Tropical Health Matters

Last month we shared the reaction of Kenyans and the international community to the newly passed “media bill that journalists say will curtail press freedom (BBC).”  The BBC reported yesterday that President Kabaki has now signed the bill and quoted him as saying that the bill will “safeguard our culture, moral values and nationhood.” Most observers fear the bill will serve as a gag to prevent the press from holding government accountable.

According to the Daily Nation (Nairobi), media advocates promised that, “the media would move to court to oppose the constitutionality of the new law and ensure that freedom of the Press is upheld.” They also made it clear that, “The media would not allow the Government to infringe on its independence and vowed to fight on until it is changed.”

Government is not unanimous on this issue. Although Parliament passed the Bill, the Nation notes that, “The Parliamentary Committee on Communications is going to come up with supplementary amendments on the offensive sections of the signed Bill once Parliament reconvenes, said its chairman, Mr James Rege on Friday.” Another angle is internal government “lack of harmony in the sharing of executive authority between President Kibaki and Prime Minister Raila Odinga, who had opposed the Bill.”

One area where government needs to be held accountable is Global Fund support. The Principle Recipient for existing malaria grants is the Ministry of Finance and the sub-recipient is the Ministry of Health.  According to the most recent Round 4 Progress Report (August 2008), Kenya is not performing well in the area of malaria treatment. What if the Kenyan media were to publicize these readily available results to encourage better grant performance? Would bringing such problems into the public forum and investigating reasons for poor performance be seen by government as a threat to the “culture”?

Ensuring that malaria interventions reach all in need requires an open and accountable process.  Will the media in Kenya be able to promote this process?

One of today’s headlines in the Independent.ie sums up much of international opinion: “Few tears will be shed over Bush’s departure.”  While the article ticks off issues of consternation ranging from wars to the economy, it does not overlook the accomplishments.

In one area at least the Bush legacy will be looked at kindly. He has accelerated dramatically efforts to combat HIV/Aids and malaria in Africa, and by the time he leaves office President Bush will have doublethe level of assistance to Africa to $8bn. Besides that, his President’s Malaria Initiative of 2005 and his emergency plan for Aids relief is estimated to have reached 25 million people in sub-Saharan Africa.

Tony Das believes that President Bush has build a good foundation for President-elect Obama, but worries about a statement by the Vice-President-elect during the debates that implied a possible ‘slow down’ in U.S. commitment to foreign aid.  Das explains that,

Health care is a pillar of U.S. assistance to Africa. Some $1 billion per year funds the President’s Emergency Program for AIDS Relief (PEPFAR). Most of that goes to Africa. Additional funds fight malaria, TB, a resurgence of polio and waterborne diseases. More African kids die from diarrhea contracted from dirty water than from AIDS and malaria combined.

Das recognizes that the public may also be less supportive of foreign aid increases during the current economic crisis, but stresses the need for leadership in the new administration to ensure people see that health aid goes beyond humanitarian ideals and serves important strategic objectives.

The answer lies not in altruism and humanitarian concern but in the fact that communicable diseases undermine the social fabric of African states and the viability of their security apparatus, threatening U.S. national security interests by creating a breeding ground for insurgencies and global terrorist recruiting.

The Global Health Council and its Malaria Roundtable offer the following recommendations to the new presidential team:

• General

• Need for high level appointee for global health within the National Security Council
• Need for a cohesive, integrated five-year strategy on global health
• Need for restructuring management and delivery of global health
• Establish a five-year initiative on family health that integrates maternal, child and reproductive health

• Malaria Specific

• Develop and Implement a five-year strategy as soon as possible
• Retain Malaria Coordinator position
• Plan to fulfill funding commitments made in H.R. 5501, Lantos/Hyde Leadership Act Against AIDS, TB, and Malaria, with a minimum of $800 m for FY 2010

Malaria itself inflicts economic hardship, and so combatting malaria is a key step in reducing the impact of the global economic crisis, especially among the more vulnerable peoples and governments in the world. The new administration should be poised to continue the fight against malaria.

The current global economic crisis has resulted in caution and worry for public health. The Global Fund Board at its 18th meeting decided that, “The Round 8 proposals to be approved for funding by the Board shall collectively be subject to a 10% adjustment (i.e. cut) for efficiency.”  While Global Fund money can help strengthen health systems, it is not meant to build systems or replace national financial commitment to health care.

What then happens when funds appropriated for health services do not reach the front line where primary care services, including malaria control, are delivered? Gauthier and Wane report on Chad that …

Although the regional administration is officially allocated 60% of the ministry’s non-wage recurrent expenditures, theshare of the resources that actually reach the regions is estimated to be only 18%. The health centres, which are the frontline providers and the entry point for the population, receive less than 1% of the ministry’s non-wage recurrent expenditures. Accounting for the endogeneity of the level of competition among health centres, the leakage of government resources has a significant and negative impact on the price mark-up that health centres charge patients for drugs. Furthermore, it is estimated that had public resources earmarked for frontline providers reached them in their entirety, the number of patients seeking primary health care in Chad would have more than doubled.

Gauthier and Wane surmise that donor support of health in Chad may actually contribute to the problem. Their study has “shown that current resource allocation seems to be linked to the discretion of regional and district administrators, and that international donor support introduces a strong crowding out effect, whereby health centres that received foreign assistance are less likely to be supported by higher administrative levels.”

Efforts had been made by the World Bank and other donors to ensure that Chad spent its burgeoning windfall of oil money on social services and poverty reduction, but the government managed to back out of its pledge. According to the New York Times, “Chad has been ranked with Bangladesh at the world’s two most corrupt countries by the corruption watchdog Transparency International. The hope that Chad would chart a more humane path fractured when its Parliament voted … to soften the oil revenue law, allowing the money to be diverted.”

Another World Bank study in Nigeria identified similar financial accountability problems with local government health funds. “Even when budget allocations were sufficient to cover estimated actual costs, the staff survey revealed non-payment of salaries for several months in the year before the survey. The paper argues that the pattern of evidence shows that non-payment of salaries cannot be explained by lack of resources available to local governments. The evidence therefore suggests that there is a general problem of accountability at the local government level in the use of public resources that are transferred from higher tiers of government.”

As seen in the picture, lack of accountability also means local government clinics are in disrepair, discouraging attendance by clients. The Nigerian study also laments that “local citizens may not be well informed” about these problems and are thus not disposed toward advocacy. Who then will be the advocates to prevent leakage?

The BBC has reported that, “The Kenya Communications Amendment Bill, which was passed by parliament, gives the state power to raid media houses and control broadcast content,” and at the same time, “Information Minister Samuel Poghisio insists that the government is committed to press freedom.”

Internally, the passage of the bill has resulted in protests and arrests. Initial reports said 23 had been arrested. Later reports in the Nation raised the number to 70. The police were worried that defense of basic freedoms might mar Independence Day celebrations.  The Nation noted that this move marked “45 years of freedom, one giant leap of censorship.”  The oposition Orange Democratic Movement indicated that it would go to court is the President signed the Bill.

It did not take long for the police to take the intent of the new bill seriously. People protesting current economic conditions during the Independence day celebrations were dispersed. Then “Police have turned their heat on journalists after they dispersed protesters at Ufungamano House in Nairobi. On Sunday, they unleashed police dogs and lobbed teargas canisters at the battery of journalists who were recording their showdown with the protesters. Journalists had no option but to film the advancing police officers from the safety of their vehicles.”

Externally AFP reports that, “The United States on Saturday voiced concern over a media bill which was recently adopted by Kenya‘s parliament and curbs freedom of the press. The United States is very concerned about recent actions which potentially threaten freedom of the media in Kenya,” the US embassy said in a statement.” Reporters without Borders has asked the Kenyan President not to sign the bill.

What does all this mean for malaria?  The new bill reflects a government sensitivity to criticism. According to the BBC, “the new bill gives the minister for internal security the power to raid a media house, search its premises, dismantle broadcast equipment and take a station off air.”  What if the press is critical of the way the government handles major donor funding for malaria.  A letter to the Nation looks at the issues at stake.

Politics, bad governance, impunity and the Government’s reluctance to fight corruption are working against Kenyans. Sometime back, the Global Fund slashed its contribution to the fight against HIV/Aids and other parasitic infections in Kenya, citing misappropriation and mismanagement of funds for its action. Kenya has failed for the fourth consecutive year to qualify for the Millennium Challenge Assistance from the US aid development programme. Of the three East African countries only Tanzania made it to the finish line.

Freedom to monitor malaria program performance and undertake advocacy to ensure proper implementation by civil society and the press is essential for accountability and success.

In March of this year the Zambezi Expedition set out on a three-month quest to rally political support for the fight against malaria and demonstrate the need for coordinated cross-border action by navigating three thousand kilometers through Angola, Namibia, Botswana, Zambia, Zimbabwe and Mozambique. The Roll Back Malaria-sponsored Expedition spread awareness of malaria with the help of NGOs like Nets For Life and corporations like ExxonMobil. In fact the ExxonMobil press release observed that exactly 150 years after the Scottish missionary David Livingstone embarked on a historic journey along the Zambezi River, malaria remains a problem for the people along its shores.

The Mail and Guardian reported that, “Expedition members said many villagers along the river must travel long distances to the nearest medical post. Limited access to medical care and a lack of regional cooperation are hindering malaria prevention, group members said. ‘There are no borders for malaria,’ expedition manager Herve Verhoosel said. ‘Mosquitoes don’t get their passports stamped at the other side of the border.'”  A Reuters television news clip available on the Expedition’s website quotes one of the travelers talking about the challenge of community members trekking 70 kilometeres to a health facility to get malaria treatment in Angola.

In June as a follow-up the Zambezi Expedition was featured during a panel at the World Economic Forum. The Expedition website noted that, “Panelists Prof. Awa Coll-Seck, Executive Director of the Roll Back Malaria Partnership (RBM) and Sipho Mseleku, CEO of the Association of SADC Chambers of Commerce and Industry (ASCCI) underlined the critical importance of political commitment in fighting diseases of poverty such as malaria. They called for increased multi-country collaboration with specific attention to strengthening community engagement against poverty and disease. ‘Malaria knows no borders and the Roll Back Malaria Zambezi Expedition is a model for multi-country cooperation,’ said Prof Coll-Seck, ‘We hope that countries in other sub-regions will collaborate in this way because they have similar problems.'”

Now more than two months after the Expedition reached its end at the Indian Ocean [see photo by Marcus Bleasdale], malaria and mosquitoes still cross the Zambezi and the borders of countries along its shores.  As stated in the theme of the expedition and the first World Malaria Day, which was celebrated along the journey, malaria is a disease without borders – the journey of collaboration among countries and partners in the region should not stop just because the boats have reached their destination.

Emmanuel Fiagbey, VOICES representative in Ghana, reports on community events that promote malaria control in Ghana.

Community events popularly referred to as community education durbars have become a powerful strategy for promoting adoption of appropriate strategies for fighting malaria in Ghana. District Malaria Advocacy Teams developed with the help of the Ghana Voices for Malaria-free Future project are the driving force behind the use of this strategy. In the Keta District of the Volta Region and the Asuogyaman District of the Eastern Region health workers now work with community health promoters and community leaders to organize these malaria education events. During these events community members are empowered with information to adopt the right approaches in preventing and treating malaria. These include:

• Early reporting of fever conditions at the nearest health facility
• Acceptance and use of the new antimalaria medication – Artesunate Amodiaquine combination for the treatment of malaria
• Quick transfer of referred cases of severe malaria to the nearest hospitals
• Attendance of antenatal clinic by pregnant women and their accessing and completing IPT

Acceptance and Use of Insecticide Treated Nets

Prevention by always sleeping in ITNs is highly promoted through the community events where community health workers demonstrate the process of hanging the nets. They also
encourage satisfied users to present testimonies of how ITN use has contributed to reduction in malaria incidences in their households to other community members.

Improving IPT through Community Mothers Support Groups

In the Asuogyaman District, the District Malaria Advocacy Team is supporting the development of Mothers Support Groups to encourage pregnant women access and complete IPT in order to protect their unborn babies and themselves.

The Mothers Support Group program goes beyond IPT promotion only and provides opportunities to mothers with babies to share ideas on managing other childhood illnesses apart from malaria. Improving the health of children under five and their mothers through better nutrition and feeding practices is also promoted through this program which is facilitated by the Community Health Nurses.

Anecdotally these community programs are yielding great benefits to the mothers in maintaining the health of their children and themselves. “The group is a wonderful source of support. For the past one year none of my group members reported of malaria in their families” said a Community Health Nurse, Apegusu, Asuogyaman District.

This update has been prepared by Emmanuel Fiagbey of the Ghana VOICES office.

Under the sponsorship of the Ghana Voices for Malaria-free Future a group of journalists have come together to form a network to promote advocacy for Malaria control. Members of the network, the Ghana Media Malaria Advocacy Network (GMMAN) come from various print and electronic media houses including the Graphic Communications Group, Ghanaian Times, Weekly Spectator, Chronicle, and the Enquirer, Adom FM, Peace FM, Volta Star Radio, Jubilee FM, Kesben FM, Eastern FM, Radio Gold, and Radio Upper West, TV3, TV Africa Ltd, Metro TV and Ghana Television (GTV).

The Objectives of the Network are to:

• disseminate timely and appropriate information on malaria control efforts with the view to promoting the use of ITNs, motivating health professionals to administer approved medications for the management of malaria, and effectively informing the Ghanaian population of the need to uphold and practice effective prevention measures;
• monitor and accurately report on ongoing malaria control interventions within the context of educating the people of Ghana to maintain clear focus on making their communities malaria-free; and
• contribute to building and strengthening the capacity of all journalists in Ghana to report positively on malaria.

“It is our hope that our efforts as media practitioners would help promote the course of malaria in the eyes of government, the donor community, the private sector and civil society in generating more resources and support for achieving a malaria –free Ghana. There are national, district and community voices against malaria but we want to assure the malaria program community that we of the media can be louder and highly positive voices against malaria,” Says Ms. Rosemary Ardayfio, Leader of GMMAN.

Since the inauguration of the GMMAN, the print media have become very buoyant with news reports and feature stories on various issues related to the fight against malaria in Ghana. Between April and May 2008 alone over 25 publications on malaria have appeared in the Daily Graphic, the Ghanaian Times and the Chronicle alone while community radio stations all over the country have been very active in organizing radio talk shows to educate the population on key malaria issues such as the use of ITNs and the efficacy and safety of the new malaria drug Artesunate and Amodiaquine Combination and IPT for pregnant women using Sulphadoxine Pyrimethamine.

The television stations have not been left out. Ghana Television, TV Africa, TV3 Ltd. and Metro TV have all increased program coverage on malaria. Thus the fight against malaria now receives great visibility in the eyes of the public and hopefully, these efforts by the media advocates will contribute to greater knowledge of prevention and treatment of malaria among the people of Ghana.

Examples of some of the malaria articles featured recently in the Ghana Chronicle are listed below.

• Eradicating Malaria And the Search for New Tools, 3 July 2008
• Malaria Constitutes 40 Percent, 30 June 2008
• Northern Health Services Declare War On Mosquitoes, 2 May 2008
• Intensify Fight Against Malaria, Ammren Tells African Leaders, 1 May 2008
• Alarming Rate of Malaria Cases in Asutifi District, 29 April 2008
• World Malaria Day – The Experts View Point, 25 April 2008

Hopefully other countries will take this experience as a cue to organize their own malaria media advocacy efforts.

Update provided by VOICES country representative for Ghana, Emmanuel Fiagbey.

The recent challenge thrown by Bill and Melinda Gates to the malaria community to work towards eradicating malaria has moved malaria advocates and program managers in Ghana to start examining the status of the country’s fight against malaria along the continuum of Control, Elimination and Eradication strategies.

The Ghana Voices for Malaria-Free Future project provided the forum. It brought together 45 malaria advocates including the leadership of the National Malaria Control Program (NMCP), the Ghana Media Malaria Advocacy Network, District Directors of Health, Malaria Scientists and Researchers, Disease Control Officers of the Ghana Health Service, NGOs and National Voices against Malaria. University of Ghana Professor Issabella Quakyi, NMCP Manager Dr. Constance Bart-Plange, and RBM Coordinating Committee Chairman Prof. David Ofori Adjei were the discussants

The forum concluded that:

• The complex life cycle of the plasmodium species makes the disease very difficult to beat.
• Significant challenges remain including drug resistance, insecticide resistance, and continuing environmental degradation. leading to increasing transmission and finally absence of an effective vaccine.
• Ghana is steadily progressing through the Control phase with the hope of reaching the Elimination phase in the next few years.

Tasks for Achieving Eradication

• Sustaining the gains so far made
• Enforcement of malaria policies and recommended practices Intensified attitudinal change among health workers, the private sector, community members and all other stakeholders
• Better monitoring of ITN utilization
• Enhanced public/private sector collaboration on drug policy implementation.
• Improved diagnosis of the disease using appropriate tools
• Adoption of integrated approaches to malaria
• Generation of local resources to support malaria control efforts
• Strengthened of NGO participation in malaria control programs

According to Prof. David Ofori Adjei, “The renewed global call for malaria eradication demands greater political will and involvement of all stakeholders. Malaria eradication is possible when we protect ourselves from getting the parasite and adopt new tools for effective management of the disease.”

The recent African Union Summit in Egypt came to a close with Civil Society and Non-Governmental Organizations questioning whether the organization had the strength and will to tackle the really serious issues facing the continent. The Inter Press Service of Johannesburg reported that, “some civil society groups felt that the AU Summit lacked the critical analysis and genuine commitment to action needed to bring forth positive interventions in conflicts such as that in Zimbabwe or on other critical issues in Africa.” In addition, “Members of the NGO community criticised the summit for not devoting enough time to pressing issues such as the ongoing food and health crisis in Africa.”

News coverage of the Summit, especially in the North, was dominated by Zimbabwe’s plight, and doubts that the African Leaders could do much of substance to this thorn in their side. The New York Times, for example, editorialized that, “The signals from Monday’s opening session of the African Union summit, with Mr. Mugabe smugly in attendance, were not encouraging.”

The theme of this Summit was “Meeting the Millennium Development Goals (MDGs) on Water and Sanitation.” A report on the Status of Malaria in Africa was also scheduled. The report issued two years ago at AU’s AIDS, TB and Malaria special Summit noted progress in policy and planning, but deficiencies in monitoring and evaluation. Concern was expressed for greater coordination on treatment/drug policies among countries. Slow implementation of IPTp was noted. The report also highlighted difficulties in achieving ITN/LLIN coverage and its proper measurement.

Then last year the AU launched the Africa Malaria Elimination Campaign. The AU communique stated that, “Stakeholders at all levels were called upon to scale up efforts and supplement each other’s role. The AU Commission should ensure that Malaria Elimination for eventual Eradication is kept high on the agenda of the AU, RECs and international organisations.” With this developing history, we are more than curious to know the next steps against malaria outlined at the 11th AU Summit.

There are many reasons for concern about the effectiveness of international and regional bodies like the African Union. One would hope that such a body could foster healthy competition among members to work toward eliminating malaria. Also as the theme of this year’s World Malaria Day makes clear, malaria is a disease without borders, and regional cooperation is needed. If all leaders at such assemblies can do is find ways to avoid embarrassing each other, there is not much hope that they can successfully tackle a disease like malaria.

As with any annual observance, concern expressed on just one day a year will not solve a problem. Here are two recent updates on cross-border malaria issues in keeping with this year’s World Malaria Day theme.

Even frosty relations across borders do not stop malaria, and so according to the Associated Press, “South Korea plans to donate more than US$1 million worth of anti-malaria supplies to North Korea. The Unification Ministry said Friday the donation will be made through the World Health Organization to buy medicine and diagnosis equipment. Yonhap news agency said North Korea’s malaria cases declined to about 7,500 last year from some 300,000 in 2001. The donation comes amid a freeze in the two Koreas’ relations.”

For South Korea, this is not just a philanthropic gesture. MedIndia.com reports that, “Soldiers guarding the border were previously the main victims but now an equal number of civilians are being infected, said Seoul National University team leader Chae Jong-Il, a parasitology professor.” AFP also observed that a “Seoul research team warned this week that the mosquito-borne disease is spreading from North Korea and beginning to take root in South Korea.”

Another cross border venture is the Zambezi River of Life Expedition. After passing through Angola, Botswana, Namibia and Zambia, the torch of the expedition is being passed to Zimbabwe. The Herald (Harare) reports that, “ZIMBABWE has taken over from Zambia the Sadc roll back malaria campaign programme code named the Zambezi River of Life Expedition aimed at intensifying the fight against the disease.”

The Zambezi Expedition is not only raising awareness but encouraging action. A Zimbabwean Ministry of Health official was quoted saying that, “Sixty percent of our population use nets and we want to reach the 100 percent mark. There is also need for community participation to complement efforts from the Government and stakeholders in this fight against malaria.”

These are practical examples of cross-border cooperation needed to eliminate malaria. Readers are encouraged to share other examples.