Posts or Comments 20 June 2024

Monthly Archive for "June 2013"

Policy &Strategy Bill Brieger | 25 Jun 2013

Taking malaria capacity building to scale: Lessons on an Integrated Policy Package from Burkina Faso


Presented at Jhpiego’s Mini-University, 24 June 2013 in Baltimore by Bill Brieger, Rachel Waxman, Elaine Roman and Ousmane Badolo

Between October 2009 and March 2013, with support from the USAID Malaria Program, the Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego  has worked in close collaboration with the National Malaria Control Program (NMCP) and the Family Health Directorate (MCH) to accelerate malaria prevention and control in Burkina Faso with a focus on nationwide scale up.

steps-to-scale-up-in-burkina-sm.jpgScale up is defined as program coverage nationwide.  During the project years, Jhpiego provided technical and programmatic support to address comprehensive malaria prevention and control with a focus on diagnostics, treatment, and malaria in pregnancy (MIP) in Burkina Faso.  This resulted in: 2,648 health facility providers trained using the integrated malaria training package; these providers in turn, oriented 4,867 of their colleagues.

Other key components of technical support included strengthening- a) supportive supervision; b) pre-service education; c) human capacity (team building); and d) communications and behavior change guidance at national level as well as targeting communication messages to both health facility providers and clients.  Training is US Peace Corps Volunteers helped reinforce that this guidance reached front line health facilities and volunteer community health agents.

Some of the lessons learned in going to scale are balancing reaching providers en mass with quality support; ensuring a link between revised policies and guidelines and both pre-service education and in-service training; and recognizing the need for national level leadership and capacity to ensure effective implementation.

As countries accelerate and scale up their malaria programs, the lessons learned from Burkina Faso a systematic development of an integrated package of malaria policies and guidelines are important to consider moving forward.

Elimination &Epidemiology &Malaria in Pregnancy Bill Brieger | 25 Jun 2013

Low levels of placental parasitemia among women delivering in health facilities in Zanzibar: policy implications for IPTp


Presented at Jhpiego’s Mini-University on 24 June 2013 in Baltimore by Marya Plotkin, Elaine Roman, and Maryjane Lacoste

Malaria in pregnancy (MIP) is a threat to the pregnant women, the unborn child and the newborn and infant. Intermittent Preventive Treatment during pregnancy (IPTp) is one of the few interventions available that specifically targets and protects pregnant women.  As malaria prevalence drops when countries aim at malaria elimination, we need to examine the continued role of IPTp and search for alternatives.

zanzibar-placental-malaria-study-sm.jpgFrom August 2011 to September 2012, Jhpiego partnered with the Zanzibar Ministry of Health to conduct a study looking at the prevalence of placental malaria infection among women delivering in selected health facilities in Zanzibar who had not had IPTp during the course of their pregnancy. The community-level malaria positivity rate in Zanzibar declined from as high as 20% in 2005 to 1.6% in 2011. In Zanzibar as in the rest of Tanzania, IPTp coverage has been quite low, but pregnant women have access to long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS) is practised in the islands.

Midwives in six clinics in in Unguja and Pemba tested the women using PCR at delivery. Of the 1,356 women with no IPTp exposure enrolled in the study, only nine (0.6%) were found to have placental malaria (95% CI 0.2–1%). Thus, even without benefit of IPTp, other interventions appear to be protecting pregnant women to some degree.

zanzibar-pcr-sm.jpgEstimations of the costs of IPTp program put the annual expenditure at $114,678, while the annual cost of intermittent screening and treatment with RDTs (ISTp) would be $155,294.  Given the extraordinarily low prevalence of malaria in pregnancy, as well as pilot experience of testing in the ANC setting, there is a strong argument for adopting ISTp and dropping IPTp in Zanzibar.

To do so, the authors argue, thresholds of prevalence or incidence of malaria infection must be set in advance in order to trigger a reconsideration of the IPTp decision, and surveillance of malaria infection in pregnancy must be strengthened.

WHO has recently issued new guidance recommending continuation of IPTp where it is currently being practiced, making Zanzibar’s decision to maintain or discontinue IPTp of particular interest to the malaria in pregnancy community. Better guidance is needed on MIP services as countries move closer to malaria elimination.

Environment &IPTi Bill Brieger | 14 Jun 2013

Malaria and the Rains of Africa

The World Health Organization is guiding countries across the Sahel of Africa to begin piloting ‘seasonal malaria chemoprevention” or SMC. We recently featured this in the May 2013 issue of Africa Health. WHO explains that “Seasonal malaria chemoprevention is defined as the intermittent administration of full treatment courses of an antimalarial medicine to children during the malaria season in areas of highly seasonal transmission.” This is an outgrowth of several years of research into intermittent preventive treatment for infants (IPTi) and children.

dscn8811a.jpgMalaria program managers wanted a more focused application of IPTi where it would be likely to make a major impact on disease control. Researchers found that areas meeting malaria seasonality definition of 60% of annual incidence within 4 consecutive months were observed more frequently in the Sahel and sub-Sahel than in other parts of Africa, and thus could provide an ideal focus for intervention.

What makes transmission more intense in those four months is the rainy season.  Ironically we have recently seen a more intense rainy season in the Sahel with serious flooding. IRIN reports that, “The African Centre of Meteorological Applications for Development (ACMAD) in a seasonal weather outlook says near-average or above-average rainfall is likely over the western Sahel, which stretches across Mauritania, Senegal and western and central Niger. These regions are ‘expected to be the area with the highest risk of above average number of extreme precipitating events that may lead to flash floods’.”

What does this flooding mean for SMC?  While breeding mosquitoes obviously need the pools that rainwater creates, too much rain may have an opposite effect with flash floods washing out breeding sites (let alone homes and possessions). When flooding results in larger and longer collections of standing water, mosquito breeding may be enhanced, but this will make logistical support for training, supervision, and drug supplies extremely difficult in the region.

dscn8824a.jpgThe Sahel is one of the areas in Africa where we might hope for some early progress toward malaria elimination. With global climate changes affecting the region we can only wonder whether the weather will cooperate and allow timely implementation of new interventions.  As IRIN implies – contingency planning is extremely important.

Education &Malaria in Pregnancy Bill Brieger | 13 Jun 2013

Promoting Education Promotes Malaria Control

Millennium Development Goal Number Two focuses on Universal Primary Education for all girls and boys by 2015.  BBC informs us that “The global figure for the number of children without access to schools has fallen to 57 million, according to the United Nations Educational, Scientific and Cultural Organization,” a fall from an estimate of 61 million missing school in 2010. Unfortunately the improvement is unlikely to be enough to meet the MDG pledge.

The BBC further notes that, “More than half of the children missing out on school are now in sub-Saharan Africa. The last annual report showed that in some countries, including Nigeria, the problem is getting worse rather than better.”

What does education have to do with the elimination of malaria?  We can look at the Malaria Indicator Survey (MIS 2012) from Nigeria to get some ideas.  The attached chart shows that several important maternal health variables are linked with improved educational levels.  It is not that education per se makes women more aware and take action, but education opens their lives and minds to the possibilities of better health and development.

education-level-prevention-of-malaria-in-pregnancy-sm.jpgThe chart shows that women with higher education report greater exposure to malaria messages in the media.  It is not a simple matter of understanding, since many media programs are in local languages. We are talking about being more attuned to health messages in the available media because of improved education.

Life saving behaviors like attending antenatal care (ANC) and getting services offered there, like intermittent preventive treatment (IPT) for malaria, are enhanced by education.  Interestingly the MIS shows an opposite trend for sleeping under insecticide treated bednets among all women of reproductive age:

  • 42% with no education
  • 22% with primary education
  • 17% with secondary education
  • 17% with post-secondary education

This may appear odd until one realizes that campaigns to distribute ITNs intentionally or not address equity issues, reaching less educated (and poorer) households.  More educated and possibly more wealthy households are more likely to have window screening and other aspects of house construction (ceilings) that help keep out mosquitoes.

One wonders then if community campaigns are successful in reversing the education gap in ITN access and use whether such approaches should be used with IPTp.  In fact we have successfully shown that community health volunteers, under the guidance of ANC staff are able to reach poor rural communities and increase IPTp coverage.

Increased access to education will enhance uptake of health interventions. In the meantime we can make every effort to bring these interventions closer to the communities through their own efforts.

Advocacy &Civil Society &Funding &Partnership Bill Brieger | 07 Jun 2013

Country Ownership and Global Fund Grants

The latest edition of Global Fund Observer (#218) from AIDSPAN raised a lingering question about the Funds founding principles – what is country ownership and how is it practiced? The thoughts range from the more altruistic – let the country decide what it needs to do and we’ll give the money – to the more crude, though not stated as such – give the country enough rope (money) to hang itself.

Another founding principle involved the Global Fund seeing itself as only a financial mechanism, not a technical one like the World Health Organization or UNICEF.  AIDSPAN demonstrates how over time, while still not providing direct technical assistance, decisions from the Technical Review Panel and the Global Fund Board, among others, can be seen clearly as offering a technical guidance that must be heeded if funds are to flow.

In short AIDSPAN has shown how the Global Fund itself has taken a more directive role, though often based on programmatic evidence and advocacy from those who have a stake or experience. We also need to look at th other side of the coin – within the country, who owns the Global Fund process?

A major overhaul of Country Coordinating Mechanisms (CCMs) some years ago was stimulated by the realization that government agencies are not the sole representatives of their countries and peoples.  While civil society and non-governmental organizations were expected to play a role in CCMs, they were often ignored and rarely had major roles in deciding on and implementing Global Fund sponsored programs in their countries.  Sometimes the advocacy mentioned by AIDSPAN was prompted by CSOs and NGOs not being heard within their own countries.

AIDSPAN mentions changes that the Global Fund has strongly suggested such as having dual track principle recipients (PRs) representing government and the non-governmental sectors.  While this may have represented a somewhat heavy hand from Geneva, the results sometimes reflected the status quo ante and NGO PRs were often relegated to less well funded aspects of programming such as behavior and social change.

Global Fund recipient countries represent a wide diversity of political systems in various stages of evolution.  It would be naive to expect that country ownership really embodies democratic participation of all stakeholders, public, private and NGO, in decision making and implementing on an equal footing – and no one really believes that is fully possible in at present.  Still it is a long term goal and a principle that should guide funding decisions as much as the quality of the technical content of proposed activities.


In the meantime we can look for additional ways and means to hold countries accountable for their health and social programming decisions. A good example is peer influence from the African Leaders Malaria Alliance (ALMA) which regularly publishes a scorecard of progress toward key health indicators. This freely available score card shows for example, in the first quarter on 2013 only six countries meeting the criteria of good financial management set by the World Bank. In the countdown to 2015, only eight countries are on track in terms of breastfeeding coverage.

As AIDSPAN observes, “But one has to acknowledge that, in the process, the concept of ‘country ownership’ is certainly evolving. Perhaps it will evolve further under the new funding model.” We hope the concept evolves along lines of full and equal partnership among all stakeholders within a country – that all sectors and peoples within a country will truly ‘own’ and thus influence the decision and actions around programs supported through the Global Fund.