Tropical Health Matters

In Nigeria there is a saying – “government money for government people.” The average citizen does not expect government officials, elected, appointed or hired, to use public money for public good, just to enrich themselves. Hence, one hears much grumbling but very little in the way of protest or advocacy for greater accountability in public expenditure.

The situation appears to be the same in Uganda, but instead this time it is global money for government people and their friends. International inquiries and complaints aside, it appears to be business as usual with Global Fund grants in Kampala.

Malaria World has brought our attention back to the continuing saga of Global Fund mismanagement in Uganda. The story stretches back to 2005 when grants were suspended for improper use of funds for ‘consultants’ and ineffective drugs, according to the Daily Monitor. On Monday the Daily Monitor reported that …

From: Emily Johnston
Sent: Saturday, April 10, 2010 12:04 AM
To: Brieger, William
Subject: Malaria Matters was named a top 50 public health blog
Hello Dr. Brieger

I’m just writing this to let you know about a new featured post we just made over here at Health Sherpa entitled, “Top 50 Public Health Blogs.” I thought that both you and your readers at Malaria Matters might find it to be an interesting article.

Please do let me know if you have any feedback — http://mastersofpublichealth.org/top-50-public-health-blogs.html

Malaria Matters: Bill Brieger is currently a Professor in the Health Systems Program of the Department of International Health at Johns Hopkins University as well as the Senior Malaria Adviser for JHPIEGO.

Warm Regards,
Emily Johnston
Health Sherpa

By Arsénio Manhice, Mozambique

Journalists can contribute to reduce the burden of malaria if they assume their role and spread continually information about how to prevent and threat malaria, particularly in South Africa, announced Dr. Aziza Mwisongo, Indepth Effectiveness and Safety of Anti-malarial Drugs in Africa (INESS) Project Manager speaking to Journalists. Dr. Aziza Mwsisongo was speaking in a three-day media sensitization workshop on INESS held in Dar-es-salaam, Tanzania, from 18th to 20th March 2010.

In the meeting, the Journalists noted that with concerted efforts from all stakeholders such as Scientists, Journalists, Governments and Non-governmental Organisations malaria can become a disease of the past.

This comes in a communiqué of the workshop promoted under the Indepth Network project in collaboration with the African Media and Malaria Research Network (AMMREN).

During the meeting, the Journalists noted that ten years after, the Declaration adopted by African leaders in Abuja, Nigeria, in 2000, is not moving ahead. In their Declaration, the leaders agreed, besides other goals, that by 2010 80% of children under-five and pregnant women will sleep in ITNs, 80% children under five with fever will have prompt access to care, 25% of childhood fevers will be correctly managed using IMCI.

“These targets have not been met. However, with concerted efforts from all stakeholders, malaria will become a disease of the past”, announced Journalists at the end of the workshop.

However, the journalists from Burkina Faso, Gabon, The Gambia, Ghana, Kenya, Malawi, Mozambique, Nigeria, Senegal and Tanzania applaud the efforts being made by INDEPTH Network and Malaria Clinical Trials Alliance (MCTA) for setting up various investigative sites in Africa to fight malaria.

At the moment, INESS is already carrying out studies in Tanzania and Ghana and will be expanding to other African countries such as Mozambique and Burkina Faso.

To reach the goals, the roll of the media is strategic as emphasized Dr. Gabriel Upunda, the Guest of Honor of the workshop on his opening speech. “The world needs your efforts. The health of the children and pregnant women suffering around Africa only can change if you keep spreading accurate information about malaria”, he said.

According him, more has done to roll back malaria using anti-malarial drugs but he believe that Africa need to do more. “I will not congratulate you because of this network. This is not because you are not implementing good activities. It’s because you still need to use your tools to contribute to reduce malaria”, he explained.

On her remarks, Mrs. Charity Binka, Executive Secretary of Ammren assumed that the networks is ready to give its contribute to fight malaria. Ammren was launched by journalists who has knowledge of malaria and keep on reporting about this disease. “I want to call you all to keep the good job you are doing. Do not ever forget why you are Ammren members. Since we launched the Network in 2006, we have done a lot, but we can do better”, she concluded.

During the workshop, the Journalists visited the Bungu dispensary, Mchukwi Mission Hospital and Ifakara Health Institute (Kwiriri) where they found children and pregnant women suffering because of malaria. Some mothers demanded for ITNs.

That was an opportunity, as well, to know more about INESS.

The malaria threat to Haiti may not be as immediate as the terrible injuries and potential infections from inadequate water and waste disposal. Malaria will be lurking – but will anyone be paying attention when it arises?

Anderson Cooper of CNN was quoted in the New York Times as saying “We all know what’s going to happen. People are just going to lose interest in this as a story. They’re going to stop watching.” Already today the BBC has only one small headline on its world news homepage referring to Haiti and one feature piece far at the bottom of the page.

More importantly, according to the Times, the major news organizations also have ‘money worries’ about the extensive coverage. The costs of coverage, and the boost it gives to donor organization efforts to raise funds, were outlined by the Times as follows: “News outlets rushed to charter airplanes and snap up extra seats on aid flights, but that was the easy part. Upon arrival, they had to establish supply lines, mostly through the neighboring Dominican Republic.”

News executives acknowledge that the media can move in and out of Haiti quickly, but efforts to scale back are already in evidence. One network reported on running out of water for its staff twice.  Overall it was estimated that each news organization would be spending $US 1.5 million on its Haiti coverage.

Well recognized media figures like Dr. Sanjay Gupta have been serving an advocacy role encouraging potential partners to reach difficult areas and provide better quality services.  The Times recognizes the importance of the visual element in this advocacy process.  Will scaled back coverage reduce this advocacy avenue?

Over 150,000 people have been confirmed dead so far in Haiti, and final estimates reach as high as 200,000.  The World Malaria Report still estimates over 800,000 malaria deaths world wide annually. These deaths may not occur in as dramatic a fashion as a natural disaster, but they add up and are still disastrous to families and nations.

The media has been an essential partner in highlighting malaria interventions and progress at all levels, especially as we count down to universal coverage.  We need all partners to ensure that the media spotlight remains on malaria, and especially right now on malaria in Haiti.

As morbidity reduces and we get closer to malaria elimination, this task may become harder – but media advocacy will be needed up to the very end to ensure adequate funding to maintain surveillance and certify elimination even when malaria seems less pressing.

We move into 2010 with the hopes that scale up for impact (SUFI) will achieve universal coverage of malaria interventions. The next several years will require sustained and consolidated effort if the MDG of reducing malaria mortality by 50% can be achieved.

The World Malaria Report of 2009 already shows us what is possible. Ten countries/areas have achieved a greater that 50% reduction since Roll Back malaria was inaugurated.  As we move to the harder to reach populations, not only will sustained action be needed, but increased funding and leadership will be needed.

It is in this context that the Malaria Round Table, supported by the Global Health Counci, met today to strategize on the current malaria programming and funding landscape and determine how advocacy efforts should move forward through sustained control into pre-elimination of the disease

The meeting was organized by the VOICES advocacy program and hosted by VOICES partner Fleishman Hillard. Over 30 members of the Round Table assembled to review their advocacy messaged first drafted in 2006 and craft new messages for the current situation that reflects hope and concern. Hope arises from the progress made in those areas with concerted and continual investment in malaria control. Concern is based on the world’s current economic malaise.

In 2006 many stakeholders did not understand malaria and that it was a problem with solutions. Since then stakeholders have made major investments, and thus, in 2010 they need to make a commitment to taking malaria control to the next level – elimination.

Below are listed the messages that arose out of the meeting – an over-arching message and four sub-messages. We hope the broader malaria community will comment on these and in particular provide factual proof that will make the messages stronger.

Your comments are not only welcome, but are crucial in bring all malaria advocates together to ensure sustained effort and coverage so we can eliminate malaria.

Please review and comment on these messages …

Overarching Message

Your investments in malaria control are paying off and we must continue our success so that we can end this disease or we will lose the progress we have made to date in saving millions of lives.

Message 1

The investment has paid off and the global funding for prevention and treatment has saved millions of lives.

Message 2

The good news is that malaria control also frees up other resources, has a direct/ripple effect, improves economies, productivity, and other health priorities.

Message 3

Without continued investment, we could not only lose the gains we’ve made, but also could see the situation even worsen, which would cost even more in the future.

Message 4

We have a plan to get the job done, but we need sustained and increased funding for malaria prevention and treatment, research, and new tools.

Please post comments here AND send comments to jon.berke@fleishman.com.

Jenerali Ulimwengu in the East African on Saturday talked about the efforts of Tanzania’s musicians to get involved in fighting malaria and commented cleverly that, “Let’s welcome our artistes as they remind us that ‘malaria is unacceptable,’ but the government should take up its responsibility and lead the nation in creating a mosquito-free country. Else, those beautiful sounds of our Lady JDs will only serve us as lullabies while our lady insects are hard at work.”

Lady JD is among 18 musicians/singers to join in what the Tanzania Daily News calls the “biggest ever musical collaboration among top local artists.” The music video in question “is blended with soothing voices and hip hop lyrics. President Kikwete sporting very casual attire appears in the video, urging everyone in the country to stand up and play a part in eradicating malaria.”

So how is such a video supposed to combat malaria? According to the Tanzania Daily News …

‘Malaria Haikubaliki’ is an initiative urging Tanzanians to think differently about the disease with an objective of increasing practices to prevent malaria such as consistently sleeping under an insecticide-treated mosquito, detecting and treating malaria early and ensuring antenatal care for pregnant women.

This experience harks back to the Africa Live Concert in 2005.  In addition to malaria-themed songs (see singers on YouTube), the concert featured “Information booths were set up at the stadium explaining how malaria is transmitted and how to use mosquito nets sprayed with insecticide to avoid infection.” An example of the songs comes from Youssou N’Dour (Senegal) –

Roll back malaria,
fight malaria, it’s so serious, clean up your area,
Roll back malaria,
don’t give them chances, not even places, to make a bite,
Roll back malaria,
fight malaria, it’s so serious, clean up your area,
Roll back malaria,
don’t give them places, not even chances, to make a bite …

In addition to responding to the messages in the songs, the audience and subsequent viewers on the web were encouraged to, “… make a financial contribution to the Roll Back Malaria cause can do so through the U.N. Foundation.”

It is not quite clear how these well staged efforts contribute to malaria fundraising or malaria behavior change.  Famous people feel good when they can make a visible statement about a health or development problem, and maybe the general public is inspired by celebrities to ‘do what I say.’ Evaluation of the effect of such efforts is certainly not easy.

In the end, while we sing our songs against malaria, we must go back to Jenerali Ulimwengu’s thoughts – if governments and donors do not supply the nets, medicines and insecticides all the way down to the grassroots, the ‘lady insects’ (female anopheles mosquitoes to be a little more accurate), will win the day.

On an almost daily basis new research studies about malaria are published. What happens to these studies? In particular how does such research affect policies and programs? Wellcome Trust has reported that, “Research funded by the Wellcome Trust has helped shaped international and national health policy for two of the world’s most important public health challenges: malaria and dengue fever.”

Wellcome points out that, “Research by Dr Noor from the Kenya Medical Research Institute-University of Oxford-Wellcome Trust Collaborative Programme has fed directly into the Kenyan government’s 10-year plan for the monitoring and evaluation of malaria,” which was launched in November 2009. This research contributed to a refined mapping of malaria in the country which will enable better targeted interventions.

The study by Noor et al. led to a “Model based geo-statistical methods (that) can be used to interpolate malaria risks in Kenya with precision … our model shows that the majority of Kenyans live in areas of very low P. falciparum risk. As malaria interventions go to scale effectively tracking epidemiological changes of risk demands a rigorous effort to document infection prevalence in time and space to remodel risks and redefine intervention priorities over the next 10-15 years.”

There is a history of WHO and the Tropical Disease Research Program conducting and using research to update malaria guidelines and policies. The 2004 document, “Scaling up home-based management of malaria: From research to implementation” explains that …

Large-scale research studies and pilot studies have shown that scaling up home-based management of malaria is both feasible and effective – and is already being implemented on a limited scale in some African countries. Research experience and demonstration projects have provided guidance on how home-based management of malaria can be scaled up to reach the majority of populations.

In developing malaria treatment guidelines in 2006 WHO explained that, “Wherever possible, systematic reviews of randomized trials that directly compare two or more treatment alternatives in large populations were identified and used as the basis for recommendations.”

The dissemination and adoption of research at the country level may be slow. The value of Artemisinin-based Combination Therapy (ACT) was proven by the time Roll Back Malaria was launched over ten years ago, but it took five or more years before some countries adopted this medicine as first-line treatment. Even after a new treatment policy was promulgated, the actual practice of ACT use by practitioners in the field lagged another 2-4 years.

Researchers themselves often need to learn how to become advocates for their own findings. The Future Health Systems Consortium has stressed the need for the research community to learn about “influencing health policy at various levels, either as a direct or indirect outcome of the proposed (research).”  FHS stresses the “need for systematic analysis of strategies to promote integration of research into policy processes.”

Research will definitely be a crucial component for progress along the pathway to malaria elimination. Vaccine research continues, new drugs must be discovered, and better net distribution mechanisms should be tested. We must always facilitate communication between researchers and policy makers to ensure progress along that pathway.

The Reproductive Health Forum discussion group on Yahoo reports plans that the “Federal Ministry of Health in its effort to revitalize the health system in the country is holding a one day Consultative Health Forum in Lere Local Government Area (LGA) of Kaduna State,” on Thursday 17th December 2009.

The town hall style meeting “will focus on maternal and child health along with related issues of water, sanitation and Malaria and will primarily be discussed with women and men of reproductive age, representatives of key health oriented Civil Society Organizations, Community Based Organizations, and Faith Based Organizations.” This is billed as the first of six such meetings that will cover all the geopolitical zones in Nigeria.

This process is in keeping with the pledge by Professor Babatunde Osotimehin Honorable Minister of Health as seen on the Ministry’s website that, “We want feedback to ensure this dialogue is dynamic, vibrant and continuous.”

The Permanent Secretary of the Ministry of Health, Mr. Linus Awute, in a recent press release acknowledged some of the problems that forum participants may also raise:

He said that it is glaring that health service delivery is not often available for the rural populace adding that 75% of Nigeria’s population is rural and cases of maternal mortality rate is very high in the rural areas. He attributed this ugly situation to the non-availability of skilled workers in the rural areas stressing that the Ministry is working round the clock to address the bad situation. He added that the Ministry is revitalizing primary healthcare as an avenue to delivering healthcare to its citizens.

As noted, the fora will address basic issues of water and sanitation.  This comes on the heels of a recent cholera outbreak in the country, about which Nigeria Health Watch observes …

Cholera is not a disease anyone should be getting in October 2009 … definitely not in Nigeria. To understand the absurdity of this; the last major outbreak of cholera in the United States occurred in 1910-1911! If we want to pursue grand dreams such as becoming one of the 20 largest economies by the year 2020 … maybe we should start with some of the apparently small steps such as preventing cholera!

Dialogue on health is definitely needed in Nigeria. Consumer out-of-pocket expenditures account for 65% of health spending in Nigeria – so citizens are definitely interested and involved in health care. The question is whether health system can be responsive to community needs. We look forward to hearing the results of the Lere LGA and the 5 other health fora.

The Malaria Advocacy Innovation Grants have recently issued a report on their activities. The grants were expected to support “ideas and partnerships that reached new audiences in creative ways and tackled difficult issues such as equity, transparency and accountability.” The 3-year program reached 16 African countries and did involve audiences ranging from the expected civil society groups to government leaders, business people and researchers.

The challenge with advocacy efforts is what do we measure as success? By way of results or indicators, the Malaria Advocacy Innovation Grants “aimed to boost advocacy efforts to improve Africa-to-Africa accountability for response to malaria suffering on the continent as well inspire African civil society organizations and media to become “leaders” in the fight against malaria.”

Examples of success reported by these “mobilizing for malaria” projects include:

• Nigeria: the partner substantially boosted the capacity of local civil society by organising a five-day malaria advocacy training session. 35 people representing 28 CSOs were trained
• Tanzania: 37 MPs were trained in a workshop, and became instrumental in forming a first-of-its kind coalition of Tanzania Parliamentarians Against Malaria (TAPAMA)
• Ghana: a magazine Eyes on Malaria was created, connecting malaria research findings and policy with day to day issues
• Mozambique: a project focused on mobilizing and engaging government representatives and businesses resulted in several enterprises starting to plan malaria control interventions as part of their social responsibility programmes

According to WOLA, Bread for the World and CEDPA, “Aspects (of advocacy) to be evaluated include the execution of strategies, the impact of the initiative in solving (or not solving) the specific problem, its contribution to the empowerment of the group and of civil society, and consequences for democracy.”

The Malaria Advocacy Innovation Grants have just concluded, and hopefully we can expect more in terms of evaluation from the project. In the meantime we have some key outputs documented. Ultimately we would like to learn how these advocacy efforts impacted on malaria programming and whether the CSOs who were trained become sustainable themselves and continue to contribute in a meaningful way to fighting malaria in their countries and regions.

by Edward Mwangi, Kenya NGO Alliance Against Malaria (KeNAAM)

The community voice in Nairobi filled the street on Wednesday at the 5th Multilateral Initiative on Malaria Pan-Africa Conference when they held a procession to call on US president Barrack Obama to take leadership for Global Fund AIDS TB and Malaria (GFATM) to increase to USD 2 billion US contribution to the Global Fund. Started in 2002, Global fund has recorded positive results in over 140 countries globally.

The community, chanting “we need the other half” was conveying the message that half of those benefiting from the GFATM commodities are living on hope that commodities will be availed to them. Chanting the popular Obama slogan, “Yes we can,” the demonstrators made their way along Nairobi streets.

The aim of the procession was also to mobilize signature on postcards to the US President Barrack Obama to be sent before the Thanksgiving holiday with the following wording:

Dear President Obama,

We’ve made great progress that has made in the fight against HIV/AIDS, TB and Malaria that nearly 50% of the people who need treatment are now receiving it, “still the other half is not” I know you don’t do things halfheartedly.  So please lead the world in achieving universal access to treatment by fully funding the Global Fund AID, TB and malaria.

The procession in Nairobi was co-organized by national network organizations for the three diseases; Kenya AIDS consortium, NEPHAK and Kenya NGO Alliance Against Malaria through the Action Advocacy to control TB internationally consortium.

PS – leadership from the US would have a stronger face if a Director for the US Agency for International Development were appointed. Al Jazeera reports on the leadership gap this problem has created for the US in the development world, and we believe it also affects the credibility of US malaria efforts – Bill

Additional media coverage of the procession can be found at the Wall Street Journal and CNN (a 7+ minute video where Nairobi appears about 3 minutes into the clip).