Tropical Health Matters

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

International Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the second feature on women fighting malaria.

Pr. Awa Marie Coll Seck, the former Executive Secretary of the Roll Back Malaria Partnership pursues her fight against malaria in her own country, Senegal, as Minister of Health. Known for her smooth diplomatic skills and experience in policy formulation, she leads an aggressive reform striving to eliminate all deaths due to malaria in Senegal.

Pr. Awa Marie Coll Seck, Minister of Health and Social Action, Senegal

As global leadership increasingly realizes that the international strategy demands a strong local response and the most active engagement of beneficiaries, Senegal’s Minister of Health walks the talk. The Zero Malaria! Count Me In! campaign aims at creating a movement around the importance of accountability and individual responsibility when it comes to putting an end to this preventable disease. Malaria elimination demands the coordinated efforts of all sectors of society.

As the Minister of Health pledges to build capacity within health facilities so that they are able to properly manage simple and severe cases of malaria, the Zero Malaria! Count Me In! campaign insists on the necessary parallel commitment that Senegalese people need to make in order for the country to reach its malaria elimination objective.

Since the past decade, the country has made tremendous progress and reduced malaria mortality by 62%. Over 6.5 million of insecticide treated mosquito nets were distributed throughout the country and lifesaving medicines are now available in public health facilities free of charge.

Women being the primary caretakers of their families, International Women Day is the perfect occasion to celebrate the leadership of Senegalese women throughout the country, without whom, malaria elimination could never become a reality.

Thank you Minister for leading by example and proving that actions speak louder than words.

Happy International Women Day to all!

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

International Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the first feature on women fighting malaria.

Amy Niambo Ndao Fall, President of the Association of Women Doctors

Dr. Amy Ndao Fall is the President of the Association of Women Doctors of Senegal (AFEMS). This Association, composed of 400 members across the country, aims to undertake sustainable activities for the health of the Senegalese populations.

On the eve of Women International Day, in partnership with the Ministry of health and UN women, AFEMS organized in Dakar on March 7, a conference on the theme “women’s health for an emergent Senegal”.

This conference attracted approximately 150 women from all over the country and was chaired by Professor Awa Marie Coll Seck, Minister of Health and Social Action of Senegal.

The conference started with Dr. Ndao signing a pledge, on behalf of AFEMS to support the “Zero Malaria, Count me In” campaign and the National Malaria Control Program in their elimination efforts.

Dr. Ndao stated the association’s commitment to support all efforts toward malaria elimination in Senegal and abroad and concluded with the following words:

“It is a pleasure and an honour for me, to sign this engagement on behalf of AFEMS, to mobilize all our efforts to eliminate malaria in Senegal. We need to keep in mind that women are particularly vulnerable to this disease and that they can be change agents in their families for more efficient vector control in particular by promoting the systematic use of long lasting insecticide-treated mosquito nets for all their family members.”

On this International Women Day, we celebrate and thank Dr. Ndao and all the women Doctors of Senegal for their leadership and commitment to eliminate malaria and are proud to see such amazing partners joining efforts to make Zero Malaria a reality in Senegal.

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

In New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

1. A strong, efficient, well-run health system
2. Affordable care
3. Accessible care
4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

While much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.

GhanaWeb reported this morning that, “The United Nations General Assembly at its 68th Session, adopted Resolution A/68/L.60, “Consolidating Gains and Accelerating Efforts to Control and Eliminate Malaria in Developing Countries, Particularly in Africa, by 2015” by consensus.”

Likewise the UN itself issued a press release confirming that in a final act the Assembly adopted this resolution in order to call for increased support for the implementation of international commitments and goals pertaining to the fight to eliminate malaria. GhanaWeb reiterated the UN’s message that, “with just less than 500 days until the 2015 deadline of the MDGs, the adoption of this resolution by the General Assembly reiterates the commitment of UN Member States to keep malaria high on the international development agenda.”

The UN Press Release explained that, “The resolution urged malaria-endemic countries to work towards financial sustainability to increase national resources allocated to controlling that disease, while also working with the private sector to improve access to quality medical services.  Further, the resolution called upon Member States to establish or strengthen national policies, operational plans and research, with a view to achieving internationally agreed malaria targets for 2015.”

This effort is consistent with moves two years ago in the 66th General Assembly when it called for “accelerated efforts to eliminate malaria in developing countries, particularly Africa, by 2015, in consensus resolution” (document A/66/L.58) where the “Consolidating Gains …” document was first shared. The draft of the 2012  resolution, according to the UN Press release was sponsored by Liberia on behalf of the African Group, and called on Member States, particularly malaria-endemic countries, to strengthen national policies and operational plans, with a view to scaling up efforts to achieve internationally agreed malaria targets for 2015.

The sad irony of Liberia’s current predicament wherein the Ebola epidemic is rendering it nearly impossible to provide malaria services should give us pause. According to Reuters, “Treatable diseases such as malaria and diarrhea are left untended because frightened Liberians are shunning medical centers, and these deaths could outstrip those from the Ebola virus by three or four fold.”

The new resolution (A/68/L.60) in calling for increases national resources allocated to controlling that disease from public and private sources demonstrates the importance of national commitment to sustain and advance malaria control into the era of malaria elimination. It is now up to local malaria advocates to ensure that their governments, as well as private sector and local NGO partners, follow through to guarantee the needed quantity and quality of malaria services.

Two articles caught my attention this morning. One reviewed the merits of improved social and behavior change communication (BCC) for the evolving malaria landscape. The other addressed the damage institutional corruption is doing in Africa. And yes, there is a connection.

When I was trained as a community or public health educator in the MPH program at UNC Chapel Hill, the term BCC had not yet been coined. We were clearly focused on human behavior and health.  What was especially interesting about the emphasis of that program was the need to cast a wide net on the human beings whose behaviors influence health.

BCC of individuals and communities may not be enough

While the authors in Malaria Journal state that, “The purpose of this commentary is to highlight the benefits and value for money that BCC brings to all aspects of malaria control, and to discuss areas of operations research needed as transmission dynamics change,” a closer look shows that the behaviors of interest are those of individuals and communities who do not consistently use bed nets, delay in seeking effective treatment, and do not take advantage of the the distribution of intermittent preventive therapy (IPTp) during pregnancy. The shortfalls in the behavior of other humans is lies in not “fully explaining” these interventions to community members.

The health education (behavior change, communications, etc. etc.) program at Chapel Hill taught us that a comprehensive intervention included not only means and media for reaching the community, but also processes to train health workers to perform more effectively, to advocate with policy makers to adopt and fund health programs, and intervene in the work environment using organizational change strategies to ensure programs actually reached people whose adoption of our interventions (nets, medicines) could improve their health.

At UNC we tried to focus change on all humans in the process from health staff to policy makers to ensure that we would not be blaming the community for failing to adopt programs that were not made appropriately accessible and available to them. We did not call it a systems approach then, but clearly it was.

This brings me back to the article on corruption. Let’s compare these two quotes from the IRIN article …

• The region accounts for 11 percent of the world’s population, but carries 24 percent of the global disease burden. It also bears a heavy burden of HIV/AIDS, tuberculosis and malaria but lacks the resources to provide even basic health services.
• Poor public services in many West African countries, with already dire human development indicators, are under constant pressure from pervasive corruption. Observers say graft is corroding proper governance and causing growing numbers of people to sink into poverty.

Illicit cash transfers out of countries and bribery of civil servants, including health workers, are manifestations of the same problem at different ends of the spectrum resulting in less access to basic services and health commodities.  Continued national Demographic and Health Surveys show that well beyond 2010 when the original Roll Back Malaria Partnership coverage targets of 80% were supposed to have been achieved, we see few malaria endemic countries have achieved the basics, and some have regressed. Everyone is bemoaning the lack of adequate international funding for malaria (and HIV and TB and NTDs), but what has happened with the money already spent?

Without a systems approach to health behavior and efforts by development partners to hold all those involved accountable, we cannot expect that the behavior of individuals and communities will win the war against malaria.

Daniso Mbewe, the Knowledge and Information Management Officer of SARN has shared with us a Press Release from the Southern African Regional Network Secretariat (SARN) of the RBM Partnership in Southern Africa. The commemoration was held under the THEME: “Be free of Malaria in SADC Region”

SALIMA, MALAWI,  08 November, 2013: The Vice President of Malawi, Rt. Hon. Khumbo Hastings Kachali, launched the 2013 SADC Malaria Day Events in the malaria endemic Lake Malawi town of Salima. The events were attended by Health Ministers and senior health officers and national malaria managers from SADC countries (Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, Tanzania Mainland and Zanzibar, Zambia and Zimbabwe, SADC Secretariat, SARN Secretariat, USAID, the uniformed Forces (military/police), RBM partners, provincial, district and local political, religious and traditional leaders, communities and school children.

The presence of traditional dance troops, dreamers, actors (drama troops) and school children made the event colorful and highly entertaining. Of special mention is Illovo Sugar a member of the SARN private sector constituency which donated 1 million Malawi Kwacha for the event and provided a demonstration of the T3, IRS, LLINs, IPTP and BCC/IEC.

Senior Chief Kalonga thanked SADC and the Malawi government for bringing the event to his region because Salima has a lot of malaria which is impacting on development especially workers, school children, pregnant women, teachers and fishermen. He thanked the National Malaria Control Program for distributing LLINs and other interventions which are on-going in his region.

Malawi Minister, Hon. Catherine Gotani Hara – emphasized the need to continue protecting the women and that they should attend ANCs and demand for malaria protection while encouraging all members of the family and community to report early for treatment. She thanked the RBM and partners for the continued support and technical guidance from  the WHO.

The Rt. Hon Khumbo Hastings Kachali, the Vice President of the Republic of Malawi, a former Minister of Health said that he was informed that there is now a trend showing a decrease in cases and deaths in Salima and he would like to see this replicated nationally. He however, warned the communities that this could be derailed by those people who use nets for fishing (Salima is a fishing community), sell nets, do not sleep under nets, do not complete their treatment and women who refuse to take IPTp. By 2015 he said  “Malawi should have distributed over 10 million LLINs” much to the applaud of the participants.

The Vice President thanked SADC Member States and all those who attended and that this level of collaboration, interaction and information sharing should continue to blossom. He further emphasized that the attainment of the MDGs is a priority for all SADC countries and as the SADC chair, Malawi will continue to encourage countries and also to appraise the Heads of States on progress made and challenges the Ministries of Health are facing especially domestic funding, health infrastructure, equipment, shortage of human resources and skill levels.

The main outcome was high and community levels advocacy, SARN-RBM visibility, regional collaboration and community education via several drama/plays with malaria themes and messages.

The main program for 6th MIM Pan-African Malaria Conference is available at the Medical Research Council website: http://mim2013.mrc.ac.za/programme.htm. We will be using #MIM2013 to share tweets. The conference runs from 6-11 October 2013 in Durban, South Africa. There will be a variety of presentation formats including Plenaty sessions, symposia, parallel scientific sessions and poster sessions/exhibits.  Many partners will be hosting special events.

Plenaries will highlight the current status of malaria intervention as well as look toward the future. In that vein several sessions address malaria elimination as for example …

• Plenary Lecture VII by Prof Alan Magill “Strategies for realising malaria elimination and eventual eradication”
• Plenary Lecture V by Dr Robert Newman“From a one-size-fits-all to a tailored approach for malaria control and elimination.”
• Symposium 19: Targeting malaria elimination in Zanziba. Prof Anders Bjorkman
• Symposium 58: Malaria eradication: identifying and targeting the residual parasite pool Mr Simon Kunene
• Symposium 41: The final decade of malaria in Africa: planning for the endgame

There are sessions on case management issues ranging from severe malaria to better diagnostics. The role of the private sector is addressed. Vector biology and entomology are featured.

Not only will there be formal media coverage of events, including interviews with key players in malaria control and elimination, but the Roll Back Malaria partnership is mobilizing its Working Group members and partners to provide a full range of social media exposure for MIM events on Facebook, twitter and various blogs.  Keep your eyes on this page for the latest updates as news is being released.

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.

While today it technically the sixth World Malaria Day, one should actually trace the origins back 13 years to the first Africa Malaria Day (AMD) in 2001, held to encourage progress based on the Africa malaria Summit in Abuja just one year before.  And since the Abuja summit and its resulting declaration were backed by the Roll Back Malaria Partnership, which formed in 1998, one could say the world has 15 years to considering in judging progress in and plans for partner investments in ridding the world of malaria.

In 2001 organizers of Malaria Day events were encouraged to feature a ‘new’ medicine that WHO said could save 100,000 child healths annually in Africa. artimisinin-based combination therapy (ACT) drugs are now the front line treatment in most all endemic countries, and deaths have declined somewhat on the order of 400,000. At that time there was only one major manufacturer of ACTs. Investments by pharmaceutical companies in generic ACTs now means that there are at least nine companies that produce prequalified ACTs. What is needed is more indigenous African pharmaceutical companies approved to invest in ACT production.

The first AMD stressed the risk of malaria to pregnant women and recommended widespread use of Intermittent Preventive Treatment in pregnancy (IPTp).  This recommendation has been adopted in countries with stable falciparum malaria transmission, but has lagged in terms of implementation, and coverage still lags below the 80% target set at the 2000 Abuja Summit.  There are missed opportunities to provide IPTp at antenatal clinics due to stock-outs, provider attitudes, and client beliefs. Weak health information systems mean that even when services are provided, reporting may not accurately reflect true coverage of IPTp.

In the meantime resistance is growing to sulphadoxine-pyrimethamine (SP), the drug used for IPTp in part due to the inability or unwillingness of country drug authorities to curb its inappropriate use for case management.  WHO now recommends more that the original two IPTp doses and suggests that pregnant women get SP at each ANC visit after quickening.  In the meantime research is underway to find substitutes for SP.

The first AMD addressed the role of insecticide treated nets (ITNs) in helping halve the world’s malaria burden by 2010.  Major progress came in 2008 when the whole United Nations community and of course companies invested in net production got behind universal coverage. In addition the advent of the long lasting insecticide-treated net with insecticide infused in the fabric from point of production pointed the way to success.

These three core interventions – ACTs, IPTp and ITNs – have been strengthened with better diagnostics and a variety of other vector control measures, Hopes for a vaccine still remain a dream, though an achievable one.  While we have high expectations for eradication, we can see that some of the health systems challenges that thwarted the first malaria eradication effort are still with us including weak procurement and supply management, inadequate human resources and gaps in health information systems.

The foregoing implies that we need at least two forms of future investment in malaria. First is investment by governments in strengthening the health system that deliver malaria services. The second investment is in continued biomedical research in order to fend off resistance by mosquitoes and parasites and of course social research to address issues of behavior, adoption of innovations and program management practices. Let’s hope that when World Malaria Day 2014 rolls around, we can measure these increases investments.

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