Posts or Comments 27 May 2024

Monthly Archive for "May 2012"

Drug Quality &Treatment Bill Brieger | 28 May 2012

Controlling the Malaria Drug Supply

The recent scare concerning the magnitude of fake and poor quality malaria drugs in circulation has raised a number of questions about malaria drug supply management in endemic countries.  The big question is who makes the decisions about what comes in and how it is used? Debates around public and private sector medicine use further complicates the debate.

dscn7285sm.JPGIn all cases there do seem to be national malaria treatment policies that specify the types of medicines appropriate for a ‘normal’ case of malaria, a case of severe malaria and cases of malaria in pregnancy.  Within these policies are strong preferences for artenmisinin-based combination therapy (ACT) drugs. WHO has gone to the extent of examining malaria drug production and has published and regularly updated lists of ‘pre-qualified’ medicines from reliable pharmaceutical companies.  This list usually guides the recommendations and purchases of major donors like the Global Fund and the US President’s Malaria Initiative.

Even with these various safeguards, the situation on the ground – and in the medicine shops and pharmacies – is quite variable. Lets look at two extremes.

Nigeria’s national case management guidelines do specify ACTs for first line malaria treatment.  The main recommendation for treatment in uncomplicated cases is artemether-lumafantrine (AL) and as an alternative artesunate-amodiaquine (AA).  Brand names are not specified, but for government and donor programs the choices do come from the WHO pre-qualified list.

Estimates vary, but roughly half of Nigerians get their malaria treatment in the private sector.  There one still finds chloroquine and sulfadoxine-pyrimethamine products on sale.  Over 100 different ACTs are registered with the National Agency for Food and Drug Administration and Control. It is not clear whether it has been possible to test the efficacy of all these different products. Let the consumer beware.

In Rwanda, not only does the Ministry of Health set malaria drug policy, it actually enforces it.  Even in private pharmacies one can only buy the approved form of AL, Coartem.

Aside from the size of the two countries, what makes the difference? Political will to adhere to scientific evidence!

Closer to Rwanda, Edward Ojulu looks north and observes that, “Just across in neighboring Uganda, authorities say they suspect nearly 30% of the drugs imported into the country to be fake counterfeits. The tragedy is that the National Drug Authority, a Uganda Government agency that regulates manufacture, import and distribution of human drugs in the country, says it has neither the equipment nor the manpower to stop fake drugs from being sold to the people.”

Edward gets to the heart of the matter when he notes that, “Malaria is big business for pharmaceutical companies world-wide and counterfeiters also know this.” It takes a lot of political will to stand in the way of the profit motive. But that may be what is necessary to save the malaria drug supply and save lives.

Funding &Procurement Supply Management &Treatment Bill Brieger | 21 May 2012

Stock-outs: how can we achieve malaria treatment goals?

Of twenty-two malaria endemic countries in Africa that receive support from both USAID/PMI and the Global Fund, eleven reported gaps in malaria medicine funding in the 2011 Road Maps countries prepare for Roll Back Malaria.  Likewise, 16 of these countries reported gaps in RDT financing and supplies.

dscn0296sm.jpgThese stock and procurement problems arise from many causes including ability to forecast need,  poor donor coordination and leadership, and lack of adherence to new guidelines that require diagnostic verification of malaria before treatment among others.  We are well past the 2010 RBM target date to achieve 80% treatment coverage, but the most recent DHS and MIS results from the 22 countries for appropriate treatment of children below five years of age show that the country with the highest achievement of ACT coverage in this age group was Malawi with only 36.2%.  The median among these 22 countries was 16.5%.

Therefore, it was not surprising that The Citizen newspaper reported from Dar es Salaam that, “Thousands of Tanzanians have continued to die from malaria annually due to lack of medicines despite massive investment by the government and donors towards improved supply of relevant drugs in health facilities.” Apparently programs like SMS for Life and AMFm have not had their desired effects.

The Citizen lamented that, “Phone calls to the CEO of Medical Stores Department (MSD), which is charged with responsibility of distributing drugs in the country, went unanswered.”  Other malaria implementation partners gave their own views that the problem was due to lack of professionalism among health officials and a lack of commitment to implementing the malaria program.

If we cannot even achieve malaria treatment targets by 2010, what hope do we have of reducing mortality by 2015 – let alone head toward elimination? Technical assistance may be needed, but cannot succeed if there is a lack of will on the part of program implementation partners from the endemic countries.

Communication Bill Brieger | 19 May 2012

Malaria – a picture in words


Corruption &Health Systems Bill Brieger | 18 May 2012

Will Economic Woes Prevent Countries from Sustaining Malaria Programs

Over the past few years everyone has been worried about the willingness and ability for donor nations to provide continued support for malaria control efforts – either multilaterally through Global Fund contributions, or bilaterally.  Recent changes at the Global Fund itself reinforced these financial fears.  What may have been overlooked is the financial health of recipient countries themselves.

slide6_0-public-sector-financing-of-health.gifDonor support for malaria control provides major assistance for commodities, but usually is not expected to support the running of the basic health system from which those commodities are delivered to people in need of prevention or treatment services.  Recent news from two malaria endemic countries in southern Africa call into question the basic ability of governments to provide basic human and material health infrastructure.

The BBC reports that, “Britain is calling for urgent action to prevent a Greece-style financial crisis in Malawi, one of the world’s poorest countries, where recent political turmoil, a suspension of foreign aid, and an abrupt currency devaluation have conspired to leave the new government with a gaping hole in its budget.”

The new president believes that there is less need to worry because of existing pledges for cash that suspended last year because of the increasingly autocratic behavior of her predecessor.  But it is often easier to turn off the financial tap than turn it back on.  Donors become wary and wait and see.

Likewise the behavior of political elites is causing concern in Swaziland. According to IRIN the International Monetary Fund is withdrawing support from the country where government spending currently exceeds its revenue. While there has been a revenue from the Southern African Customs Union since 2008, a more proximate cause of financial woes is “The spending habits of King Mswati III – sub-Saharan Africa’s last absolute monarch – and the royal household are routinely splashed across newspapers, from the overseas shopping trips of his 13 wives to a “birthday present” for the king this year of a multimillion-dollar private jet.”

IRIN notes that “About two-thirds of Swaziland’s 1.1 million population live in chronic poverty in a food insecure country that also has the world’s highest HIV/AIDS prevalence, with one in four people aged 15-49 infected.” This is not an environment where malaria can be eliminated, as is the goal of the South African Development Community.

Controlling and eliminating malaria in the context of a strong health system requires political will.  Some countries are making great strides. Maybe the African Leaders Malaria Alliance can be a forum for applying peer pressure for ‘good political behavior’.

Civil Society &Community Bill Brieger | 10 May 2012

Fate of Civil Society at the Global Fund

The Global Fund Observer has poignantly highlighted the risks of losing a voice for civil society at the Global Fund.  The Fund to date had been one of the few donor groups to actively encourage civil society organization (CSO) participation on grant writing and management and has developed the innovative community systems strengthening approach to show that the people who live with the conditions supported by grants are as important as the systems that deliver formal health services.

kenaam-2.jpgWhile civil society is not perfect, it has served important functions within the Global Fund strategy.  To date the Global Fund Board has asserted the need for civil society representation on Country Coordinating Mechanisms (CCMS) as well as ensuring that CSOs are also considered equally as principal recipients (PRs) of funding.  This was based in part on findings some years ago that CSOs achieved better grant performance scores on average than did government or UN agency PRs.

CSOs come in many colors, but an important function of CSOs in any setting, even beyond the funding and management of Global Fund projects, is to serve as advocate and watchdog.   This is a crucial role as the GFATM’s Office of the Inspector General continues to uncover problems in grant management.  Here we don’t want to confuse NGO with CSO because some politically well connected NGOs have been caught with their hands in the till just as have government ministries. (One even wonders if recently disclosed Global Fund improprieties in Mali’s Ministry of Health were not a symptom of government weakness and corruption that led to its downfall?)

There is even worry expressed by the Civil Society Action Team that these moves might threaten the role of civil society in CCMs.
After dissolving the Civil Society Team at the GFATM, the new management wants civil society to feel happy that they now have several paths through which to pursue their interests – thus is laughable – the more paths, the more confusion and the less clear the status of civil society.

As mentioned from the start, the GFATM pioneered civil society involvement in major international grants processes because the ultimate recipients of such grants are often ignored with the consequence that targets are not achieved.  Most of the money that the GFATM receives comes from individual taxpayers in G8 countries. We taxpayers as members of our own communities want equal recognition of the members of endemic country communities in providing oversight to grants and becoming active participants in program implementation and evaluation.

It is not too much to ask that the people who should benefit most from the Global Fund have a distinct, definable role in the Fund’s processes.

Elimination Bill Brieger | 08 May 2012

Tackling Efficiency for Malaria Elimination in the Asia Pacific

Nancy Fullman shares highlights of Asia Pacific Malaria Elimination Network (APMEN) fourth annual meeting.

apmen_banner.gifThe twelve-country Asia Pacific Malaria Elimination Network (APMEN) is generating knowledge on what works to sustain the gains in malaria control and elimination during a time of malaria funding uncertainty. With the Republic of Korea as its host, the 2012 APMEN annual meeting takes place May 7 –11th 2012 in Seoul with the theme of “Efficiency in Elimination.” Focused on pressing malaria issues in the Asia Pacific region, APMEN countries and partners will discuss antimalarial drug resistance, cross-border importation of malaria cases, and maximizing program efficiency by identifying malaria “hot spots” and focusing interventions in these areas.

As the fourth of its kind, this APMEN meeting’s theme of “efficiency” reflects the urgent global need to maintain and expand malaria programs, in spite of substantial funding shortages related to the global financial crisis (e.g., postponed grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria)

With this meeting APMEN country representatives and partners aim to learn from country success stories – such as Cambodia’s impressive 35% reduction of malaria from 2010 to 2011 – and discuss strategic approaches for addressing the looming challenges of spreading artemisinin resistance and reducing the prevalence of Plasmodium vivax in the Asia Pacific. Although P. vivax is thought to account for fewer malaria deaths worldwide than P. falciparum (i.e., most prevalent strain of malaria in Sub-Saharan Africa), P. vivax is a main source of severe illness throughout the Asia Pacific region. Further, P. vivax currently has fewer effective treatment options than P. falciparum, which is a key research and investment issue identified by APMEN partners.

Since 2009, APMEN has brought together countries in the Asia Pacific that have adopted a national or subnational goal for elimination, as well as a broad range of key academic, development, non-governmental, and private sector partners. Through its regional network collaborations and annual gatherings, APMEN promotes the exchange of best practices, early introduction of innovative strategies, and support needed for country malaria control programs to push toward their goals for malaria elimination.

In 2012, work from several APMEN countries, including documentation of Bhutan’s malaria elimination efforts and subnational surveillance programs in the Solomon Islands, has received international attention. With Cambodia’s recent welcome to APMEN as the network’s twelfth country partner, this year’s APMEN meeting in Seoul aims to further broaden the dialogue among country partners and harness the region’s collective expertise to improve malaria elimination efforts in the Asia Pacific region.

Further information regarding APMEN can be found at