Posts or Comments 19 June 2024

Monthly Archive for "March 2013"

ITNs Bill Brieger | 26 Mar 2013

Mosquito Nets: Misuse or Misunderstanding

A photo contest sponsored by the Swiss Malaria Group has stirred some controversy among colleagues. One photo shows a conical net suspended from a tree branch and covering a chicken on the ground, with rocks placed around the edges to ensure the chicken does not escape. The question arising is whether such photos do disservice to malaria control programs and discourage donors, when in fact the net pictured is most likely an old one being re-purposed. Fortunately only a few of the 712 photo entries depict this situation.

There are worries that such photos are fodder for untrained or unscrupulous journalists to derail malaria control campaigns.  In fact most of the material on net misuse is anecdotal and found in the press and on the web.  A quick search on PubMed found very few articles that directly addressed the problem. There is more on non-use than misuse.

One well known article appeared in Malaria Journal in 2008 and even had pictures of nets spread on the shored of Lake Victoria as platforms for drying fishing catches. The authors reported that, “The most popular reasons were because the bed nets were inexpensive or free and because fish dried faster on the nets.” They also noted that excess nets had been distributed in the area due to lack of planning and coordination among agencies.

Another article about nets after a major state-wide campaign in Rivers State Nigeria had misuse in its title.  All houses in the villages had nets after the campaign, but only 72% had any hanging at the time of the survey.  Twenty percent of these were hung as window curtains (which is in fact another legitimate, though in this care unintended use of insecticide treated materials). Only 38% of children below five years of age had actually slept under a net the night before the survey. In this case non-use was more of an issue that misuse.

The third article dealing with the concept of misuse appeared in PLoS Medicine in 2011.  The authors faulted the one article they found in peer reviewed publications (the Lake Victoria study mentioned above) for methodological reasons. The authors conclude that, “Inaccurate news stories of widespread ITN misuse should be rebuked directly through the dissemination of empirical data contradicting anecdotal reports and in rebuttal editorials in newspapers and journals.”

llins-for-goal-post-dated-sm.jpgYes, there does need to be better systematic documentation to determine the extent to which new nets are misused and old nets are re-purposed in communities (or even a combination of practices).  Unfortunately we do have pictorial evidence from the field not long after the 2010 mass distribution of LLINs in Akwa Ibom State where we also had a malaria in pregnancy control program in several local government areas.

The two photos shown here were taken a few months after the campaign and showed clear signs of misuse. This was not a question of re-purposing old nets, since hardly any existed prior to the campaign, and again the staff inspected these directly. In addition to the uses seen here we found new nets being used to cover vegetables to keep off insects as well as used in making goat pens.

super-market-dated-sm.jpgOur project in Akwa Ibom had trained volunteer community health workers (CHWs) to provide malaria in pregnancy control services, and they were directly involved in the larger net distribution campaign. These misuse problems were not found in the communities with CHWs.  The clear lesson to us is that mass distribution without clear follow-up plans in place will result in both non-use and misuse of nets.

Unless donors demand that local health authorities build in a community follow-up component to net distribution, they will indeed be wasting their funds. In the meantime we need to be vigilant and carefully document whether nets in strange places are in fact misused new nets or re-purposed old nets. Re-purposing has an important role to play since safe disposal of old nets is a major environmental concern.

Community &Health Systems Bill Brieger | 21 Mar 2013

Malaria Control in Akwa Ibom State: The need for consistent health systems strengthening

Akwa Ibom State is pivotal in the fight against malaria in Nigeria. The environment supports year round transmission of the disease. While it has a strong basic health infrastructure, it has been unable to live up to its potential consistently to deliver high quality malaria control services.

cdd-service-community-iptp1a.jpgIn 2006 Jhpiego and ExxonMobil conducted a situation analysis of malaria programming in the state. At that time Akwa Ibom was considered an ‘orphan’ state in the context of malaria control since other states benefited from the Global Fund and other donor agencies. Findings from both desk review and field work pointed to low use of and access to malaria commodities such as insecticide treated bednets (ITNs), appropriate treatment with artemisinin-based combination therapy (ACT) and intermittent preventive treatment (IPT) of pregnant women with sulphadoxine-pyrimethamine (SP). In short, the health system was failing to make these lifesaving technologies available to the public.

The state was not implementing national malaria program guidelines, and in fact front line health staff were unaware of these.  In addition basic primary health care services like antenatal care (ANC), which could serve as a platform for delivering malaria services, did not function well and were seriously underutilized.  Little effort to reach out and involve the community in malaria or health matters generally was found.

By 2007 Akwa Ibom was transitioning away from its ‘orphan’ status. ExxonMobil agreed to fund a proposal by Jhpiego, arising from the previous year’s situation analysis. The World Bank Malaria Booster program in Nigeria chose Akwa Ibom to be one of its seven states for enhanced malaria commodity supplies. While not using a formal agreement, the World Bank and Jhpiego tried to work in concert such that the Bank loan could help increase the supply of ITNs and ACTs while Jhpiego would work on health systems strengthening so that the commodities would reach intended audiences.

Over the ensuing six years at the State level, Jhpiego built an interdisciplinary malaria training team that could update local government area (LGA) health department staff on national malaria policies and guidance. This team in turn facilitated LGA staff to organize updating for the staff of their PHC facilities.  Jhpiego rallied all malaria-related organizations working in Akwa Ibom, ranging from government agencies and departments, donors and local non-governmental organizations, to form a malaria program coordination partnership. This partnership committee met regularly to share information and updates and plan advocacy efforts that would encourage increased State and LGA support for the malaria program.  Jhpiego assisted the World Bank supported effort to inventory all public, private and informal health (and thus malaria service) providers in the state.  Finally, Jhpiego was constantly on call to advise the State’s Malaria Control Unit.

community_training_of_cdds-sm.jpgJhpiego was able to work directly in seven LGAs to develop and implement an innovative community directed intervention that was based on a community-clinic partnership.  The trained health facility staff reached out to villages and kin groups (clans) in their catchment area who in turn selected volunteer community directed distributors (CDDs), also known as community health workers (CHWs). The CDDs were trained and stocked from their nearest PHC facility, and those health staff provided supervision and encouragement.  CDDs kept records which were incorporated into the PHC monthly summaries, thus demonstrating a significantly increased coverage of malaria services by the health team in that catchment area because of the community-clinic partnership.

Challenges existed in terms of the actual availability of malaria commodities. Jhpiego had to buy starter supplies of SP and involve other NGOs in giving the first stack of ITNs.  Later Jhpiego also had to buy demonstration stocks of malaria rapid diagnostic tests (RDTs) for community case management, all because the start up of the World Bank Booster effort in Akwa Ibom was extremely slow and cumbersome. Here again is why Jhpiego’s constant consultation with the State malaria Unit and work with the State Malaria Partners Committee was of great value.

Most NGO contributions to the fight against malaria consist of short term, one-off contributions of ITNs or media based communication campaigns that leave little behind in terms of a functioning health system.  Jhpiego’s commitment to health systems development over the long haul is what is needed to turn dysfunctional systems around.  Not only did Jhpiego focus on the formal health system, but strengthened community systems so the two could work hand-in-hand.

Even after six years the work is not complete. Since Jhpiego’s funding stopped the State Malaria Unit has suffered from staff changes and the World Bank project has been put on hold. If donors want to see progress in the fight against malaria at State and LGA level in Nigeria, they must be willing to commit to the longer term strengthening of health and community systems.  Without such a commitment mosquitoes and malaria parasites will once again get the upper hand and malaria deaths will rob the communities of a promising future.

Funding Bill Brieger | 18 Mar 2013

Death by Sequestration

Across the board cuts in US funding for almost everything government does (except the salaries of members of Congress!), will have effects on people’s lives. Damage from sequestration is reported daily. Even civil rights are threatened as reported in the Washington Post in a story that highlights the plight of poor people who must remain jailed because funds for public defenders have been cut and there are not enough lawyers to ensure a speedy trial.

amfAR, The Foundation for AIDS Research, has been tracking the potential effects of the sequester on global health programs of the US Government. amfAR has made estimates based Congress’ action in January 2013, and reported that, “The Office of Management and Budget (OMB) has calculated that, as of March 1, 2013, funding for non-defense discretionary programs must be cut across the board by 5.0 percent.1  As we found in our earlier calculations, applying sequestration cuts to US government global health programming will have minimal impact on deficit reduction, but will be devastating to the lives of many thousands of people globally.”

sequestration-infographic_031113-malaria-part-sm.pngHere are the specifics on malaria programs:

  • 1.16 million fewer insecticide-treated mosquito nets will be procured …
  • leading to over 3,000 deaths due to malaria
  • 1.9 million fewer people will receive treatment

InterAction and Global Communities have produced an informational graphic that summarizes the impact on disease control, nutrition and education (see malaria section to right). This comes as part of a general leveling and possible downturn in malaria funding over the past few years. It will be hard to sustain the scale-up in malaria interventions that has been achieved since the United Nations called for universal coverage in 2009.

Most of the decision makers who vote on funds to curb global disease scourges will not likely ever see a case of malaria, much less experience one.  Hopefully this does not mean that they will be immune to advocacy to prevent needless deaths from malaria and other causes of maternal and child mortality.

Eradication Bill Brieger | 17 Mar 2013

South Africa at the Forefront of Malaria Elimination

South Africa as just hosted the 2013 Africa Nations Cup (AFCON) football finals. At the launching of the United Against Malaria (UAM) campaign in collaboration with Confederation of African Football (CAF), RBM (MAWG), and SARN among other partners, the Minister of Health for South Africa explained his country’s commitment to eliminating malaria. Excerpts from the meeting, kindly provided by Daniso Mbewe, summarize the Minister’s remarks.

malaria-profile-south-africa-sm.jpg“We are so excited to host 2013 AFCON. We love to have visitors come to our beautiful country. One of the advantages to coming to South Africa for the African Cup is the much reduced risk of getting malaria. We are proud to be among the first African countries to be working on eliminating malaria. There are less than 10,000 cases of malaria a year, and they are in an area that we are monitoring closely. Ten years ago, we couldn’t talk about eliminating malaria on the African continent and be taken seriously. Even 5 years ago, many would have never believed it. Today, we have the data to help us tell this story.

“In recent years, we have learned about how a robust health system, with close monitoring of malaria cases can give us the information we need to correctly diagnose and treat each case of malaria. You can’t believe how important it is to track each case down, and be sure that treatment is successful and complete.

“Here in southern Africa; there are already four leading countries well on their way to malaria elimination including provinces and districts in the remaining E8 countries (Botswana, Namibia, Swaziland and South Africa in tier one, and Zimbabwe, Angola, Zambia and Mozambique in tier two) However, for us to stay on track and for other countries to reach sustained malaria control like we have, it required investments and commitments from all sectors. Then and only then, will the malaria map shrink. ”

Of interest, Dr Pakishe Aaron Motsoaledi, the Minister of Health, was born in Phokwane Village in Limpopo – one of the few regions where malaria remains, though at a steadily diminishing rate. The Ministry’s commitment to eliminating malaria is therefore not surprising. In fact South Africa has shown leadership in the region through participation in two cross-border malaria elimination efforts. This is an example of political will that all countries on the continent need to follow.

Elimination &ITNs Bill Brieger | 13 Mar 2013

What Goes Around – Net Protection and Malaria Elimination

In 1998 Fred Binka and colleagues published an article that showed the value of living near someone with an insecticide treated net (ITNs), even if you did not have your own net. They documented a 6.7% increase in likelihood of malaria mortality in children for each 100 meter shift away from a house with ITNs the non-user was located.

Then Otten et al. looked at the effects of a short campaign in 2006 to distribute ITNs to children during immunization campaigns and ACTs through CHWs in Rwanda. Eight months later 60% ITN coverage was documented. The interventions resulted in a greater than 50% decline in inpatient malaria cases and outpatient laboratory confirmed malaria cases among children even with less than optimal intervention coverage.

Now, these hints of success in net use have been modeled mathematically to achieve a more realistic target for net coverage instead of relying solely on arbitrary estimates like 80% or 85%. Agusto and colleagues have published their findings which propose that, “If 75% of the population were to use bed-nets, malaria could be eliminated.”

llin-use-from-recent-dhs-mis2.jpg“We conclude that more data on the impact of human and mosquito behavior on malaria spread (are) needed to develop more realistic models and better predictions.”  Of particular concern is learning more about how human handling and mishandling of nets affect these estimates.

So what progress toward this potential target of 75% have we made? The attached chart was derived recent from Malaria Indicator and Demographic and Health Surveys.  Except for the preliminary results of the Tanzania survey, most countries were not even close to the RBM target of 80% coverage for 2010, let alone a slightly more modest 75%. A frustrating trend is the fact that even in households that posses at least one net, children are not sleeping under them.

Now that we have more realistic targets, planning should be easier. Even so after all the push towards universal coverage since 2009, we still have a long way to go to reach targets, let alone talk of elimination.

Indigenous Medicine Bill Brieger | 12 Mar 2013

Traditional Medicine in Uganda: Is it a ticking time bomb?

Violet Okech, Georgina Kirunda, Remy S M Muhire and Paschal Ssebbowa posted this blog at SBFPHC Policy Advocacy. We have added more information on malaria and traditional medicine in Uganda.

travel_uganda_medicine_man2.jpgIt is estimated that over 60% of Ugandans seek medical attention from Traditional Healers. This pattern cuts across all social classes and educational levels.  With a medical doctor: patient ratio of 1:20,000 compared to traditional healer: patient ratio of 1:200-400, high poverty levels and a poor health system, the traditional healers’ services are the most accessible to the majority of Ugandans. With such statistics, it is inconceivable that the country has no national policy to regulate the activities of the traditional healers.  It is possible that their services may be causing more harm than good to their clients.

[Photo: Traditional Medicine man selling herbs courtesy of]
The World Health Organization encourages sharing of information about Traditional Medicine/ Alternative medicine policy formulation because they acknowledge the complexity of the process.  The traditional healers in Uganda have mobilized themselves under The National Council of Traditional Healers and Herbalists Associations of Uganda (NACOTHA). They seek to unite and to push for their field of Traditional Medicine to be given greater consideration by the government.  It is reported that the Ministry of Health in Uganda drafted a Policy so as to regulate and improve research in Traditional Medicine in 2008. This policy has not been finalized to date.

There is need to formulate a policy to track, regulate traditional medicine in Uganda and  conduct intensive research in traditional medicines so as to ensure proper determination and monitoring of drug safety. There is also need for preservation of the medicinal plants against extinction. Relevant medical training should also be offered to traditional healers.

A look into the literature on herbal medicine for malaria in Uganda found a 1999 report on a trial in the southwest on one indigenous herb. “No severe adverse reactions were observed, although about 50 per cent experienced minor side-effects. Although complete parasite clearance was achieved in only one case, the geometric mean of parasite counts had declined significantly by day 7. There was also a marked symptomatic improvement in 17 of the 19 patients.”

Another study in eastern Uganda documented that, “Twenty-seven species distributed between 24 genera  and 16 families were reportedly used in herbal preparations for the treatment of malaria. The most frequently mentioned species were Vernonia amygdalina Delile, Momordica foetida Schumach., Zanthoxylum chalybeum Engl., Lantana camara L. and Mangifera indica L.” As Okech and colleagues note, much more research is needed on the efficacy and safety of this valuable herbal resource.

Private Sector Bill Brieger | 11 Mar 2013

Invest in the Future: How Corporations Can Impact Malaria

The word “invest” in the new World Malaria Day theme encourages us to focus our attention on the role of the corporate community.

A recent study completed on behalf of the Roll Back Malaria partnership by Malaria No more and McKinsey and Company, reviewed the potential impact of future business investment on malaria control.  They found that, “According to the McKinsey report, if business were to invest approximately $10.9 billion over 5 years, we’d be able to achieve full coverage of prevention and treatment measures in the most affected African countries.”

chw-akwa-ibom-nigeria-trained-with-corporate-support-demonstrated-malaria-testing-at-community-event-sm.jpgExxonMobil, has contributed broadly to malaria control programs and research both from the headquarters level as well as through its national affiliates.  ExxonMobil Foundation, the company’s philanthropic arm, has committed $110 million worldwide since 2000 to its Malaria Initiative.  For example, with ExxonMobil Foundation support, Jhpiego conducted proof of concept interventions in Akwa Ibom State, Nigeria that showed how community directed interventions (CDI – the foundation approach for onchocerciasis control in Africa) could be adapted to increasing coverage of insecticide treated nets, intermittent preventive treatment for pregnant women and community case management for malaria, diarrhea and pneumonia.

Corporate contributions do not have to be direct financing. Corporations have certain skills and mechanisms that can be applied to public health challenges. In a press release The Coca-Cola Company and the Global Fund to Fight AIDS, Tuberculosis and Malaria “announced they will expand a project leveraging the Company’s expansive global distribution system and core business expertise to help government and non-governmental organizations deliver critical medicines to remote parts of the world, beginning in rural Africa.” This has been dubbed “Project Last Mile.”

AngloGold Ashanti in Ghana provides another model of corporate involvement.  Starting in 2005, AngloGold began indoor residual spraying (IRS) of all houses in Obuasi District.  Within a few years there was a noticeable drop of 74% in malaria cases in the district health facilities.   Bringing its experience managing a large program in Obuasi, AngloGold as “AngloGold Ashanti Malaria Control Limited,” has become the Principal Recipient of a Global Fund grant in Ghana to conduct IRS in 40 districts.

Corporate involvement in social programs generally and malaria control specifically is obviously not completely without controversy, especially in countries where corporations need to interact with governments that have questionable human rights records.

What is of importance in considering corporate investment in malaria control may not necessarily be the scale of investment, but its quality.  Corporate activities can demonstrate good management practices that should be adopted by other major players in the malaria control arena. Corporate supported projects may provide proof of new concepts that can be taken to scale by national malaria control programs to increase their coverage.  Finally corporate contributions set an example and serve as an advocacy point to encourage national governments to fulfill their own obligations to their citizens.

A longer version of this article will appear in the March 2013 edition of Africa Health.

Advocacy Bill Brieger | 11 Mar 2013

Tweet Archivist #Malaria Word Cloud

An interesting service helps track key words and issues on social media. We used TweetArchivist to track #malaria and 290 mentions occurred between March 9-11. The word cloud map produced can be seen below. As can be seen malaria is often mentioned in the same tweet as TB. Not all most common words found in the tweets seem directly related to malaria. That said, a visual presentation can be powerful.


Drug Quality &Private Sector &Treatment Bill Brieger | 10 Mar 2013

Revisiting the AMFm Controversy

Paul Kartchner contributes this guest blog via the SBFPHC Policy Advocacy Blog.For years, a major obstacle to controlling malaria in developing countries has been the high cost of effective medications. Yet in recent years a coalition of public health agencies and organizations are targeting this problem by subsidizing the most effective medications. Called the Affordable Medicines Facility – malaria (AMFm), the project hopes to make these medications more available and affordable to hospitals, physicians, and local pharmacies in developing countries.

amfm-2010-04-23_malaria-shipment-abuja-novartis.jpgPhoto shows Workers load AFMm medications in Abuja, Nigeria (courtesy Novartis International AG)

Yet even though the project has been found to increase the supply of medications, criticisms have been raised regarding the program’s long-term benefits. A recent report by Oxfam, an international aid group, claims that although these medications are now broadly available, they are not being used appropriately to treat patients with malaria. They also claim that many patients that do need these medications, including women and children, still do not have access to them.

Another aid group, Doctors without Borders/Médecins Sans Frontières (MSF), claims that a project like AMFm cannot be successful if it is not carefully integrated into a larger strategy to combat malaria. Instead MSF recommends a plan whereby not only the medication but also treatment by knowledgeable providers is subsidized.

These criticisms raise important questions about the nature of complex global diseases such as malaria. Focusing efforts and resources on a particular aspect of a problem without considering the larger context may not only fail to improve the situation, but potentially make it worse.

Funding &ITNs Bill Brieger | 08 Mar 2013

Towards a Malaria-Free Kenya

Elizabeth Kubo has written this guest blog posting that originally appeared in SBFPHC Policy and Advocacy.

Malaria is a leading cause of morbidity and mortality in many developing countries, where children and pregnant women are the most vulnerable groups. In Kenya, the disease is responsible for 34,000 under five child deaths annually. About 70% of Kenya’s total population is at risk for malaria.

itn-use.jpgWith funding predominantly from international donors and development partners, the country has adopted and implemented multiple malaria control strategies, resulting in a remarkable decline in the national all-cause under 5 mortality. Despite the gains, a slight downward trend was noted in the proportion of households with at least one insecticide treated net (ITN), the proportion of children under five years old who slept under an ITN, and the proportion of pregnant women who slept under an ITN between 2008 and 2010.

The Global Fund for AIDS, Tuberculosis and Malaria, the Department for International Development (DfID), and the US President’s Malaria Initiative have confirmed funding for the 2013 implementation period, but this falls short of the expected need. Despite repeatedly reiterating its commitment to the fight against malaria, the Kenyan government has previously played a minor role in financing the control efforts.

There is an urgent need to intensify scale-up of targeted interventions in order to reverse the downward trend and attain universal targets. It is possible to close the funding gap through greater in-country resource mobilization. Government commitment to malaria control needs to be reflected in ministry of health budgetary allocations. Civil society organizations also have a role to play. It is possible to have a malaria free Kenya.