Tropical Health Matters

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.

With 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.

Tuberculosis is one of the big three receiving Global Fund support, and like HIV and malaria control efforts, the emphasis is on multiple interventions to ensure ultimate success. Compared to the other diseases, TB’s interventions have been mainly limited to immunization and directly observed treatment. Both of these interventions have recently met some major challenges that have also plagued the other big diseases.

Roger Bate and colleagues, who have focused on the problems of fake and substandard malaria drugs have turned their attention to TB. (see http://masetto.ingentaselect.co.uk/fstemp/a5829970064042ab6ec12023d514ef4f.pdf ). Their investigation at pharmacies in 19 Asian and African countries found around 9% of TB drugs were substandard/poor quality. The rate of fake medicines was 16% in Africa and 10% in Asia.

Governments in these countries were encouraged to give these issues greater attention including better regulation and collaboration with international policing efforts.

The need for new vaccines is a necessary development to maintain a strong disease control arsenal. For TB, “A new vaccine, modified Vaccinia Ankara virus expressing antigen 85A (MVA85A), was designed to enhance the protective efficacy of BCG.” (as reported in The Lancet http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960177-4/abstract )

As the BBC report on this study pointed out, “BCG is only partially effective against the bacterium that causes TB, which is why several international teams are working on new vaccines.” (see BBC at http://www.bbc.co.uk/news/health-21302518 )

While the new vaccine “… was well tolerated and induced modest cell-mediated immune responses. Reasons for the absence of MVA85A efficacy against tuberculosis or M tuberculosis infection in infants need exploration.” Fortunately research on other vaccine candidates is underway.

Continued control and eventual elimination of malaria and TB will require research that is both basic (vaccines) and applied (drug quality) in order to develop, maintain and implement effective strategies. Disease research budgets should not be compromised in the ever changing world of pathogen/parasite evolution.

The March 2013 issue of Discover Magazine provides a chilling overview of why a standard vaccine against pertussis (whooping cough) is no longer as effective as we hoped. About 20 years ago the US switched from killed whole bacteria vaccine to one that contained five key proteins. The change was necessitated by some severe reactions to the original vaccine. http://discovermagazine.com/2013/march#.URdn-2fn_1k

[PVirot, WHO Ethiopia 2002.]

It has come to light that the effects of the current pertussis vaccine, given in combination with tetanus and diphtheria immunization (DPT) last only a short time, as little as one year for adults receiving the booster. It seems that the five chosen bacteria proteins may have evolved and that those in the vaccine confer less immunity.

There are efforts to find new adjuvants to enhance efficacy, but what we are witnessing is a constant battle for balance between finding both safe and effective health interventions. http://www.ncbi.nlm.nih.gov/pubmed/23291942

Why should malaria program people be concerned about pertussis? Recent trials of the new RTS,S/AS02D malaria vaccine is that research trials of this new malaria tool were designed to integrate it into existing childhood immunization programs, including DPT. Not only are we concerned about whether the malaria vaccine works, but whether there might be any negative interactions with other concurrent vaccines. http://www.ncbi.nlm.nih.gov/pubmed/23297680

Community members may not easily distinguish all the different diseases in a vaccination program, but the success or failure of any one component may affect their attitudes to the whole package.

In the case of malaria, an effective vaccine that guarantees more protection than those currently under trial, will be important tools in efforts to control the disease. Vaccines may not yet provide the key to elimination. Also as we can see, vaccines that were once effective may loose their edge, much as parasites and vectors may develop resistance to medicines and insecticides. That is why program managers must always ensure adequate resources for a multi-intervention approach.

The Malaria in Pregnancy Working Group of the Roll Back Malaria Partnership has compiled a briefing document on the importance and effectiveness of available interventions to protect pregnant women from malaria. Below are some of the highlights. The full document can be accessed at the MCHIP website.

The devastating consequences of Plasmodium falciparum malaria in pregnancy (MiP) are well documented; these include higher rates of maternal anemia and low birth weight (LBW) babies in areas of stable malaria transmission. In areas of unstable P. falciparum malaria transmission, pregnant women are at increased risk of severe malaria, death and still birth of the fetus. Approximately 11% of neonatal deaths in malaria endemic African countries are due to low birth weight resulting from P. falciparum infections in pregnancy. However, until recently, there was limited documented evidence of the protective effect of malaria prevention in pregnancy on neonatal mortality.

A recent meta-analysis of national survey datasets by Eisele et al. (2012) showed exposure to intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine pyrimethamine (SP) and insecticide treated bed nets (ITNs) to be associated with reductions of both neonatal mortality and LBW under routine program conditions. Menéndez et al. (2010) also showed the protective role of IPTp-SP in reducing neonatal mortality under trial conditions. Further, Sicuri et al. (2010) in the context of the Menéndez trial showed IPTp to be highly cost effective in the context of routine antenatal care (ANC) services. These studies highlight the critical importance of continuing IPTp as well as ITN use among pregnant women to prevent the adverse consequences of malaria in pregnancy.

In October 2012, the WHO Malaria Policy Advisory Committee (MPAC) reviewed guidance based on the most recent evidence of the efficacy and effectiveness of IPTp-SP in light of growing SP resistance in children and also potential SP resistance in pregnant women receiving IPTp-SP. Based on the review the MPAC determined that frequent dosing (3 doses or monthly) of IPTp-SP is effective in reducing the consequences of MIP.

WHO concluded that prioritizing IPTp as a key intervention for pregnant women (combined with ITN use and effective case management) should remain a priority across stable malaria transmission countries. The WHO’s recent policy update, confirms the critical importance of increasing the frequency of IPT-SP, in addition to ITN use among pregnant women and effective case management.

IPTp-SP and ITNs continue to have an important and significant effect on reducing neonatal mortality and LBW (low birth weight) and need to be recognized as interventions to reduce newborn mortality. IPTp and ITNs reduce neonatal mortality even in programmatic settings, where use may be less than optimal and where SP resistance may exist.

Although the majority of women attend ANC at least once during pregnancy and often twice, IPTp-SP uptake as well as ITN coverage among pregnant women is alarmingly low across most countries. This is a major missed opportunity, at present.

Key References:

• Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg 2001; 95: 569-76.
• Elisa Sicuri, Asucena Bardaji, Tacita Nhampossa, Maria Maixenchs, Ariel Nhacolo, Delino Nhalungo, Pedro L. Alonso, Clara Menéndez. Cost-Effectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy in Southern Mozambique. PLoS ONE; Oct. 2010; Volume 5, Issue 10
• Clara Menéndez, Azucena Bardaji, Betuel Sigauque, Sergi Sanz, John J. Aponte, Samuel Mabunda, Pedro L. Alonso. Malaria Prevention with IPTp during Pregnancy Reduces Neonatal Mortality. PLoS ONE; Feb 2010; Vol. 5, Issue 2.
• Thomas P Eisele, David A Larsen, Philip A Anglewicz, Joseph Keating, Josh Yukich, Adam Bennett, Paul Hutchinson, Richard W Steketee. Malaria prevention in pregnancy, birthweight, and neonatal mortality; a meta-analysis of 32 national cross-sectional datasets in Africa. The Lancet. Published online Sept 18, 2012.
• Anna Maria van Ejik, Jenny Hill, Victor A Alegana, Viola Kirui, Peter W Gething, Feiko O ter Kuile, Robert W Snow. Coverage of malaria protection in pregnant women in sub-Saharan Africa: as synthesis and analysis of national survey data. The Lancet. Vol. 11. March 2011.
• WHO. http://www.who.int/malaria/iptp_sp_updated_policy_recommendation_en_102012.pdf October 2012
• Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg 2001; 95: 569-76.

By Emmanuel Fiagbey, VOICES Program, Ghana

When 60 journalists from 7 Television stations, 10 print media establishments and 12 radio stations gathered at the Novotel Hotel in Accra on this day, the clarion call was that, even though civil wars, border disputes, political rivalries and disputes, hunger, poverty and armed robberies etc. are critical issues attracting the attention of the media, Malaria must not be forgotten otherwise the lives of children, pregnant women and the workforce at large would be kept perpetually at risk.

In her address to the media practitioners representing the Ghana Media Malaria Advocacy Network and 15 representatives from the Ghana Football Association, the Private Sector and NGOs at this event, DR. Constance Bart-Plange, Manager of the National Malaria Control Program stated that progress so far made by Ghana in managing Malaria – almost 87% national household ownership of nets; 90% of mothers knowing the mosquito as the true cause of malaria; and national adoption of ACTs for treating the disease need to be protected.

She therefore appealed to the media to remain responsible in their reportage and promotion of all interventions being applied in the country. She called on the private sector companies in the UAM partnership to step up their workplace malaria-safe programs and always endeavour to feed the media with appropriate information on their contributions to the fight against the disease. Dr. Bart-Plange further emphasized that engaging the media, the Private Sector and the Football Association in promoting malaria advocacy tells the full story of the disease as a social and development issue that concerns all sectors of society. “It is a healthy malaria-free people who must play, watch and cheer football, the game we all love and so, we must all be part of this fight,” she reiterated.

An official of the National Malaria Control Program, Ms. Vivian Aubyn on her part reminded the media and the private sector partners of the objectives of the Ghana 2008-2015 Malaria Control Strategy and the various policies such as the New Drug Policy and the Integrated Malaria Vector Management Policy. She pleaded with the media and private sector partners to ensure their programs and activities always conform to the prescriptions of the national strategy and the existing policies.
Mr. Fred Crentsil, Vice President of the Ghana Football Association in his contribution reminded Ghanaians that “there is no excuse for a footballer to fail to perform at his or her maximum best because of a malaria attack when we all know that sleeping under insecticide treated nets effectively prevents this disease.”

In his delivery, Mr. Emmanuel Fiagbey, Country Director of the Johns Hopkins University Center for Communication Programs VOICES project called on the media to continue to strategically employ the art of news making to promote public debate and leadership decision making on important issues concerning malaria through direct news items, editorials, features, rejoinders, live interviews and documentaries. In this way, he stressed, the media will remain a powerful mechanism for mobilizing public opinion on emerging issues on Malaria and attracting appropriate responses from local and national leadership as well as the donor community. He urged members of the Ghana Media Malaria Advocacy Network and all other journalists to sustain their watchdog role of exposing abuses and misdeeds by miscreants in the health and allied professions, the pharmaceutical industry, politicians, senior civil servants, NGOs, etc in managing resources meant for malaria control.

In launching the colourful AFCON 2013 GOAL Malaria Magazine at the event, Prof. Isabella Quakyi, Former Dean of the School of Public Health of the University of Ghana and Member of the Ghana Health Service Council, who chaired the event, described the GOAL as a self teacher on Malaria prevention and treatment which should engage the attention of everyone during the AFCON 2013 tournament and after. The GOAL Magazine, she explained, “is simply telling all readers, if you love football then you must have the passion to fight malaria.” Prof. Quakyi called on all organizations and individuals to support the continued publication and distribution of this special magazine.

The Ghana AFCON 2013 Media Malaria advocacy event was organized by the Johns Hopkins University Center for Communication Programs Voices for a Malaria-free Future project in collaboration with the National Malaria Control Program, the Ghana Football Association and the Ghana Media Malaria Advocacy Network.

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.

The 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 AllAfrica.com 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.

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”

ODA 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.

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.
Background

The 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.

Recommendations

• “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).

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

The 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.

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.

Funding 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.