Tropical Health Matters

It is hard to argue against principles of fiscal responsibility – except where lives are at stake. What some might have thought was a somewhat simple matter of continuing the US Government’s Fiscal Year 2006 budget through FY 2007 now appears to be provoking potentially long debates in the US Congress. Associated Press notes that the budget tightening dilemma arises in part because, “There are, however, scores of exceptions for agencies and programs that simply must have increases to avoid imposing furloughs and hiring freezes, or cutting critical services.”

Celebrities are getting into the picture, according to the AP article. “Pressing for a $1 billion boost to fight AIDS, malaria and poverty in Africa, Bono wrestled with (Representative) Obey in a meeting last month – with House Speaker Nancy Pelosi, D-Calif., looking on – only to emerge without a commitment. ‘This isn’t over,’ Bono said in a statement issued after the meeting.”

Although the President’s Malaria Initiative (PMI) was underway during FY06, no specific funding was allocated for the program. $30 million was carved out of the existing USAID malaria budget to start PMI in the first three targeted countries. Since then two rounds of announcements have brought the total PMI countries to 15. Another year of ‘borrowed’ $30 million will hardly maintain the PMI in the first three countries let along conduct assessments and begin intervention to save lives in the remainder. A number of malaria advocates argue over how malaria funds should be spent – commodities versus capacity building. This debate will become irrelavant if there are inadequate funds to allocate.

Congress has some tough decisions to make – and the world is watching.

According to the Ghana Chronicle of 24 January 2007, the National Malaria Control Program (NMCP) reports that the number of child deaths due to malaria has been cut in half.  The achievement is credited to the country’s grant from the Global Fund to Fight AIDS, TB and Malaria (GFATM).  Ghana is the recipient of two GFATM grants for its malaria program. The NMCP Director was quoted as saying, “Malaria reported cases dropped from 3.5 million in 2003 to about 3.1 million in 2006”, as a result of these grants. She went further to enumerate that 1.5 million ITNs had been distributed and 4 million tablets administered for malaria treatment. This sounds good in the press, but is this progress real? A visit to the Global Fund website confirms achievements.

A GFATM representative who was present stressed that the Global Fund is a performance based organization.  In short, release of funds is based on achievement of targeted indicators. During the first two years of a GFATM grant, known as Phase 1, key indicators are more along the lines of processes (staff trained, resources in place) and outputs (commodities distributed).  On entering Phase 2 a country is expected to start reporting actual epidemiological progress on disease control. Effective and integrated national monitoring and evaluation systems are crucial for measuring performance that guarantees continued release of grant money.

Ghana’s Round Two Malaria Grant has passed this hurdle and has entered Phase 2.  The ‘score card’ issued for Round 2 Phase 1 performance is quite positive in noting that, “Within the first 16 months of the Program and in spite of procurement delays, 150,000 ITNs have been distributed (reaching the Month 18 target three months ahead of schedule). Additionally, by the fifth quarter of the program, 57,623 women had received IPT (360% of target). The program’s community-based agents (4039 trained, 183% of target) raised awareness and sustained the demand for both of these interventions. In Ghana 70% of malaria attacks are managed at home. A key feature of the program has been to educate home caregivers to respond more quickly and efficiently to malaria cases as they occur within the family. 1454 health workers (309% of target) and 3828 community agents (239% of target) have been trained in home-based malaria care.”

Ghana’s second malaria grant, awarded during Round 4, is also performing well according to the progress report on the GFATM website: “PR (Principle Recipient) has achieved or overachieved most targets. Surveys are ongoing to document results related to three outcome/impact indicators. Expenditure rate is satisfactory and implementation rate is on track with planned activities.” For example, implementers report that 214% of the target for women received Intermittent Preventive Treatment, and 155% of the targeted children under five years of age had slept under an ITN prior to the survey.

Ghana sets a hopeful example for not only getting malaria resources and commodities out to people in need, but also in being able to track and report progress. Fortunately the GFATM offers guidance in Monitoring and Evaluation. The challenge in phase two will be verifying that this infusion of external funds does result in lower morbidity and mortality and that the country can sustain these efforts after the grant expires.

Most people anticipated President Bush’s State of the Union Speech for clues about the direction of war or domestic policy. Obviously we at Voices for a Malaria Free Future were anticipating news on the fate of the President’s Malaria Initiative, which is threatened by lack of adequate funds if the fiscal year 2006 budget levels remain in place. In fact, the President said to the assembled Houses of Congress, “I ask you to provide $1.2 billion over five years so we can combat malaria in 15 African countries.”  Hopefully Congress knows the importance of this initiative and the lives at stake, because the address was not a very strong sales pitch.

An interesting feature in the New York Times today is a comparison of the frequency of key words used in this President’s past State of the Union addresses.  Malaria was mentioned once last night, twice last year and not at all in previous years. More commonly mentioned words in last night’s address were Iraq (34), insurance (14), oil (9) and economy (8).  Africa, where the most deaths from malaria occur, was mentioned three times, and AIDS, the focus of another major Presidential initiative was voiced only once this year, but four times in 2006.

Political commentators muse that malaria control may be one of the key points in Presiden Bush’s legacy.  This will only happen if there is greater leadership and advocacy for malaria programs, and if a true bipartisan spirit prevails, putting the long term interests of children, pregnant women and workers in malaria-endemic countries ahead of short term political gains.  Malaria needs to be mentioned more than once for this interest to develop.

The new chairmen of the Appropriations Committees in the House and Senate decided to keep U.S. government spending at its current level until October 2007. While getting rid of the porkbarrel earmarks is laudable, this action also means no new money for the President’s Malaria Initiative. Fiscal year 2007 PMI funds were going to be used for programs in Malawi, Senegal, Rwanda and Mozambique. Without including PMI money in some sort of supplemental funding bill, these programs will have to be put on hold and programs in Uganda, Tanzania and Angola will continue to operate at current funding levels. 
It is helpful to put malaria funding in context.  In FY 1997 the U.S. through USAID spent only $10.9m on malaria. This rose to $100m in FY 2006. With the introduction of PMI spending on malaria is projected to increase to $500m by 2010 (see chart). In FY 2006, PMI was accommodated within existing USAID malaria spending, and thus more than two-thirds of the $30 million were taken from smaller country programs to meet the needs of the PMI countries. It was hoped that FY 2007 would mark the beginning of specific PMI funding. Unfortunately, malaria-specific programs, the Global Fund to Fight AIDS, TB, and Malaria, and a number of other initiatives may spend the first part of the new year fighting each other for scarce dollars in a hoped for supplemental funding bill, rather than fighting the diseases.

As luminaries gathered in Washington last week at the White House Summit on Malaria, the issue of funding was not mentioned, even though President Bush announced eight more countries would be added to the list of focus countries. However, lawmakers did attend the high-profile affair including Sen. Patrick Leahy, a Vermont Democrat expected to lead the Senate appropriations subcommittee that oversees foreign aid. Leahy later told the New York Times that he wanted to find a way to fund PMI. “We’re trying to get the kind of money we spend in a day in Iraq,” he told the Times. “Somewhere we’ve got to have our priorities right. It’s a moral issue.”
With 3,000 children dying from malaria each day, you better believe it’s a moral issue.

A total of 85 grants were approved in Round 6 of the Global Fund to Fight AIDS, TB and Malaria (GFATM) at it recent Guatemala meeting, but malaria advocates are disappointed that only 19 (22%) of the approved grants were for malaria programs, and only eight will go to high-burden countries in Sub-Saharan Africa. In previous rounds, malaria got up to a third of the total funds. In addition, only 31% of 35 submitted malaria proposals made the cut, compared to 38% for HIV and 62% for TB. This experience raises two important issues. First, does burden of disease play any role in prioritizing grant awards? Secondly, are there specific problems with malaria proposals?

Each of the three diseases is a serious health and development challenge. TB has been neglected by international health programs, HIV is devastating large portions of the productive age population in many countries, and malaria is a major cause of child mortality. In Africa HIV accounts for twice as many deaths overall as malaria, but in children under five years of age, malaria deaths are three times higher than HIV. Arguments in support of the lion’s share consistently allocated to HIV may relate to the cost of interventions, but with Long Lasting Insecticide-treated Nets (LLINs) and Artemisinin-based Combination Therapy (ACT) being recommended for malaria, that argument carries much less weight. Under these circumstances, one would expect relatively equal treatment for the diseases.

Possibly the problem rests in the quality of malaria proposals. This would be ironic since during proposal writing time, donors join together to help countries develop them , even when there is uncertain capacity on the ground to carry out a grant if it is awarded. Another factor in judging a new proposal is performance of existing grants. GFATM prides itself in being a performance based organization, and no one would ever wish for less accountability when it comes to international grants. What could be happening is that Round 6 malaria proposals were denied due to poor performance of their predecessors.

Poor performance can be due to basic lack of capacity and competence, but also due to unrealistic goal setting in the early grants. Many projects underestimated the time it would take to get set up and running – the need to address customs and drug registrations, the ability of M&E systems to report, etc. Thus, projects promised unrealistic progress on indicators and may have been penalized in Rounds 5 and 6 for this. Instead of penalties, technical assistance (TA) to overcome the problems would be more helpful and result in saving more lives from malaria deaths. The reality though is that the GFATM is strictly a financial agency and does not provide TA. Donors flock around during the grant writing process, but where are they when the grants begin to falter?

So far in-course TA for the malaria grants has been provided through regional workshops by the RBM Partnership, and recently the US Government made TA services available if CCMs or PRs would apply. Unfortunately few of the eligible countries/projects availed themselves of this TA, and even among those who did, few were malaria grantees.

Announcements for Round 7 and 8 also came out of the 14th GFATM Board Meeting. It is crucial for partners to plan now not just to help write new malaria grants, but to get on board in making the existing malaria grants perform up to expectations.