Tropical Health Matters

The Global Fund to fight AIDS, TB and Malaria (GFATM) represents a different business model in international health and development aid. Unlike traditional aid agencies, the GFATM does not maintain a direct in-country presence of technical and administrative staff who work directly with counterpart local agencies to develop plans for funding.  The GFATM’s business model basically raises funds and turns these over to local recipients (government ministries, national NGOs, international partners etc.) who have submitted technically and financially feasible proposals during annual funding rounds.

These local recipients set their own targets and basically are given enough rope to succeed or to hang themselves.  The latter appears to have garnered the attention of the international media after several grants have been suspended and words of caution have been directed at others who not only have not achieved their self-set targets but appear to have misappropriated, misused or otherwise ‘lost’ some of their funds. One recent account shows that such loss may be in theft of product, not just straight-forward embezzlement of funds.

Local recipients receive some oversite in terms of both expenditure and achievement of program targets. In theory the local recipients – both Principle Recipients (PRs) who are money managers and Sub-Recipients (SRs) who are program implementers – are screened and approved by a national Country Coordinating Mechanism (CCM). The set of projects in a country are also overseen by a Funds Manager based in Geneva who reviews reports and makes occasional site visits.

There are quarterly progress reports submitted through CCMs to independently contracted Local Fund Agents (LFAs), who in the past were more of accounting firms, but apparently now can also ‘audit’ technical aspects, and ultimately to GFATM itself. After two years (or functionally 18 months) each project is reviewed both finacially and technically and given a ‘Go’, ‘Conditional Go’ or a ‘No Go’ to enter ‘Phase 2.   This exemplifies another basic tenet of of the business model, performance based funding.

The GFATM is a consciously evolving organization and has conducted and contracted various evaluations in order to make decisions about program and organizational directions. Such have included the specific, a CCM assessment that identified the need to ensure these bodies were independent of government (or any other group) as well the general, a series of 5-year evaluations. As a result the GFATM has reconsidered funding processes and is evolving toward more alignment with national disease control strategic plans and less on focused annual funding rounds.

Another example of GFATM decision making based on evidence was the change in PR requirements for proposals. After an evaluation showed that NGO PRs performed generally better than government of international agency PRs, and also after it was found that NGOs better represent the interests of the recipient communities (e.g. people living with AIDS), the GFATM Board decided that all grant proposals should have at least one NGO PR.

In short, the GFATM has shown an ability to learn by actively seeking knowledge of its operations and make changes and monitor those.  Of course the recent reports from the Office of the Inspector General show that this is not an easy process to manage from afar given such a large portfolio.

The calls by some for the US Congress to do its own study of the stituation will hopefully not result in throwing the babies sick and dying from AIDS, TB and malaria, out with the bathwater. The GFATM has shown itself willing and able to change without such dire threats. We can still question whether the Global Fund would change its basic business model and become more than a funding agency.

Other aid partners are often left holding the bill for technical assistance to address needs and gaps in country programs. In theory country recipients can use their GFATM funds to pay for TA, but most prefer to go the guaranteed route of buying the commodities (that have gotten some in trouble). Agencies like WHO, USAID, DfID, Unicef, and the Clinton Foundation, to name a few, have always been willing in the end to cough up their own funds to support the TA that is not paid by the GFATM. This creates an uncomfortable marriage among aid agencies.

So maybe the Global Fund will preserve its business model, but if the Fund cannot or will not have a more active presence on the ground, maybe it should pay its aid partners to do this work, for which they have generously been using their own funds in desparation.

Researchers on the new RTS,S/AS01E malaria vaccine have extended the follow-up period on the children who had received the vaccine in Kenya and Tanzania and the vaccine which had offered 53% protection against malaria at 8 months, continued to be protective, though at a slightly reduced rate of 46% at 15 months.

People who bet may not like those odds, but the key to understanding this vaccine, which is likely to be the first into the public health system when final trials are over, is the nature of the actual effect. While the vaccine does not prevent the occurrence of malaria in most recipients over the long haul, it does prevent life threatening severe malaria including cerebral malaria and severe anemia – factors that contribute to malaria mortality.

The public health challenge going forward is three-fold (at least). The first challenge will be affective delivery of the vaccine though national immunization programs, which have had trouble keeping up with coverage of the routine immunizations like DPT and measles.

The second is convincing the public that a vaccine that does not completely prevent malaria in all children is worth their effort to get imminuzed. This is compounded by local perceptions that any fever might be malaria, and as we know there are many viral and bacterial causes of fever co-existing in the same environment and children as malaria. The vaccine will prevent malaria to an extent, but not preent fevers. This chalenges out ability to communicate.

The third challenge is how one should combine vaccination with prompt and appropriate case management (diagnosis, treatment and counseling) for those who do get malaria after the full regimen of the new vaccine.  This tests the oft stated premis that a vaccine is not a magic bullet, but part of a package of control interventions. One also hopes that people trust the vaccine to the extent that they abandon their insecticide treated bednets.

The battle for a malaria vaccine just begins when the research trials are finished. It is at this point where the human element, represented by health systems managers, community leaders and health consumers, need to be considered.  If this were a new soft drink or cell phone product facing the effectiveness and efficacy challenges described above, one could forgive investors from being wary.  In this case we cannot afford to be overly cautious investors when children’s lives are at stake.

Health literacy was a term coined to express people’s knowledge of useable health information.  Although the word ‘literacy’ is obviously about reading, just an numeracy is about one’s ability to comprehend and perform mathematical functions, it has been used because no one has come up with a comparable single word like ‘healtheracy’.

The implications of this concept introduces a prejudice into the coversation about health.  Especially in developing societies the word literate shines with positivity, while saying someone is illiterate is a term of abuse.  Are we therefore implying, even if we don’t say it, that people who lack our ideas of ‘health literacy’ are health illiterates?

Health knowledge is a culutral commodity.  Orthodox scientific knowledge about health is one cultural manifestation of what people know about what makes us healthy and what makes us unwell.  If not carefully used though, one can come across as saying that this scientific knowledge is the ‘correct’ way of viewing the world, and everyone else is ‘illiterate’ or wrong.  The term clearly can have neo-colonialist connotations.

Communities have local knowledge about the cause, effects, treatment and prevention of common ailments that have survival benefits and also some negative consequences. Scientific knowledge is also not without negative consequences since it is an evolving process – like knowledge in any cultural setting. What may seem scientifically correct today may be found to be misleading or dangerous tomorrow.  While we give science the benefit of the doubt when crafting our health literacy campaigns, we are not so charitable with local knowledge.

Neglecting local knowledge in the name of health literacy is a one way conversation.  Behavior change will never occur without dialogue where both parties learn from each other.  By engaging in a dialogue that shows respect for different point of view we can arrive at a solution that not only promotes health, but does so in ways that are culturally acceptable.

Use of long lasting insecticide-treated nets has an impact on malaria transmission, but the key to achieving an effect is ensuring that people both own and use the net.  A study from southern Benin has taken this process to the next level. Georgia Damien and colleagues found that, “only correct use of LLINs conferred 26% individual protection against only infection.”

The authors distinguished the use of LLINs – whether children were sleeping under it during the control – from the correct use – whether the LLINs were correctly hung and tucked and were not torn.
As reported by other sources, possession of a LLIN, in this case over 90% of households in a southern Benin community, did not guarantee use, which varied on average from 73% in the rainy to 67% in the dry seasons.  Correct use likewise varied from 68% to 42% by season.

Although the Benin study implies that the protective effect of nets may result only from ‘correct use’, earlier work in Ghana showed that some protection was possible even if a household did not have LLINs.

Binka and co-researchers reported that, “The death rate among unprotected individuals increased with distance from the nearest compounds with bed nets. This suggests that (insecticide-treated nets) are protecting other individuals without bed nets who sleep close to protected compounds.”

Much of our hope for achieving morbidity and mortality goals rests on what could be called this community protective effect of nets, since it is difficult, considering the nature of human behavior, to expect everyone to use a net, let alone use it correctly.

We now know our goal for universal net coverage will not be met until well into 2011. The challenge as can be seen in the photos is not just distribution, but effective community health education to ensure that nets are valued and used correctly.