Tropical Health Matters

US President Bush has arrived in Benin Republic on the first leg of his second Africa tour that will highlight achievements in various health and development programs including the President’s Malaria Initiative (PMI). The Washington Times reported that, “In what some are calling a “victory lap,” Mr. Bush’s trip will highlight the effect over the past five years of the $1.2 billion the U.S. has sent to fight malaria and the $15 billion to fight HIV/AIDS, which the president wants to double over the next five years.”

There is hope that this trip will help guarantee continuity in US disease efforts after the current administration. The Washington Times reports further that, “The administration’s malaria program has distributed more than 6 million insecticide-treated bed nets. ‘We’ve literally wiped out malaria on the island of Zanzibar,’ Mr. Pittman the president’s senior director for African affairs) said, referring to the semi-autonomous archipelago off the coast of Tanzania.”

But are specific disease control efforts enough to eliminate malaria as a public health problem? We have argued here that there also needs to be attention to the underlying social and economic factors that make people more susceptible to malaria, and when these are not addressed and when donor programs wind down, malaria returns.

BBC News highlights such concerns. “However, international aid agencies have said US trade policy in Africa may undermine struggling African economies. Benin relies on cotton production, for instance – but cannot compete with US cotton because of the large subsidies paid to US farmers.” Unless we connect all parts of the development picture – disease control, trade, economic development, agriculture, etc. – malaria will remain a threat to world health and security.

Ray Chambers, the US Secretary-General’s newly appointed Special Envoy for Malaria, addressed the press. The UN press release explained that Mr. Chambers hoped that, “over the next five years, a true private-public partnership led by the “Roll Back Malaria Partnership” could raise some $8 billion to $10 billion.” Mr. Chambers whom the UN characterized as a “full-time and hands-on philanthropist” talked about the need to involve multiple partners and employ multiple tools in tackling the problem of malaria.

Although Chambers co-founded Wesray Capital Corp, one of the most successful leveraged-buyout firms of the 1980s, he has spend nearly two decades doing philanthropic work. Mr Chambers described his new duties thus: “What the secretary-general has charged me with is working out what we can do in the next two years, the next three years, the next five years to get mortality from malaria as close to zero as possible,”

The Malaria Foundation included Ray Chambers among its 2007 Honorees,and outlined his achievements as follows: founding co-chairman of Malaria No More, for jump-starting and launching this new organization in December 2006 to help raise the profile of malaria, support the goals of the President’s Malaria Initiative, and raise $10 donations from the public for the purchase and effective distribution of long-lasting insecticide-treated bednets. An example of Mr. Chambers fundraising skills was evident at the Millennium Promise and Malaria No More Joint Benefit event which raised $2.7 million to fight extreme poverty and disease in Africa last June.

Laura Bush at the 2006 White House Malaria Summit also praised the new envoy. “Ray Chambers, who is the Chairman of Malaria No More. Ray is an example to all of us of someone who because of fortune in his life, a fortunate life, he has reached out around the world to help other people. And thank you so much, Ray, for being so involved in this.” Reuters quoted World Health Organization Director-General Margaret Chan as saying that Chambers “has the passion, experience and commitment the world needs right now to secure the political will and the funds needed to profoundly reduce this threat.”

Mr Chambers was realistic at the UN Press Conference when he explained that, “A long-term cure, or eradication, would come from a vaccine, but that goal was years away. It is very difficult to prepare a full-scale, comprehensive vaccine against the malaria parasite. In the short term, attention has to be paid to science, as in the past, both the mosquito and the parasite have developed resistance to certain insecticides and medications.”

Mr. Chambers appears to be starting of with ‘enthusiasm’ as people are saying, but also with a good dose of realism, whether it be about the near term potentials for eradication or limitations of environmental measures to control malaria. We hope this enthusiasm, realism and commitment will spread to policy makers in all donor and endemic countries faster than malaria can spread.

Many candidates for the 2008 US Presidential Election have mentioned an interest in continuing disease control commitments made by the US government to date. Last week more specific numbers were given to these proposals by Hillary Clinton. On 29 October the Roll Back Malaria Partnership reported that “U.S. Presidential candidate Hillary Clinton today pledged to expand the U.S. government commitment to malaria to US$1 billion a year if elected, setting the goal of ending malaria-related deaths in Africa by the end of her second term. The campaign said this funding would be in addition to U.S. government support of malaria control through the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which finances the majority of malaria control efforts around the world.”

This pledge can also be considered in light of recent discussions to eradicate malaria, which certainly will be an extremely costly endeavor. An RBM meeting participant did just this -“It’s encouraging to see a leading U.S. presidential candidate step out with such a bold commitment on malaria,” said Rajat Gupta, Chairman of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. “We have the opportunity to eliminate malaria as a global health concern but we’ll need continued American leadership to do it.”

The candidate is said to have pledged for$50 billion for HIV/AIDS. The proposed $1 billion dollars over five years for malaria is not much different that the current requests/projections for the President’s Malaria Initiative, which covers only 15 countries. So $1 billion for malaria seems paltry, especially in light of the candidate’s own words that, “To end AIDS, we need to end malaria in Africa. Malaria is overwhelming the health infrastructures in the developing world, accounting for 40 percent of health spending in many countries – money we need to fight AIDS.”

At any rate, the candidate’s commitment to tackle malaria is sincere as evidenced by her comments that, “Malaria is a challenge to our conscience in its own right. It is appalling that more than a million people die every year from a bug bite. And nearly all of them are children. A child in Africa dies from malaria every 30 seconds. We made a decision to eradicate malaria in North America and in Europe. And we can do the same in Africa and Asia. So I’ll set a goal of ending all deaths from malaria in Africa by the end of my second term. We can do this if we are committed together.”

There seems to be little doubt that the next President of the United States will be under moral obligation to continue funding the international partnership against malaria. The US public has certainly joined in with many NGOs raising money to buy ITNs. In this regard the public may be out in front of most candidates who should all catch up before the primaries and caucuses start.

Ruth Ansah Ayisi shares her experiences from Mozambique.

Hundreds of people in different regions of Mozambique gathered to join in festivities marking Malaria Day, 9^th November, for the countries of the Southern African Development Cooperation (SADC). The theme “Leadership and Partnership for Malaria Control and Economic Development” is particularly pertinent for Mozambique, one of the world’s poorest countries whose economic development continues to be undermined by malaria and HIV/AIDS.

In the southern province of Maputo, the District Health Authorities in Moamba joined with partners like Malaria Consortium, the National Islamic Council and different cultural groups in what was a vibrant event. The event featured cultural and educational activities including traditional dances, educational songs and quizzes. Mosquito nets, T-shirts and caps with messages on malaria and HIV/AIDS were given out as prizes.

Ivete Meque, a doctor at the local hospital, explained how the IRS program is safe and kills mosquitoes. She introduced some of the sprayers and urged people to allow the “sprayers” into their homes, since some people had refused, believing that IRS was ineffective.

Arminda Langa, a young volunteer who visits people sick with HIV/AIDS, stressed that people living with HIV/AIDS need to be extra careful to protect themselves against malaria. “I lost a woman who I visited two months ago,” Langa said. “She was HIV positive, and had malaria. She had no mosquito net, because she could not afford one, and she died before the spraying began.”

“Such events are an important opportunity to transmit key messages to a large number of people at once through entertainment,” said Ali Mecusserima, a member of the National Islamic Council and president of Roll Back Malaria-Facilitator’s Group for Maputo province. He explained that “now we talk about malaria prevention, too” in the mosques.

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The SADC countries do have something to celebrate with Mozambique, South Africa and Swaziland reporting major declines in malaria incidence. Zimbabwe also observed progress on Malaria Day toward meeting its malaria targets. Over 850,000 ITNs have been distributed by UNICEF there since 2004. In Namibia, Malaria Day corresponds with the start of the rainy season, and this year the country is appealing to citizens to take advantage of ITNBs, IRS and malaria treatment. Health education was also a key feature of Malaria Day in KwaZulu Natal. Again in Mozambique, UNICEF and health officials used Malaria Day to announce that, “A wide-ranging campaign to distribute over 500,000 mosquito nets is currently under way in 5 of Mozambique’s 10 provinces.”

Malaria Day is a good opportunity for advocacy and education, and these activities need to continue throughout the year.

VOICES is hosting a 5-day “International Conference of Malaria Advocates” in Bamako, the capital of Mali. The overall objectives of the meeting include:

• Strengthen coordination among malaria advocates particularly information-sharing, planning, and priority setting
• Highlight achievements and challenges in achieving SUFI and malaria advocacy
• Advocate to President Amadou Toumani Toure for more visible political support for malaria control.

According to Panapress as reported in Afrique en ligne, “Malaria represents 33 per cent of the complaints in the health centres in Mali and children below five account for 34.4 per cent of the cases.” The conference will build on such important malaria statistics to hone the advocacy skills of participants.

Mali is an appropriate host country for this effort as it is a recipient of malaria support from both the Global Fund to Fight AIDS, TB (GFATM) and Malaria and the US President’s Malaria Initiative (PMI). PMI selected its focal countries based on existence of other donor support in order to provide synergies that will hasten malaria control. Advocacy in Mali should help forward this agenda.

Early assessment of the malaria grant by GFATM found that, “The overall program performance in meeting the overall expectations was inadequate. Results on the impact indicators have also not been reported on. However … the program has demonstrated potential for improvements.” (See “MAL-102-G01-M-00-GSC.pdf” at GFATM Mali Website.) There was also need for better program monitoring on the ground. Advocacy can help turn the potentials into realities.

MSF and Save the Children are not waiting for more children to fall ill and die from malaria. They are using community volunteers to get treatment out to the villages. According to the UN IRIN, “The results from both the MSF project and a similar one being run by Save the Children are due to be presented to the government later this year, but the staff of both projects told IRIN that provisionally they have recorded at least a 50 percent improvement in the number of children being treated.” These successful efforts are another boon to the advocacy process. International donors and NGOs should use the example of Mali to pull together for advocacy efforts in all malaria endemic countries.

Do people have a right to live without malaria? This appears to be a theme that will be addressed at the first Annual Lecture on Malaria and Human Rights sponsored by the European Alliance Against Malaria and the UK Coalition Against Malaria on 10^th December 2007. The key speaker will be Professor Paul Hunt, UN Special Rapporteur on the Right to Health.

The Special Rapporteur on the right to the highest attainable standard of health defined this human right as “an inclusive right not only extending to timely and appropriate health care, but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health.”

According to the report, Water and the Right to the Highest Attainable Standard of Health, by Hunt and Khosla, “The prevention, treatment and control of epidemic, endemic, occupational and other diseases is a central obligation of the right to health.” These issues also feature prominently in the UN Millennium Development Goals.

Are the MDGs a ‘Bill of Rights’ to overcome poverty? The nations who signed on in 2000 “committed themselves to making the right to development a reality for everyone and to freeing the entire human race from want. They acknowledged that progress is based on sustainable economic growth, which must focus on the poor, with human rights at the centre.” In fact Hunt and Khosla note that the MDGs “cannot be achieved without effective health systems that are accessible to all.

Paul Hunt outlines two broad approaches to promoting the ‘right to health’, the judicial and the policy. “The “policy” approach demands vigilant monitoring and accountability.” This is where research and advocacy is needed. Hunt notes that neglected diseases affect neglected communities, and a rights approach helps spotlight the neglect and form a basis for advocacy.

UNICEF reports on use of this approach in Mozambique. “Malaria represents a significant health problem in Mozambique. Since the late 1990s UNICEF-Mozambique has developed a new strategy to fight malaria through a methodology combining human rights-based approach to programming and community capacity development,” and has used this to guarantee among others the distribution of free ITNs in areas of need. A health rights based approach is therefore, a valuable tool in the fight against malaria.

Bill and Melinda Gates held an important malaria summit this week, where Melinda Gates stressed , “A goal of anything short of eradication would be unethical and a bad business decision, despite unsuccessful efforts to stamp out the disease in the 1950s and 1960s.” She stressed that scientific advances since those early eradication days make it worthwhile to revisit the idea of eradication. Truly there are vaccines on the horizon, new malaria treatments, long lasting insecticide nets, a variety of insecticides for IRS and strategies like IPTp to prevent malaria in pregnancy that did not exist before.

Bill Gates also pointed to the relatively large infusion of funding into malaria control: “The new initiatives have committed 3.6 billion dollars to control malaria.” Though of course this is still below amounts needed for control, let along eradication. This raises the issue of national and health systems support, not only in terms of financially matching donor funds but also in guaranteeing a system that is capable of long term sustainability of gains and concerted prompt effort to really achieve eradication.

A veteran in the efforts to eradicate smallpox and guinea worm, Donald Hopkins of the Carter Center, did raise a note of caution. “We have a very complicated disease with a history of failure in eradication,” he said. Simply striving to control the disease is a difficult enough task, he pointed out.” Experience has shown that eradication needs to rally strong human, organizational, financial and technical resources in a relatively short period of time. The lack of the organizational resources was a stumbling block of first effort to eradicate malaria, and one needs to be sure that health systems are up to the task this time. GFATM and World Bank do give resources for health systems strengthening, but other malaria programs do not.

Donors and people lose interest if eradication is promised but not fulfilled. “Bill Gates also called on US politicians running in the 2008 presidential campaign to keep Bush’s 1.2 billion-dollar malaria initiative alive,” according to the Seattle Times, so the advocacy process for eradication has started. Let’s take this as a sign of hope, but remain realistic of the hard work needed by all partners to make eradication happen.

The Future Health Systems (FHS) Research Programme Consortium aims to find ways to translate political and financial commitments to meet the health needs of the poor. The consortium addresses fundamental questions about the design of future health systems, and work closely with actors who are leading the transformation of health systems in their new realities. This consortium addresses fundamental questions about the design of future health systems, and works closely with people who are leading the transformation of health systems in their own countries. FHS research themes are:

• Protecting the poor against the impact of health-related shocks
• Developing innovations in health provision
• Understanding health policy processes and the role of research

Eight partners in eight different countries are exploring various ways to make health systems work for the poor. The team based at the University of Ibadan, Nigeria, has been exploring the role of Patent Medicine Vendors (PMVs) in providing quality, appropriate malaria treatment in the poor communities where they are based. A recent workshop analyzed and wrote a working paper based on the first-year scoping study.

Several key aspects of PMV behavior and knowledge were identified. “This study has documented the problems that people have in getting access to appropriate treatment for malaria. They have little knowledge of the changing patterns of drug resistance and the consequent changes in the drugs that are effective. They must rely either on traditional practices or on the advice of the people who provide the drugs. Since patent medicine vendors provide anti-malarial treatment in a substantial proportion of cases, their knowledge and practice strongly influence people’s wellbeing. This study made two major findings about this knowledge and practice. First, patent medicine vendors have little knowledge about new guidelines for drug use and they still recommend that people use drugs whose efficacy is doubtful. Second, there is a lot of concern about the quality of the drugs they supply. Action is needed to address these problems.”

Watch here as well as the FHS website for further updates on this important research that documents the challenges of a major informal provider, the patent medicine vendor, who has been ignored in formulating malaria access policy. In fact the 2003 Nigeria Demographic and Health Survey found that only about 25% of parents sought malaria treatment for their children in the formal sector. The few efforts to train and upgrade PMVs has been documented by BASICS, but more needs to be done if malaria drugs are going to reach all.

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As a note of interest, the previous entry here on Kenya’s looming drug shortage was filed from one of only two cyber cafes in the town of Igbo-Ora in southwest Nigeria pictured here. The town has 60,000 residents, but electricity is erratic to rare. It took several visits to find that the cafe’s generator was working strongly enough to access this site and make a posting. That is life on the edge of the digital divide. This current posting is being made at the airport lounge in Lagos on wireless connection – shows how the average person in Africa has little access to the internet to gather malaria information and engage in malaria advocacy.

Not long ago, Kenya was sharing its malaria achievements with the Director of WHO’s Global Malaria Program. According to a government brochure to mark the occasion, “12 million treatment doses of the new first line treatment, artemether-lumefantrine, have been procured and distributed.” In addition after the new drug treatment policy was rolled out in 2006, “numbers of children accessing free treatment in government health facilities (increased) from 50% to 63%.” In this column we also made note of the importance of Kenya’s national policy of universal coverage rather than targeting only vulnerable groups. It would seem that these achievements are at risk.

The East African Standard quoted the advocacy group Kenya NGO Alliance Against Malaria (KeNAAM) on 28th September 2007 that, “Failure on the part of the Government to budget for this vital drug and to adequately account for Global Funds resources now puts the lives of thousands of Kenyans at risk”.

Although we found stocks of artemether- lumefantrine in clinics in the Kisumu area in late August 2008, apparently there are stock-outs now that threaten the life saving achievements to date. KeNAAM therefore, calls on other donors to step in and fill the void.

A closer look into the funding situation sheds some light on the current problem. Kenya has two grants from the Global Fund to fight AIDS, TB and Malaria (Rounds 2 and 4) as can be found on the GFATM website. Round 2 includes drugs for integrated management of child illness (IMCI) along with ITNs and IPT. The Round 4 Grant addresses prompt reatment, epidemic control and ITNs. According to the Grant Score Card for Phase 1 of the Round 2 Grant, only half of the funds planned were disbursed due to slow implementation and late reporting.

The Round 2 Grant was given a ‘conditional go’ requiring additional clarification from Kenya’s Central Coordinating Mechanism before additional funds could be released. Additional report cards on the GFATM website show that disbursements have been held up due to procurement problems as well as lack of forecasting based on workplans.

Although disbursements for Round 4 are more closely in line with expectations, the grant report card still expresses concerns about procurement, transparency and also linkages with Round 2 activities.

Like KeNAAM we stress the need for all donors to help in the short term. In the long term though there is need for
better management of GFATM resources. The competition for these resources is high, and malaria proposals have not fared as well as those for TB and HIV, in part due to management problems and bottlenecks in national malaria programs. Kenya would do well by its people by paying more heed to the accountability and performance standards required from the Global Fund.

Recently we discussed the value of the website for the Global Fund to Fight AIDS, TB and Malaria as an advocacy tool to get financial, policy and programmatic support for malaria programs. During a recent visit to Kenya I learned that for many NGOs and front line health service staff the internet is a dream at best. Members of civil society organizations complained that it is only those in a well financed NGOs based in the capital who can browse and receive email communication about the latest developments and thus be in a good position to act on new grants and information. This was reiterated by a key development partner who warned that we in the international development community and the national health and development agencies tend to forget that few people can or do access information about malaria funding and technical information through the internet.

The website, Internet World Statistics, helps make this problem graphically clear. Overall only 3.6% of people in African use the internet compared to 20.2% worldwide. In continental Sub-Saharan Africa, South Africa takes the lead at 10.3% while DRC and Ethiopia are lowest at 0.2%. Some of the isalnd nations where mosquitoes and malaria are more easily controlled have internet usage approaching world averages.

One assumes that with the wealth of free information on the internet, though obviously some of questionable quality that the internet would be a most valuable resource for health program planners. In Nigeria we learned that the digital divide seen between Africa and the rest of the world in the attached chart also extends within countries. In southwest Nigeria we found that staff of NGOs were 50% more likely than those of government health agencies to have access to a computer and to browse the internet.

There are a large number of free malaria e-mailings that go out frequently to subscribers. Most helpful is the weekly summary of malaria news and scientific articles from the Roll Back Malaria partnership. Even in Africa AMANET sends out an e-mail newsletter. Africa Fighting Malaria is another group that puts out regular news summaries. But these are of little value if one does not have reliable internet access.

Part of development assistance in the war against malaria therefore, needs to include internet access to government and NGO staff in Sub-Saharan Africa as a major component of its armament. This will enable African malaria workers to be on top of the latest developments and access the information and funds they need to succeed against this killer disease.