients with symptomatic fever are being given anti-malarial drugs and more receive better treatment counseling based on the rapid and accurate results.

But these encouraging figures are tempered with news that Luapula, Northern and Eastern Provinces reported higher levels of malaria and severe anaemia.  This can partly be attributed to heavy, late rains that possibly extended the length and intensity of the transmission season and partly because net ownership and use of nets in Luapula and Northern Provinces saw a marked decrease since 2008.

mis2010_parasitemia06-10d-2.jpgThe MIS is a powerful tool needed to maintain predictable funding streams to sustain levels of commodity coverage.  Gains are fragile; any interruption in supply, e.g. bednets, can quickly result in a malaria comeback.  Zambia and partners are already taking steps to address the country’s gap in bednet coverage. Other countries could benefit from more timely surveys and stronger partnership responses.

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