Posts or Comments 15 July 2024

Monthly Archive for "January 2013"

Corruption &Drug Quality &Funding Bill Brieger | 31 Jan 2013

Fakes and Fraud: another threat to malaria funds

While some countries are being praised this week for their progress in controlling malaria, Uganda seems to be suffering from a double knock out punch when it comes to malaria financing. Challenges have appeared in both the private and public sectors.

In the most recent scorecard from the African Leaders Malaria Alliance (ALMA) scored poorly in terms of long lasting insecticide treated net distribution and low on the measure of government financial support for the health sector.

herbshop2a-sm.jpgThe private sector challenge has come in the form of fake medicines in local shops. This comes in the form of a threat to individuals and families who spend their hard earned cash, that is out-of-pocket expenditure (OOP) of malaria medicines that at best inappropriate and at worse are devoid of active ingredients, increasing the likelihood that the sick person will develop severe disease and maybe die.

Specifically the Washington Post reported that an indigenous medical practitioner “in Kampala, says he has seen a big increase in business as patients turned off by the prospect of dangerous fake drugs seek relief from illness.” The article explains that although “Officials and international aid agencies have long encouraged the sick to place their trust in modern medicine. But fake pharmaceuticals believed to have come from Asia have flooded” African Markets including Uganda.

The irony is that Uganda is part of the testing of the Affordable Medicines Facility malaria (AMFm) project that was supposed to drive out fake and inappropriate medicines by making low cost (subsidized) quality antimalarials available in both public and private sectors. While Uganda witnessed an increase in market share of the green-leaf branded quality assured artemisinin-based combination therapy drugs, it did not achieve other benchmarks such as supportive behavior change communication and low cost targets (mark-up averaged 133% – highest among the 8 pilots).

The second threat comes from extensive embezzlement by national malaria program staff.  Earlier this month Uganda was in the news for returning 4 million Euro of misappropriated funds to the Irish Government.

Then an ongoing investigation into embezzlement came to light a few days ago. The Observer Newspaper as shared on reported that …

“An investigation into the financial practices of officials running the ministry of Health’s Malaria Control programme (MCP) shows they forged almost everything from workshops, car hires, allowances and fuel expenses. The investigation has now shifted its focus to the extent of the forgery and theft by officials implicated in the loss of nearly Shs 78bn (US $29m). The shift in the focus of the inquiry follows a review of stacks of documents provided by three suspects involved in the MCP scandal. Police confirm that the documents show the extent of the forgery by some officials involved in the anti-malaria campaign.”

In these times when it is difficult to increase health development spending for malaria both domestically and from international donors, all efforts are needed to ensure that waste and fraud are eliminated.

Civil Society &Funding Bill Brieger | 30 Jan 2013

Have we reached a funding plateau for malaria?

As all eyes are on the Global Fund to Fight AIDS, TB and Malaria with its launching of the new funding mechanism in February 2013, but we have been cautioned to curb our enthusiasm.

Karanja Kinyanjui in Aidspan’s Global Fund Observer explained that “While funding for all health sub-sectors grew over the 2002 to 2010 period, funding for HIV/AIDS, malaria, and TB increased at faster rates than other sub-sectors such as family planning, nutrition, workforce/management and other infectious diseases,” the growth spurt has leveled off. Readers were asked to see the new Kaiser Family Foundation report on the funding situation.

For malaria we are likely to be plateauing at levels that are only half of what is needed annually to move countries into the pre-elimination phase. The Kaiser Report specifically concludes that …

“While health grew as a share of overall ODA between 2002 and 2010, reflecting its priority among donors, year-to-year increases peaked in 2007 and have declined in each subsequent year. Combined with the OECD’s announcement that ODA in 2011 declined in real terms after more than a decade of steady increases and preliminary estimates that ODA (overseas development aid) is not expected to increase significantly in the coming years, caution about future donor assistance for health may be warranted”

kaiser-oda-for-health-2002-10-sm.jpgODA Health funding did grow from $4.4 billion to $18.4 billion between 2002 and 2010. Even under this increase, malaria funding did not meet needs. Malaria was a negligible component in 2002, and reached $1.6 billion, but this along with aid for nutrition, reproductive health, basic health services and others was dwarfed by HIV/AIDS funding at $7.4 billion for 2010.

In the past two years since the Global Fund Round 11 was cancelled there has been “a significant impact on programmes to fight AIDS, TB and malaria including, in particular, programmes being implemented by civil society organisations (CSOs). Programme scale-up and even some essential life-saving interventions that were planned by countries were halted.”  The transitional funding mechanism allowed some countries to tread water, but the new start up in February will not hit the ground with funds for at least a year.

Other aid sources such as bilateral programs in the UK, USA and Germany and multilaterals like the World Bank and UNICEF are certainly key players in malaria program financial support, but their help can supplement the big source, Global Fund, not replace it. Bilateral programs in particular are hit by budget problems that yield at best no increase in ODA, if not cuts.

The Eurasian Harm Reduction Network describes the current funding situation succinctly – “Quitting while not ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction …” The situation with CSOs shows their dependence on large donors, too – so we cannot find our way out by simply donating to charity no matter how many NGOs assure us our individual dollars will give someone a bednet.  Malaria elimination is a problem that requires going to scale by the whole global community.

Advocacy Bill Brieger | 22 Jan 2013

Malaria Advocacy Working Group Tackles World Malaria Day Theme

The Malaria Advocacy Working Group (MAWG) has been developing Recommendation for the 2013 World Malaria Day Theme. They have shared the results of these consultations below.

world_malaria_day_en.gifThe MAWG Messaging Workstream has been working with the wider malaria community through the MAWG to develop ideas for the 2013 World Malaria Day Theme. After an open consultation process, the final shortlisted theme suggestions were put to the vote, with 74 respondents from 18 countries across 5 continents providing their input. The results showed a clear preference for the three recommendation options outlined below.


  • “Invest in the Future: Defeat Malaria” To be the topline theme used for World Malaria Day in 2013.
  • Linkage to The Big Push Initiative: Significant advocacy channels are being developed around The Big Push* initiative over the course of 2013 and beyond. RBM partners will be invited to fully leverage these channels and messages in connection with WMD 2013 as a complementary option to the theme.  The MAWG messaging team will be providing partners with options and tools to link to and help build momentum behind this initiative in the lead up to and beyond World Malaria Day 2013.
  • Extend use beyond World Malaria Day 2013

It was overwhelmingly agreed that it would be useful to extend the application of the World Malaria Day Theme for 2013 over a longer, multi-year period of 2013-15. This will allow more time to build theme messaging, collateral and use to maximize its impact. It is envisaged that the accompanying messaging and evidence points under this theme will be checked and evolved over this period.

Next steps

A smaller sub-group of the MAWG Messaging Workstream will be working over the coming months to develop options and collateral around the selected theme. We look forward to being able to share these ideas with partners early in the New Year.
We encourage RBM Board Members to play a crucial role in ensuring that the theme is used consistently by Partners of their respective constituency.

*Background on the “The Big Push”: This initiative was developed around the UN General Assembly in September. The idea is to use TheBigPush as a unifying rallying cry for multiple initiatives working towards the 2015 health MDGs (and beyond). It has already been taken up by the UNSG Every Woman Every Child initiative and by the Global Fund (in partnership with the Huffington Post).

Advocacy &Funding Bill Brieger | 20 Jan 2013

Malaria Funding – advocacy and creativity needed

Is there a malaria lobby? Who advocates for more funds from donor countries and within endemic countries? The Roll Back Malaria Partnership has a Malaria Advocacy Working Group (MAWG) that has as one of its objectives, “to ensure the wide dissemination of accurate information on resource allocations to inform the malaria community of current status and improve accountability both by donors and implementers.”

The MAWG has drawn attention to the wide scope of efforts to enhance malaria funding to support the Global Malaria Action Plan.  In addition to the usual international donors and domestic/government support MAWG points out the need to consider innovative fund raising mechanisms such as UNITAID’s air ticket tax. There is also stress on cost efficiencies with existing funds such as …

  • More effective ways of procuring LLINs
  • Less overlap of LLIN and IRS programs, at least until benefits are proven
  • Rotation of insecticides used for IRS to delay resistance
  • Accelerated availability and appropriate use of RDTs
  • Better understanding of efficiencies of integrated health packages

illustrative-alma-scorecard-sm.jpgThe African Media and Malaria Research Network (AMMREN), was formed in November 2006. It has over 100 member journalists in 10 African countries, and is encouraging more journalists to become involved. One of AMMREN’s key Objectives is to advocate for implementation of international agreements on malaria signed by African leaders. Local advocacy becomes even more crucial with CCMs when it comes to future division of Global Fund support among the three diseases, and addition to boosting local counterpart funding.

Arsenio Manhice, an AMREN member and a reporter for the newspaper Notícias based in Maputo, Mozambique provides an example of this advocacy function. He reported on the lack of qualified human resources for malaria work and also spoke of the lack of infrastructure and logistics for indoor residual spraying. These logistical resources are the kind that need major national financial commitments for sustainability.

Both Ethiopia and the US Agency for International Development, according to VOA, are encouraging African countries to adopt a “scorecard that publicly collects and reports health data.” Such a scorecard would track 1) input indicators that relate to policy issues and availability of resources; 2) process indicators; and 3) impact and outcome indicators that outline the data results. This is an important tool for both accountability and advocacy.

A scorecard actually already exists and is maintained by the African Leaders Malaria Alliance (ALMA). The ALMA Scorecard tracks malaria related indicators in the areas of policy, public finance, financial control, commodities, implementation, and impact in addition to what are termed tracer indicators for maternal and child health. This publicly available scorecard enables countries to compare themselves and may serve to boost support for malaria and health programs. An example comparing Rwanda and Angola is seen in the attached chart.

We can conclude from the present situation that funding to sustain the current levels of progress against malaria morbidity and mortality is at risk, even though current levels are possibly only one-third of actual need.  Creative and alternative sources of funding are needed as well as better use of existing resources and greater national financial commitment in endemic countries.  Advocacy for improved malaria financing, while strong in the past, is just entering its most crucial phase.

Funding Bill Brieger | 19 Jan 2013

Time Has Come for Stronger Domestic Funding of Malaria Programs

The changing scene among international donors points to a need to re-evaluate domestic contributions to finance malaria and other health and development programs.  Ethiopia is an example where policy thinking along those lines is underway.  The Voice of America (VOA) points out that, “Ethiopia stands out because it already has reached a 60% reduction in the mortality rate of children under five years old.” This progress has been facilitated by a decade of economic growth. VOA notes that although United States aid contributions to Ethiopia are now being reduced, Ethiopia is considering finding more domestic resources by scaling up a health insurance scheme that has been successfully piloted in thirteen districts.

Ghana has a long experience with its National health Insurance Scheme.  The World Bank reports that …

Ghana spends less than 5 percent of its GDP on health, slightly below average for a country at its income level. According to the 2009 World Health Organization (WHO) National Health Accounts, 47 percent of total health spending in Ghana is private (37 percent paid out of pocket and 10 percent paid by private insurance and other private risk-pooling mechanisms). Of the 53 percent public spending share, the NHIS accounts for some 30 percent of public spending on health and 16 percent of total health spending. According to the NHIS, active membership in 2010 was 8.16 million, some 34 percent of the population. Since 2005, outpatient visits have increased by a factor of 23, inpatient service by a factor of 29, and expenditures by a factor of 40. (Schieber G, Cashin C, Saleh K and Lavado R. Health Financing in Ghana. International Bank for Reconstruction and Development/The World Bank, 2012, Washington DC)

There are some caveats with health insurance. “Although the benefit package of insurance is generous, insured people still incurred out-of-pocket payment for care from informal sources and for uncovered drugs and tests at health facilities. Nevertheless, they paid significantly less than the uninsured.”  In addition ability to pay premiums initially or in subsequent years is a concern. Obviously poorer people are affected more by the premiums, and that was why people were hopeful about Affordable Medicines Facility malaria (AMFm) though out of pocket (OOP) expenditure was still required of the poor. The Global Fund did not cancel AMFm when its Board last met, but it did bundle the concept into existing and future malaria grants should countries wish to do so, leaving this subsidized treatment option, often through the informal private sector, in limbo.

domestic-funding-sm.jpgFunding levels are not the only concern in reaching and sustaining malaria targets. One also needs to concentrate on how the resources are being used. The Guardian recently described how top-down commodity distribution approaches need to be complimented with bottom-up community approaches. Without community understanding and demand net deliveries from donors may sit in warehouses for months and when they reach the community they may be used as fishing nets or even wedding dresses, according to The Guardian.

International partners are quite aware of the need for better use of resources. The World Health Organization’s Global Malaria Program GMP in revising its guidelines for malaria treatment in 2010 stated that, “The scale up of diagnostic testing will improve patient care (and) make more efficient use of scarce resources (emphasis added).”

Overall domestic funding has accounted for about one-fifth of total malaria expenditure in recent years. While this may not be enough, it is this contribution and better use of available funds that may pull us through to 2015.

Malaria in Pregnancy Bill Brieger | 17 Jan 2013

Malaria in Pregnancy Sessions at #GMHC2013 Arusha

Today there are two sessions that provide information on Malaria in Pregnancy at the Global Maternal Health Conference holding in Arusha this week. Session topics and speakers are outlined below. These can be followed through the Maternal Health Task Force (MHTF) on Twitter, at the MHTF Website or the Conference Website.

Malaria in pregnancy: What it takes to deliver quality health services as a component of comprehensive MNCH
Session Type: GMHC2013: Track 3
Time & Date: 13:30 - 15:00  17/01/2013
Location: Tausi

Malaria in pregnancy: Approaches to improving the quality of policies and programs
Session Type: GMHC2013: Track 1
Time & Date: 11:00 - 12:30  17/01/2013
Location: SB-312A

Moderator: Catharine Taylor, PATHImproving the quality of malaria in pregnancy prevention and care in Ghana, 2010-2012
Kwabena Larbi, University Research Company, LLC

Quality of care for malaria in pregnancy services during antenatal care: Survey results from six African countries
Barbara Rawlins, Jhpiego

Increasing malaria prevention in pregnant women in South Sudan
A. Frederick Hartman, Management Sciences of Health

Intermittent screening and treatment for malaria during pregnancy
Martin De Smet, Médecins Sans Frontières

Burden &Funding &Surveillance Bill Brieger | 16 Jan 2013

Malaria Funding from the Perspective of International Donors

The recently released 2012 World Malaria Report (WMR) brought in to focus both malaria progress as well as the charges in malaria funding for the 104 malaria-endemic countries. Increased rates of coverage with vector control and malaria case management measures has mean that 274 million cases and 1.1 million deaths have been averted between 2001 and 2010. Unfortunately, The WMR observes that, “The enormous progress achieved appears to have slowed recently. International funding for malaria control has leveled off, and is projected to remain substantially below” projected needs.

We are not talking about small amounts of money or minor contributions to date. The WRM reports that, “The past decade has witnessed tremendous expansion in the financing and implementation of malaria control programmes. International disbursements for malaria control rose steeply from less than US$ 100 million in 2000 to US$ 1.71 billion in 2010 and were estimated to be US$ 1.66 billion in 2011 and US$ 1.84 billion in 2012.” This must be put in context with amounts estimated to be needed to achieve universal coverage (including use) of the major prevention and treatment interventions.

The WMR explains that “The enormous progress achieved appears to have slowed recently.” As noted above international funding for malaria control has leveled off, and “is projected to remain substantially below the US$ 5.1 billion” annually required to achieve and maintain universal coverage of malaria interventions. The Roll Back Malaria Partnership has estimated a higher projected annual need. “Resource requirements for global malaria prevention, control and elimination were estimated in the GMAP (Global Malaria Action Plan) to amount to some US$6.1 billion annually between 2012 and 2015.” This figure includes both program management costs as well as research needed to develop new tools.

The link between funding and coverage is clear in the WMR. The number of ITNs procured in 2012 (66 million) is far lower than in 2011 (92 million) and 2010 (145 million). “With the average useful life of ITNs estimated to be 2 to3 years, ITN coverage is expected to decrease if ITNs are not replaced in 2013.” Recent reports from a regional malaria elimination meeting in Kigali show that replacement time may be even shorter, possibly every 18-24 months based on local use and environmental conditions.

When identifying what is happening in malaria financing, it is important to recognize that there are relatively few direct donors. Major international malaria funders accounting for over 90% of donor financing are Global Fund, US President’s Malaria Initiative (PMI), Department for International Development (DfID), World Bank, and AusAid. Others include bilateral assistance, corporate donors and foundations.

international-funding-sm.jpgThe Global Fund as an entity and as the sum of its country contributors shocked the malaria and global health communities in 2011 when it announced the cancellation of its Round 11 of annual funding. The situation was complex and reflected weak financial pledging and inputs as well as internal management issues. The new funding approach was discussed in the WMR.  There are some uncertainties causing concern for the malaria community.

According to the 2012 WMR, “countries will be grouped by the Global Fund into Country Bands based upon a composite score which is a combination of a country’s GNI and its disease burden. Then there will be a “global disease split (i.e. 52% for HIV, 32% for malaria and16% for TB), until a new formula is determined, the Board,” that will be combined with a split according to Bands.  Finally actual allocation decisions will be made by the country coordination mechanisms (CCMs).  Malaria appears to be in greater direct competition with the other two diseases than what obtained in the past.  How other donors will compensate for any country shortfalls is unknown at present.

One possible implication of bands is that there may be less focus on lower burden countries that are heading toward malaria elimination.  Just because disease burden is low, or becomes low due to effective intervention does not mean that funding is not needed. Continued surveillance and case containment activities are not cheap, and require constant vigilance and sustained efforts since not all of one’s neighboring countries are at the same stage of malaria elimination.