Tropical Health Matters

The changing scene among international donors points to a need to re-evaluate domestic contributions to finance malaria and other health and development programs.  Ethiopia is an example where policy thinking along those lines is underway.  The Voice of America (VOA) points out that, “Ethiopia stands out because it already has reached a 60% reduction in the mortality rate of children under five years old.” This progress has been facilitated by a decade of economic growth. VOA notes that although United States aid contributions to Ethiopia are now being reduced, Ethiopia is considering finding more domestic resources by scaling up a health insurance scheme that has been successfully piloted in thirteen districts.

Ghana has a long experience with its National health Insurance Scheme.  The World Bank reports that …

Ghana spends less than 5 percent of its GDP on health, slightly below average for a country at its income level. According to the 2009 World Health Organization (WHO) National Health Accounts, 47 percent of total health spending in Ghana is private (37 percent paid out of pocket and 10 percent paid by private insurance and other private risk-pooling mechanisms). Of the 53 percent public spending share, the NHIS accounts for some 30 percent of public spending on health and 16 percent of total health spending. According to the NHIS, active membership in 2010 was 8.16 million, some 34 percent of the population. Since 2005, outpatient visits have increased by a factor of 23, inpatient service by a factor of 29, and expenditures by a factor of 40. (Schieber G, Cashin C, Saleh K and Lavado R. Health Financing in Ghana. International Bank for Reconstruction and Development/The World Bank, 2012, Washington DC)

There are some caveats with health insurance. “Although the benefit package of insurance is generous, insured people still incurred out-of-pocket payment for care from informal sources and for uncovered drugs and tests at health facilities. Nevertheless, they paid significantly less than the uninsured.”  In addition ability to pay premiums initially or in subsequent years is a concern. Obviously poorer people are affected more by the premiums, and that was why people were hopeful about Affordable Medicines Facility malaria (AMFm) though out of pocket (OOP) expenditure was still required of the poor. The Global Fund did not cancel AMFm when its Board last met, but it did bundle the concept into existing and future malaria grants should countries wish to do so, leaving this subsidized treatment option, often through the informal private sector, in limbo.

Funding levels are not the only concern in reaching and sustaining malaria targets. One also needs to concentrate on how the resources are being used. The Guardian recently described how top-down commodity distribution approaches need to be complimented with bottom-up community approaches. Without community understanding and demand net deliveries from donors may sit in warehouses for months and when they reach the community they may be used as fishing nets or even wedding dresses, according to The Guardian.

International partners are quite aware of the need for better use of resources. The World Health Organization’s Global Malaria Program GMP in revising its guidelines for malaria treatment in 2010 stated that, “The scale up of diagnostic testing will improve patient care (and) make more efficient use of scarce resources (emphasis added).”

Overall domestic funding has accounted for about one-fifth of total malaria expenditure in recent years. While this may not be enough, it is this contribution and better use of available funds that may pull us through to 2015.

The recently released 2012 World Malaria Report (WMR) brought in to focus both malaria progress as well as the charges in malaria funding for the 104 malaria-endemic countries. Increased rates of coverage with vector control and malaria case management measures has mean that 274 million cases and 1.1 million deaths have been averted between 2001 and 2010. Unfortunately, The WMR observes that, “The enormous progress achieved appears to have slowed recently. International funding for malaria control has leveled off, and is projected to remain substantially below” projected needs.

We are not talking about small amounts of money or minor contributions to date. The WRM reports that, “The past decade has witnessed tremendous expansion in the financing and implementation of malaria control programmes. International disbursements for malaria control rose steeply from less than US$ 100 million in 2000 to US$ 1.71 billion in 2010 and were estimated to be US$ 1.66 billion in 2011 and US$ 1.84 billion in 2012.” This must be put in context with amounts estimated to be needed to achieve universal coverage (including use) of the major prevention and treatment interventions.

The WMR explains that “The enormous progress achieved appears to have slowed recently.” As noted above international funding for malaria control has leveled off, and “is projected to remain substantially below the US$ 5.1 billion” annually required to achieve and maintain universal coverage of malaria interventions. The Roll Back Malaria Partnership has estimated a higher projected annual need. “Resource requirements for global malaria prevention, control and elimination were estimated in the GMAP (Global Malaria Action Plan) to amount to some US$6.1 billion annually between 2012 and 2015.” This figure includes both program management costs as well as research needed to develop new tools.

The link between funding and coverage is clear in the WMR. The number of ITNs procured in 2012 (66 million) is far lower than in 2011 (92 million) and 2010 (145 million). “With the average useful life of ITNs estimated to be 2 to3 years, ITN coverage is expected to decrease if ITNs are not replaced in 2013.” Recent reports from a regional malaria elimination meeting in Kigali show that replacement time may be even shorter, possibly every 18-24 months based on local use and environmental conditions.

When identifying what is happening in malaria financing, it is important to recognize that there are relatively few direct donors. Major international malaria funders accounting for over 90% of donor financing are Global Fund, US President’s Malaria Initiative (PMI), Department for International Development (DfID), World Bank, and AusAid. Others include bilateral assistance, corporate donors and foundations.

The Global Fund as an entity and as the sum of its country contributors shocked the malaria and global health communities in 2011 when it announced the cancellation of its Round 11 of annual funding. The situation was complex and reflected weak financial pledging and inputs as well as internal management issues. The new funding approach was discussed in the WMR.  There are some uncertainties causing concern for the malaria community.

According to the 2012 WMR, “countries will be grouped by the Global Fund into Country Bands based upon a composite score which is a combination of a country’s GNI and its disease burden. Then there will be a “global disease split (i.e. 52% for HIV, 32% for malaria and16% for TB), until a new formula is determined, the Board,” that will be combined with a split according to Bands.  Finally actual allocation decisions will be made by the country coordination mechanisms (CCMs).  Malaria appears to be in greater direct competition with the other two diseases than what obtained in the past.  How other donors will compensate for any country shortfalls is unknown at present.

One possible implication of bands is that there may be less focus on lower burden countries that are heading toward malaria elimination.  Just because disease burden is low, or becomes low due to effective intervention does not mean that funding is not needed. Continued surveillance and case containment activities are not cheap, and require constant vigilance and sustained efforts since not all of one’s neighboring countries are at the same stage of malaria elimination.

The 13th meeting of the RBM HWG is taking place in Dakar, Senegal this week. Some thoughts about the. Current status of malaria programs emerged from member experiences and are shared here.

Since the cancellation of the Global Fund Round 11 may have been denied around one billion dollars annually. If funding does not fully resume until 2014, we could be looking at nearly $3B loss.

In the meantime there is need to help countries spent what remains most efficiently. Effort to secure approval for phase two renewal of existing grants is a priority.

Some countries may have many donor partners but still face problems due to lack of coordination. Problems come when countries do not budget for major activities likely implementation of LLIN (net) campaigns. Procurement and supply management problems persist. Stock-outs are the resulting “disease” but we need to find the root causes.

Not all partners bring funds and commodities, but their input is still important. For example Peace Corps has been making important contributions in advocacy and community education.

When there are funding gaps we need to document the impact. Lives may be lost. Advocacy is needed using country case studies.

As malaria prevalence reduces there is still a possibility of outbreaks, especially in context if cross border situations. Better epidemic response planning is needed with full collaboration of neighboring countries. The challenge is that funding is still country based.

Vigilance is needed to determine how the new Global Fund financing processes will affect malaria prospects.

Issue 204 of the Global Fund Observer explains efforts to clarify funding challenges with the Ugandan malaria grant from the Global Fund. Their posting is shared below to increase access to this information. The financial problems have extended over several years, and GFO provides links to its previous articles on the problem, of which putting money into personal bank accounts was just one example.

… NEWS: Uganda and the Global Fund to strengthen control and financial oversight of anti-malaria programmes: Global Fund insists on refund of ineligible expenses: PR told to stop transfers of malaria programme funds to personal bank accounts

The Global Fund and Uganda’s Ministry of Health are implementing a plan to safeguard Fund disbursements in the country following concerns over possible mismanagement of a $51 million grant to support antimalarial bednet distribution. The principal recipient (PR) for the grant was the Ministry of Finance, but the implementing entity was the Ministry of Health (MOH).

The Fund said in a statement that options to strengthen financial oversight and management to mitigate the risk of fraud are also being discussed.

The statement follows a review by the local fund agent, PriceWaterhouseCoopers Limited Uganda, which was commissioned by the Global Fund. The purpose of the review was to assess part of anti-malaria support programmes which involved the procurement and distribution of over seven million insecticide-treated nets to pregnant women and mothers with young children. As a result of the findings from this review, the Global Fund asked the LFA to expand its review even further.

Meanwhile, Uganda’s MOH carried out an internal audit to verify expenditures and address the internal control weaknesses.

The Fund said in the statement that it instructed the PR to discontinue transfers to individual personal bank accounts of funds intended for programme implementation. The Fund has also warned Uganda that it will seek a refund of all improper payments related to the $51 million grant for supply of anti-malarial bednets, and will insist on appropriate disciplinary action against anyone found to be involved.

Global Fund programmes in Uganda currently provide ARV treatment for 291,000 people and have distributed 7.7 million insecticide treated nets. According to the country’s Malaria Control Strategic Plan, malaria kills between 70,000 and 100,000 people in Uganda annually.

A detailed account of the genesis of the problems facing Global Fund grants in Uganda can be found in GFO issues 90, 103, 113 and 125. [This article was first posted on GFO Live on 21 November 2012.] To comment on this article at the GFO website, click here.

Of twenty-two malaria endemic countries in Africa that receive support from both USAID/PMI and the Global Fund, eleven reported gaps in malaria medicine funding in the 2011 Road Maps countries prepare for Roll Back Malaria.  Likewise, 16 of these countries reported gaps in RDT financing and supplies.

These stock and procurement problems arise from many causes including ability to forecast need,  poor donor coordination and leadership, and lack of adherence to new guidelines that require diagnostic verification of malaria before treatment among others.  We are well past the 2010 RBM target date to achieve 80% treatment coverage, but the most recent DHS and MIS results from the 22 countries for appropriate treatment of children below five years of age show that the country with the highest achievement of ACT coverage in this age group was Malawi with only 36.2%.  The median among these 22 countries was 16.5%.

Therefore, it was not surprising that The Citizen newspaper reported from Dar es Salaam that, “Thousands of Tanzanians have continued to die from malaria annually due to lack of medicines despite massive investment by the government and donors towards improved supply of relevant drugs in health facilities.” Apparently programs like SMS for Life and AMFm have not had their desired effects.

The Citizen lamented that, “Phone calls to the CEO of Medical Stores Department (MSD), which is charged with responsibility of distributing drugs in the country, went unanswered.”  Other malaria implementation partners gave their own views that the problem was due to lack of professionalism among health officials and a lack of commitment to implementing the malaria program.

If we cannot even achieve malaria treatment targets by 2010, what hope do we have of reducing mortality by 2015 – let alone head toward elimination? Technical assistance may be needed, but cannot succeed if there is a lack of will on the part of program implementation partners from the endemic countries.

By the end of this week someone will be nominated to replace Robert Zoellick as President of the World Bank.  Traditionally this nomination has been made by the United States, and it appears that this tradition is likely to be maintained.  The question is whether the traditional nominee – a white, older male of US citizenship – will be able to lead the World Bank in the Twenty-first Century.

The Washington Post today features two articles on this critical rite of passage. Howard Schneider raises, “The question now is whether the bank’s new leader, who could be named in the coming days, can enhance the institution’s role at a time when developing countries are emerging as the engines of world economic growth.” The mixed roles of the Bank – lender, donor, provider of technical assistance – and the emergence of other major and upcoming economic strong houses leads Amar Bhattacharya of the G-24 Secretariat to ask whether there is a clear goal for the institution at this point in time. His answer is ‘No.’

In contrast Michael Gerson sees a positive future because Zoellick’s leadership, he believes, leaves the “rarest of legacies: a multilateral institution with its reputation enhanced. Zoellick acted decisively to help stabilize the finances of struggling nations during the worst of the financial crisis, as well as to provide relief to countries hit hard by a worldwide spike food prices. He has increased transparency at the bank while successfully raising funds to recapitalize it.”

Gerson stresses the Bank’s need to listen to countries that receive its loans or grants since he sees no ‘silver bullet’ emanating from external development or aid experts. He traces as an example the evolution in country needs and requests from Rwanda which asked for emergency food aid in 2007, but a few years later sought investments to increase agricultural productivity and “Now is asking for help building storage facilities, so expanding crop yields are not wasted.”

Schneider does stress that the technical knowledge provided by the Bank is of equal importance as the financial resources it can mobilize. Who then is in the best position to marshal needed technical inputs while at the same time maintaining a humble leadership style that emphasizes that we need to learn from the low and middle income countries themselves?

According to the Washington Post, the current suspected nominees have ranged from Hillary Rodham Clinton and Sen. John Kerry to Susan Rice and Lawrence H. Summers, though for various reasons these have said they are not interested or are unlikely choices.

Jeffrey Sachs has let it be known that he is interested in the job, though Schneider notes, “But he says the administration has not approached him.” Sachs is certainly familiar with the needs of low and middle income countries, but would he or the other US candidates take a learning, rather than a prescriptive approach to working with these countries?

Another name breaks the US white male mold – Nigeria’s Finance Minister and Coordinating Minister for the Economy, Dr. Ngozi Okonjo Iweala. CP-Africa recently reported that, “Dr. Okonjo Iweala reportedly recently told the BBC that it is time to open it up to competition and that top jobs at international institutions should be filled on merit.”  They also though that such an appointee would only be successful with support from China.

What is at stake for the malaria community? Currently the World Bank has commitments for malaria control in 21 African countries up to US$ 762.8 million.  This has been used to finance over 73.8 million treated mosquito nets and 25.3 million doses of effective malaria medication over the past five years, a major dent in the overall efforts to scale up malaria control.  Given the current questionable status of Global Fund support, efforts by all other partners including the World Bank are crucial.  Hopefully the new leadership at the Bank will sustain this in line with the commitments of each national malaria control program.

The American Society of Tropical Medicine and Hygiene’s 60th annual meeting began today in Philadelphia with a keynote talk by Jeffrey Sachs, Director of the Earth Institute at Columbia University. The talk echoed Sachs’ recent online writings about the uncertainties in Global Fund support from major donors, especially the United States. But first the good news.

Sachs reminded the audience that this year marks ten years of Global Fund existence.  In that time, he explained, many new malaria technologies have become available ranging from an alphabet soup of ACTs, RDTs, LLINs, IPT, SMS and more.  This period has also seen a major increase in global malaria financial support (World Bank, Global Fund, PMI, etc.,) from $0.2 billion in 2004 to $1.8 in 2010.

Sachs cautioned that figures in the millions and billions were not the usual grist of macroeconomists who prefer to consider the movement of trillions of dollar or more. And yet, he noted that even with this scale up over the years, millions of malaria deaths have been averted.

Then came the challenges. Global Fund support has been mostly used for commodities, as ‘acronymed’ above. What is needed are string primary health care systems, including community health workers, to deliver these interventions.  Sachs stressed that such commodities should be free to poor people, and that social marketing strategies were actually a death sentence to poor people who could not protect their families without free and equitable access to these services.

Finally, the bad news. Sachs called our current situation with Global Fund a crisis in development assistance.  He described the crisis in terms of …

• Unprecedented attaches on development assistance by Republican candidates for the US Presidency
• Lack of current White House Leadership
• Cancellation of Global Fund Round 11

Sachs wondered whether the Millennium Development Goals can now be achieved. He concluded that gains against the diseases are all at risk, and that we are on the edge of collapse after ten years of work.Clearly much of the research and programs discussed at this weeks meetings will be threatened by expected cuts in development assistance, but more importantly, lives that the rearch and programs could benefit are at greater risk.

This morning two key advocacy groups organized a teleconference with Christoph Benn, the Director for the External Relations and Partnership Cluster at the Global Fund to Fight AIDS, TB and Malaria, so that we could learn more about the recent GFATM Board Decision to cancel Round 11 proposals/funding. The main take away message is that the GFATM is NOT in an immediate financial crisis, but that longer term projections could be at risk.

Christoph Benn was reassuring about the ability to carry on and scale up commitments made for funding rounds 8, 9, and 10. Organizers of the teleconference, the Foundation for AIDS Research (amfAR) and Friends of the Global Fight (Friends), encouraged participants to strengthen advocacy efforts with the US Congress where the longer term challenges lie in getting pledges for future funding.

There was talk of the GFATM 2012-16 Strategy that calls for funding based on national policies, national need (gap analysis) and dialogue with partners.  Christoph Benn indicated that Round 11 would have been the last of the formal funding rounds as we have known them, and its cancellation simply pushes us faster towards the new funding strategy. It was also made clear that there would be a weaning of G20 countries off of GFATM money, though commitments to high risk target groups in existing projects would be honored until those grants closed.

Again the short term effect is that countries that would have needed Round 11 funding will be encouraged to apply for transitional funds that will hold them over until the 2012-16 Strategy is fully implemented.  The Roll Back malaria Harmonization Working Group, for example, will be helping countries who intended to apply for malaria grants in R11 to undertake their gap analysis and planning in order to obtain transition funding.  This can only happen after the GFATM revises the application guidelines. As Christoph Benn explained, the ramifications of last months’ Board meeting in Accra are still being worked out.

Back to the longer term concerns or what was termed the uncertainties  of funding forecasts based on donor conditions.  Many donor countries have pledged to continue their funding levels to GFATM, and the United Kingdom has even pledged an increase. But all eyes are on the U.S. Congress, who initially pledged to maintain level funding this past summer, but now is uncertain whether global health and foreign assistance will receive support. It was basically this change of heart that put the brakes on R11 funding.

Our advocacy partners had heard from members of the Congress that they were worried about the financial health of the GFATM, but now have been told that the GFATM is still very much viable.  It is the longer term expansion beyond current commitments that is in question.  Rephrasing Jeffrey Sachs’ concern, “Will Washington leave millions to die?”

Just as the Asia Pacific Malaria Eradication Network’s community engagement workshop was ending in Chiang Mai Thailand, word reached the group that the Global Fund had cancelled its call for Round 11 funding. During the workshop participants and facilitators had discussed the community systems strengthening potential of Global Fund grants and how this could benefit APMEN counties’ community engagement strategies.

The Global Fund euphemistically phrased this cancellation at the just completed Global Fund Board meeting in Accra with a key decision point that notes the Board “Agrees to establish a Transitional Funding Mechanism … in order to provide this continuation funding (and) Decides to convert Round 11 into a new funding opportunity …”   Jeffrey Sachs clearly laid a large portion of the blame on the U.S. Government, which is responsible for about a quarter of the Global Fund project money when he observed that the U.S. …

… had pledged $4 billion during 2011-13 to the Global Fund, or $1.33 billion per year. Now it is reneging on this pledge. For a government that spends $1.9 billion every single day on the military ($700 billion each year), Washington’s unwillingness to follow through on $1.33 billion for a whole year to save millions of lives is a new depth of cynicism and recklessness.

The APMEN meeting therefore closed with a call on donors to honor their commitments to the Global Fund and the community programs it makes possible.  The final session was also devoted to action planning that included brainstorming by country teams of alternative funding sources to support community engagement.

Gawrie Galappaththy from Sri Lanka expressed clearly the workshop participants’ surprise and disappointment over the Global Fund announcement.  “Many of our countries have been receiving Global Fund support since 2003, and we are collectively dependent on the Global Fund from its different rounds. The reality is that with Global Fund support being so regular, governments have shifted some of their financial support for health to other areas. An abrupt stop to Global Fund support will hit us hard.  It will be necessary to regenerate the political will all over again for malaria and health.”

Gawrie also worried that, “Malaria is a dynamic disease. If we let the pressure off, it will re-grow as happened after the first eradication effort.  If we can’t get this elimination done now, we may never have a chance to do it again.”

The Globe and Mail summarizes the problem succinctly. “The global economic crisis has claimed a new victim: a $22-billion (U.S.) health fund that has saved millions of lives in Africa and other low-income regions during the past decade… The cuts by donor governments are not just because of the economic slowdown and the financial crisis in Europe, but also because of concerns over corruption in several recipient countries.”

The BBC interviewed the HIV/AIDS Alliance on this issue, and not surprisingly learned that this is the worst of all possible times to see cutbacks in funding for disease control.  The Alliance’s Director mentioned issues that could equally apply to malaria when he said that, “These should be exciting times – the latest scientific developments …”  New vaccines, new medicines and strengthened community participation strategies are just a few of the latest malaria developments that could be threatened.

Community engagement does take time and effort, even if it does not cost anywhere near the price of nets and drugs. Communities bring valuable resources to the table, but at the same time we do not want to foist malaria control and elimination responsibilities off on vulnerable poor people in developing countries.  APMEN workshop participants are going to be engaged in advocacy themselves, and are optimistic that donors old and new will not let communities down.

The Global Health Council’s Malaria Round Table shared the information that follows.  Reducing the already tiny USG commitment to international development would not only be mean-spirited, but would jeopardize global security.

This Thursday, November 3^rd, the Senate is likely to begin consideration of the State & Foreign Operations bill, probably as part of a “mini-bus” package with other components of the FY2012 Budget. With the current Continuing Resolution set to expire on November 18^th the Senate is under pressure to pass a bill to fund the government over the next fiscal year.

The Senate State/Foreign Operations bill is $5 billion higher than the House number, including a $700 million higher mark for global health. We need to do all we can to protect this higher funding level for global health and international affairs.

Call your Senator and urge them to protect funding for global and international affairs, and oppose all cutting amendments on the State, Foreign Operations bill during floor consideration and rejection of all harmful policy riders.

Talking Points

·         For less than 1% of our federal budget millions of lives are impacted each year. U.S. investments in global health have:

• Treated more than 3 million people living with HIV and prevent HIV transmission among millions more;
• Cut  the number of malaria cases by more than 50% in 43 countries in the last 10 years;
• Contributed to immunizing more than 100 million children each year;
• Treated 10 million people with tuberculosis;
• Delivered more than 255 million treatments to approximately 60 million people  for neglected tropical diseases;
• Increased the number of skilled birth attendants present during deliveries; and
• Supported research to develop and deliver new vaccines, drugs, and other critical health tools.

·         Further cuts to global health and international affairs programs would put lives at stake, threaten our diplomatic standing in the world, and put thousands of current and future American jobs in jeopardy. 

Putting Lives at Stake:

 

Global Health dollars support American jobs.

·         In 2005, global health activities generated $1.5 billion in Washington state and created or sustained more than 14,125 jobs.

·         In 2007, the global health sector supported more than 7,000 jobs and $508 million in salaries and wages in North Carolina.