Tropical Health Matters

The Washington Post reported today that a key official in the US President’s Administration has been blocking the publication of the Surgeon General’s 2006 “Call to Action on Global Health,” a draft of which is available on the link provided. Specifically the Post noted that, “A surgeon general’s report in 2006 that called on Americans to help tackle global health problems has been kept from the public by a Bush political appointee without any background or expertise in medicine or public health, chiefly because the report did not promote the administration’s policy accomplishments, according to current and former public health officials.”

Reading through the report one does not find specific mention of the President’s Malaria Initiative (PMI) but does cite the President’s Emergency Plan for AIDS Relief. The report does highlight various global efforts such as the Global Fund to Fight AIDS, TB and Malaria, of which the U.S. is a major supporter/donor, the Roll Back Malaria Partnership, and the United Nations Millennium Development Goals. Concerning the MDGs, the draft report states, “Beyond reducing the disease burden, a successful fight against malaria will have far-reaching impact on child morbidity and mortality, maternal health, and poverty, which in turn could increase global stability.”

The draft report emphasizes that, “Malaria treatment, control and prevention should be an integral function of an effective health system, supported by strong community involvement. Sustained success in malaria reduction calls for development of the health sector; improved case management, the use of intermittent presumptive treatment programs for pregnant women, insecticide-treated bed nets, and spraying of households with insecticide.” This recognition of a comprehensive approach to malaria control programming by the United States certainly needs to be shared widely with other donors and endemic country policy makers.

The draft report also touches on an issue that has been politically sensitive to the Administration, global warming. The report explains the link between malaria and global warming as follows: “The distribution of insects and other organisms that serve as hosts to the microorganisms that cause infectious diseases is likely to be affected. This could lead to changes in disease patterns. For example, malaria might appear in areas where it is currently unknown because of the spread of the mosquito that carries the disease.” In another politically sensitive move the report acknowledges malaria research and technical efforts by the French, the Japanese and the Multilateral Initiative for Malaria.

Although the current Bush Administration may have brought attention to malaria to a new level through PMI, the U.S. has been a leader and a champion of malaria control and prevention for decades through the US Centers for Disease Control and Prevention, the National Institutes of Health, and USAID, to name a few. Some sense of balance is needed. One certainly does not want to see a document that is only a self-congratulatory piece, but one would also expect to see adequate recognition of all contributors and stakeholders who promote global health. The report does deserve to have wide circulation to stimulate greater discussion of and commitment to solving global health challenges by US Citizens and their elected representatives.

When nations, states, provinces and districts are not allocating enough funds for malaria treatment and prevention, will people speak out? When allocated malaria funds are being used for other purposes, will people speak out? When bed nets are being given only to those who voted for a particular political party, will people speak out?  These are some of the questions that come to mind when reading the new World Bank Report on Governance.

According to the BBC, report measures the quality of government in 212 countries from 1996 to 2006 found Africa had shown the greatest improvement. Six measures that comprise governance include:

• Voice and Accountability
• Political Stability and Absence of Violence
• Government Effectiveness
• Regulatory Quality
• Rule of Law
• Control of Corruption

Voice and Accountability is a major concern in our efforts at the Voices Project. This measure is defined as follows: “The extent to which a country’s citizens are able to participate in selecting their government, as well as freedom of expression, freedom of association, and a free media.”

The report links Voice and Accountability with Control of Corruption. “Countries with voice and accountability challenges … tend to have much more corruption. This is consistent with the idea that when citizens can demand more accountability through the ballot box, or where there is freedom of expression, of the media, and of information, governments become cleaner and less corrupt.” Corruption, as we know, leads to poor prognosis in terms of delivering health services, including malaria control programs, in an efficient and equitable manner.

The Voices Project is focusing on four malaria endemic countries, Ghana, Kenya, Mali and Mozambique, in addition to the major donor agencies and countries.  The World Bank report traces progress for each country on governance issues between 1996 and 2006.  A co-author of the World Bank Report states that, “The good news is that some countries, including some of the poorest ones in Africa, are deciding to move forward, and are showing to the world that it is possible to make substantial inroads in improving governance.” We can see in the chart that the rankings of the four Voices Project countries on Voices and Accountability mean that there will be challenges to advocacy efforts, but there are hopeful signs that the advocacy climate is improving in Ghana and Kenya.  Malaria advocacy will serve as a test case for improving Voice and Accountability in these countries, and the benefit will hopefully go beyond lives saved from malaria to lives lived freely in a more open and free society.

Advocacy is really a behavior change strategy aimed an policy makers and policy implementers. As such it turns the tables on the traditional behavior change communication approaches that target the community and consumers. Instead the community and consumers through advocacy try to educate the policy makers. At minimum there are three basic components to advocacy:

1. Promoting enactment of policies, laws, standards, guidelines
2. Ensuring that policies are actually funded
3. Monitoring approved policies to be sure they are fully implemented

Galer-Unti and colleagues outline several advocacy strategy approaches to make sure policies are enacted and their benefits reach the public. These strategies involve individual and as well as community commitment for action.

1. VOTING for officials who are likely to enact and uphold policies that promote public health
2. ELECTIONEERING and campaigning for candidates who promise to support public health
3. LOBBYING elected officials and decision makers to follow through on promises to promote public health
4. MOBILIZING THE GRASSROOTS to petition, meet and influence decision makers
5. USING THE INTERNET to draw attention to public health concerns
6. ADVOCATING THROUGH THE MEDIA either by writing news and opinion pieces, serving as a resource for reporters or even better, by staging events that will attract media attention and thereby, that of policy makers

What does this mean for malaria? These days most countries have received guidance from WHO and the Roll Back Malaria Partners in developing national malaria treatment and prevention guidelines and policies. For example, these policies spell out national support for the use of Artemisinin-based Combination Therapy (ACT) for first line case management. It is therefore often at the second and third levels – budgetary support and implementation support – where much of the advocacy is needed.

An example of the follow through needed to make policies a reality comes from Nigeria’s ITN Massive Promotion and Awareness Campaign (IMPAC). The federal government rallied donor support and some domestic funds to acquire seed stocks of ITNs. Memoranda of Understanding (MOUs) were signed with most state and local government (LG) officials indicating that they would supplement ITN stocks to ensure all in need were reached. Unfortunately after the initial federal stocks were exhausted, no further supplies were provided by states and LGs. The federal government continues to mobilize donor support for ITNs, for example through Global Fund, USAID and DfID, and some corporate philanthropic and foundation efforts contribute additional nets, but supplies have been limited.
Fortunately the National Malaria Control Program (NMCP) had budgeted some funds for advocacy. Visits to selected states yielded some results. For example even though it was not a donor recipient, the Niger State Government after an advocacy visit actually purchased nets and undertook distribution. More work is needed to mobilize the grassroots so that they demand nets from their local health departments, but at least we can see that advocacy can work in an African setting. Hopefully this will inspire NMCPs in other countries to get on the advocacy bandwagon.

One of our newest African malaria advocates, the Voices Mali Coordinator, Djiba Kane Diallo, appeared in a press conference on French TV channel TV5.  Djiba was in Paris at a press conference about the lack of progress toward achieving the Millennium Development Goals for health.  The conference was organized by Médecins du Monde and the story was broadcast globally on TV5.  She was interviewed and spoke specifically about logistical problems in managing malaria commodities in Africa.  Supply chain management is one of the systems that need to be strengthened to improve malaria control across Africa.

Watch the clip (in French!) at http://www.tv5.org/TV5Site/info/jt_ja.php?edition=20070705&par=6

Les pays européens doivent investir d´urgence dans les services de santé des pays pauvres 

(aired on 5 July 2007)

For non-Francophones, here is the translation of the newsclip:

In a meeting in Paris on July 5, 2007, European NGOs demand that European governments invest more in health services in developing countries in order to meet MDG goals.

It’s the first evaluation of the Millenium Development Goals. At the midway point, a report edited by 15 NGOs gives a poor grade to Europe, and to France in particular. Current financing for goals like reducing child mortality means that they will be met only in 2220. Twenty million Euros were promised for health, but only half of what was promised has been spent.

[Patrick Bertrand, NGO network leader] “Data from 2004-2005 shows that France gives 4% of its foreign aid for the health sector. The average among OECD countries is 11%.” 

On the ground, they are impatient for the missing funds. For the NGO Voix du Mali, which works to control malaria, it’s an emergency. Medicines are there, but there are few funds to distribute them.

[Djiba Kane Diallo, Voix du Mali] “If there is more financing, that enables countries to not only to distribute the medicines out to the community level, but also to stock them in appropriate conditions.”

In the report they highlight not only the need for more money, but also the need to change practices and policies in the health sector. Promote research, train health personnel, and put more responsibility on African governments.

[Michele Brugiere, Medicins du Monde] “African governments need to commit more of their budgets to health - they should be comitting 15-20%. Right now it’s two, three, four percent.”

MDG health goals can still be reached, but donors’ political will must now change into economic reality.

 

Nothing is straightforward in Washington, though with modern communications technology it is a bit transparent for those willing to dig out the facts.  USA Today reports that, “The Senate Appropriations Committee … is boosting Bush’s $4.2 billion request for the foreign aid bill’s global HIV/AIDS account by $940 million. Lawmakers are adding $590 million to the Bush administration’s request for a global fund to combat AIDS, tuberculosis and malaria; that is enough money to almost triple it,” while cutting money from the Millennium Challenge Corporation (MCC). The reason for the latter move is lack of absorptive capacity – a charge that is often leveled against grant recipients in developing countries.

Ironically the lack of faith in the US contribution to the Millennium goals process comes at a time when the UN warns that anti-poverty targets in Africa will not be met. According to the Guardian, “UN said the world was failing in the battle to combat hunger, cut infant mortality and put every child in school.” Likewise Reuters reports that, “Sub-Saharan Africa, the poorest corner of the world, has struggled to keep up with other regions, the report said, noting urgent needs in its fight against HIV/AIDS, malaria and tuberculosis, as well as basic medical care and education.”

The MCC recently awarded “Mozambique’s five-year $506.9 million Millennium Challenge Compact aims to reduce poverty levels through increased incomes and employment by improving water, sanitation, roads, land tenure, and agriculture. This program is expected to benefit approximately five million Mozambicans by 2015.”  This package should compliment  efforts by the President’s Malaria Initiative in Mozambique, for example as “improved water systems, wastewater disposal, and storm water drainage” may help control mosquito breeding.

While we certainly do not advocate funding agencies that cannot spend money in a wise and timely manner, we do encourage the viewpoint that sees malaria control as part of a wider health and development effort.

The American Enterprise Institute has raised concerns about the quality of drugs that might be purchased for large scale donor efforts. Roger Bate explained that for malaria, “only 7% of malarial drugs on the Global Fund’s list have undergone bioequivalence testing yet malaria kills more than a million people a year.” He goes further to note that, “Some of the drugs are “monotherapies,” single drugs which have been actively discouraged by WHO because they encourage drug resistance. The list contains further drugs which go against good medical practice, the specific advice of the WHO and even, according to insiders, against the technical advice of competent people at the Global Fund.” The head of Kenya’s malaria control program quotes as saying that their ministry “plans to buy untested Indian copies of Coartem.” Mr Bate is therefore concerned that, “Uganda and Nigeria are likely to do the same. And this is probably just the tip of the iceberg.”

As we have reported before, there are definite concerns about cost and availability of malaria drugs expressed by African countries. What can be said about quality? The Global Fund, one of the largest sources of money for malaria drug purchases, addressed the quality issue through its Board, which has issued guidelines for countries. These guidelines distinguish four categories od medicines: A, B, Ci and Cii. Of note, “The Global Fund does not endorse or warrant the fitness of any product on the Compliance List for a particular purpose,” These categories are defined as follows:

A – Products acceptable under the WHO Prequalification Program

B – Products authorized for use by a stringent regulatory authority

Ci – The manufacturer has submitted an application for approval of such product to the WHO Prequalification Program or a stringent regulatory authority

Cii – If the manufacturer of such product has not submitted an application for approval of such product to the WHO Prequalification Program or a stringent regulatory authority, such product is manufactured at a GMP compliant manufacturing site, as certified (after inspection) by the WHO or a stringent regulatory authority

Only one drug in the list is found in category A: Artemether-Lumefantrine by Novartis. Only one is ranked in category B: Artesunate-Mefloquine by Mepha. This list is available in the internet for all countries to review and use for planning. The so-called monotherapy drugs are in large part artemether rectal capsules for use in severe malaria only. Sulphadoxine-pyrimethamine is listed since it is the drug used for Intermittent Preventive Treatment/Therapy in Pregnancy.

For the past three months the international Roll Back Malaria Partners have been providing technical guidance to African countries as they develop their next proposal for the Global Fund, and these partners are using such guidance from WHO and GFATM to ensure that countries order quality medicines. Contrary to fears that Nigeria may be ready to buy cheap, poor quality alternatives, the Nigerian proposal development team is at this very moment basing all its procurement and costing estimates on Artemether-Lumefantrine (Coartem). A positive and synergistic aspect of the planning is that if high coverage of long lasting insecticide treated nets is achieved, demand for ACTs will actually decrease, which addresses in part the cost issue.

Finally, although major RBM partners are trying to address quality issues, there are still many areas of concern – what malaria drugs are being imported and sold through the private sector? – what malaria drugs are governments in endemic countries buying with their own funds? The RBM partnership has made a start to ensure malaria drug quality, but must continue advocacy until all organizations and agencies that purchase malaria drugs adhere to quality standards and more drugs are added to the prequalification list.

Claudia Vondrasek, based in Mali for the Voices Project, offers these perspectives (in French and English) on malaria control in Mali.

Quel rôle le secteur privé devrait jouer ?

Le paludisme constitue un problème prioritaire de santé publique de part sa fréquence, sa gravité chez la population malienne. La politique nationale de lutte contre le paludisme prend désormais en charge les couches vulnérables que sont les femmes enceintes et les enfants de moins de 5 ans. Cependant, force est de reconnaître, que malgré la volonté des autorités, il manque suffisamment de ressources pour faciliter l’accessibilité et la disponibilité du traitement à un moindre coût (en subventionnant par exemple) pour les couches hors cibles. Le secteur privé peut combler ce vide en partie en jouant un rôle important dans la protection et la prise en charge des employés et leurs familles. En plus, le secteur privé pourrait soutenir le ministère de la santé dans l’acheminement des produits antipaludiques et la construction ou la réhabilitation de magasins appropriés pour le stockage de ces produits.

Le paludisme est–il la chasse gardée du ministère de la santé ?

Vu la gravité et l’ampleur de la maladie, les défis pour éradiquer le paludisme au Mali dépassent les seules capacités du ministère de la santé. Il est aujourd’hui nécessaire de stimuler des actions citoyennes des entreprises et sociétés au Mali pour contribuer de façon significative à la protection et prise en charge de leurs employés et familles du paludisme. Les entreprises peuvent ainsi offrir de l’éducation sur le paludisme aux employés ; rendre accessible et disponible les produits antipaludiques (SP, CTAS, MII, TDR…) dans leurs infirmeries ou dans les centres de santé inter – entreprises…

Fort de cette opportunité, Le projet Les Voix du Mali a organisé, le samedi 2 juin, un dîner-gala pour stimuler l’engagement des entreprises privées dans la lutte contre le paludisme. Quatorze sociétés et entreprises se sont engagés à prendre des actions concrètes contre le paludisme dès cet hivernage en faveur de leurs employés et leurs familles.

Ces engagements peuvent s’expliquer par une prise de conscience des chefs d’entreprises de la gravité et l’impact socio-économique du paludisme. Il apparaissait clairement que les chefs d’entreprises ne disposaient pas d’informations fiables sur les conséquences du paludisme. Une action soutenue d’information des chefs d’entreprises permettra d’aboutir à l’adhésion d’un grand nombre d’entre eux non seulement pour concrétiser la volonté du Conseil du Patronat National de créer une coalition des chefs d’entreprise contre le paludisme au Mali mais aussi et surtout de protéger tous les travailleurs du secteur et leur familles contre le paludisme.

Egalement, tous les ministères (que ce soit Agriculture, Mines, Tourisme, Communication, Transport …) et la Société Civile dans sa totalité, doivent absolument s’engager aux côtés du Ministère de la Santé pour lutter contre le paludisme et faire du Mali un pays sans paludisme, une réalité.

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What role should the Private Sector play in Malaria Control? Malaria is a priority public health problem due to its frequency and its burden on the Malian population. National policy now targets the most vulnerable populations: pregnant women and children under 5 years old. However, the Ministry of Health lacks the resources today to facilitate access and availability of subsidized treatment on a national scale to other adults and older children. The private sector can fill this void in part by playing an important role in protecting and taking responsibility for their employees and their families. In addition, the private sector can support the Ministry by helping with supply chain for antimalarial products and by constructing or installing appropriate storage facilities for stocking these products.

Malaria: is it the exclusive domain of the Ministry of Health?

In light of the gravity and magnitude of the disease, the challenge of eradicating malaria in Mali surpasses the capacity of the Ministry of Health alone. Today it is necessary to galvanize Malian companies and businesses to make substantial efforts towards protecting and taking responsibility for their employees and families from malaria. Companies can thus offer education about malaria to their employees, and help make antimalarial products (SP, ACTS, ITNS, RDTS…) accessible and available in the company clinics or health centers.

To encourage this opportunity, the Mali Voices project organized a diner-gala on Saturday June 2, 2007 to engage the private sector in the fight against malaria. Fourteen companies and businesses agreed to take concrete actions against malaria during the upcoming rainy season for the benefit of their employees and their families. These actions are the results of companies’ executives becoming aware of the seriousness of the socioeconomic impact of malaria. It appears clear that the CEOs were not previously aware of the consequences of the disease. Getting a steady flow of information to executives will encourage many of them to participate in malaria control activities, and build support in the National Business Council to create a Private Sector coalition against malaria in Mali.

Every year in Mali, malaria kills more than 100,000 people, mostly children. It is the responsibility for all sectors to contribute to a successful fight against malaria parasites and vectors. Civil society organizations and Ministries of Agriculture, Transportation, Mines, Tourism, Communication, etc. must take on the responsibility of complementing Ministry of Health actions to make Mali malaria free.

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PRIVATE SECTOR NEWS FROM RBM

Meeting in Dakar aims to improve private sector involvement in the global fight against AIDS, tuberculosis and malaria
In cooperation with Global Fund, ILO, WHO, UNAIDS, Partners against AIDS, and the Roll Back Malaria Partnership Secretariat, a West and Central Africa regional workshop was organized in Dakar to exchange experiences and develop country strategies in order to enhance private sector involvement in the response against the three major diseases. It brought together private sector stakeholders, finance institutions, workers, international agencies, professional associations, labour unions, and 18 countries from West and Central Africa.

Réunion à Dakar vise à améliorer l’engagement du secteur privé dans la riposte mondiale contre le sida, la tuberculose et le paludisme
Avec la cooperation du Fonds Mondial, le BIT, l’OMS, l’ONUSIDA, les Partenaires Contre le Sida, et le Partenariat “Faire Reculer le Paludisme” un atelier régional a été organisé à Dakar afin de faciliter l’échange d’expériences et d’aider les pays à développer des stratégies visant à augmenter l’engagement du secteur privé dans la riposte contre les trois maladies les plus importantes. Cet atelier a regroupé les parties prenantes du secteur privé, les institutions financières, les travailleurs, les agences internationales, les syndicats, et 18 pays d’Afrique de l’Ouest centrale et d’Afrique centrale.

Hannah Koenker has put together the following update on progress made in the four country-based programs of VOICES for a Malaria Free Future. Hopefully this will encourage other countries to strengthen their advocacy efforts.

Ghana
Ghana has mobilized leadership in government and civil society to form the National Voices Team, whose advocacy strategy has been accepted by NMCP and its partners as the national malaria advocacy strategy. As remarked by the Program Manager “Advocacy has received very little attention in our malaria control activities; Voices has come to fill the gap.” A number of malaria Champions have been recruited, including government and traditional chiefs. Two monthly Action Alerts have been published, and are seen by the NMCP as a great tool to keep the leadership awake on malaria control issues and to motivate sustained effort. Last but not least, the District Malaria Advocacy System is starting up. The key issues Ghana continues to grapple with are

1. Slow implementation of the new malaria drug policy – the use of the A+Aq. Lack of confidence in the drug due to earlier problems during introduction
2. Failure of the District Assemblies to program the 1% Common Fund for malaria control activities. (We know that at least from our 2 districts.)

Mali
Mali has organized a series of “War Room” meetings with the NMCP and its partners to discuss ITN distribution, household and community barriers to accessing treatment, and the introduction of ACTs for pregnant women and children under five. They have met with a variety of partners, including PSI, UNICEF, Peace Corps Volunteers, PMI, the National Pharmacy, the Koulikoro Regional Health Office, and the Global Fund. The team has also met with several private sector partners to plan employee net distributions. Most notably they have successfully advocated for the renewal of the presidential exoneration of taxes and tariffs on ITNs and insecticides for net treatment, and have written several newspaper articles about their efforts. For Africa Malaria Day, which in Mali is being celebrated throughout the month of April, VOICES produced four 3-minute skits with the director and actors from the popular Malian soap opera “D’ou la famille”, touching on messages like prompt treatment, the role of fathers in treatment-seeking, myths about malaria and mosquitoes, and the importance of ITNs and ACTs. Several Malian musicians have been recruited as malaria champions, and activities are being planned for the near future.

Challenges have been to carry out activities in the workplan while responding to the PMI team’s request for information and help during their visits. In addition, while the government is promising free ACTs and ITNs to pregnant women and children under five, there are not yet enough drugs and nets in-country to meet demand.

Mozambique:
Mozambique continues to update their Resource Center and has scheduled a calendar of malaria talks. They’ve helped the NMCP create a multi-sectorial committee for malaria activities and are serving as the secretariat, as well as helping to set up a database that will map malaria activities. Their advocacy strategy and workplan are finalized and the M&E plan is being finalized, with input from stakeholders. Voices also facilitated the trip of one Mozambican journalist  to participate in the presentation of the UK All Party Parliamentary Malaria Group report (“Financing Mechanisms for Malaria”) and Yvonne Chaka Chaka’s Princess of Africa Foundation launch. With coalition members Voices will tackle the issue of community health workers (CHW), to improve access to malaria prevention and treatment services, and will contribute to the First Lady’s campaign, “Malaria Free Children”.

Kenya 
Kenaam has conducted a two-day advocacy training for KeNAAM members after which a task force was established to develop the Kenya VOICES advocacy strategy. Additional task forces will take on the role of identifying champions, and gathering information on the malaria situation in Kenya.  They have successfully managed the constituency election process so that more malaria CSOs have a voice on the GFATM CCM, and continue advocating for release of funds to NGO implementers. Kenaam’s new communications officer has developed a Kenya work plan that includes activities such as training, outreach to new partners and voices, and documentation of activities. She has also developed a media database and the team is planning a media training targeted for journalists from regions where malaria is particularly bad. A database of Members of Parliament from malarious areas was also created, and contacts have been made so that malaria can be made part of the Parliamentary Health Committee agenda. Partnerships were developed with the Boy Scouts, several youth groups, and the Ministry of Education to train new youth voices in malaria advocacy, and to work with Pfizer’s school health program to include malaria messages in teaching curriculums. A notable recruit was the Kenyan UN Youth Ambassador, who has the potential to be an advocate at global level. Success and advocacy stories are in development, including the Kilifi “Talking Nets” story, and will be featured on the CORE website, later on the KeNAAM site, and linked to the VOICES Homepage. Kenaam’s draft advocacy strategy includes plans for M&E and sets out Kenya’s main challenges,

• the low priority of malaria within the government
• the need for more resources to be included in the GOK budget
• the need for the flow of resources to be less restrictive (GFATM for example and how CSO still have not received Round 2 funds)
• the need for ACTs to be made available at a reduced cost in the private sector (roll out of the new policy is only happening in public hospitals and clinics, but most people access drugs from shops).