Tropical Health Matters

David Reiff, in reviewing the book Famine and Foreigners: Ethiopia Since Live Aid by Peter Gill, quoted William Easterly, who argues “not only that much aid is wasted—about this optimists and skeptics largely agree—but that, after five decades, outside aid, whether given by governments or by the increasingly important philanthropic sector … has done little to alleviate the condition of the world’s poor.”

This view provides an interesting contract to a review by Steketee and Campbell entitled “Impact of national malaria control scale-up programmes in Africa: magnitude and attribution of effects.” These two authors report on studies occurring up to the end of 2009, that identified a three-fold increase in ITN household ownership (34 studies) and in malaria-endemic countries in Africa, with at least two estimates – pre-2005 and post-2005 when massive scale-up started.

Another key finding of the scale-up review was child “mortality declines have been documented in the 18 to 36 months following intervention scale-up.” They concluded that while, “Several factors potentially have contributed to recent health improvement in African countries, but there is substantial evidence that achieving high malaria control intervention coverage, especially with ITNs and targeted IRS, has been the leading contributor to reduced child mortality.”

In contrast to the pessimism of the wider development Aid Community, Steketee and Campbell stress that, “The documented impact provides the evidence required to support a global commitment to the expansion and long-term investment in malaria control to sustain and increase the health impact that malaria control is producing in Africa.”

Reiff also refers to James Grant, the former Unicef Executive Director who “was as unyieldingly optimistic about human possibility as he was clear-eyed about the extent of human suffering among the bottom half of the world’s population.”  The fact that Grant’s “optimistic scenario for what could be achieved has not come to pass does not necessarily mean that Grant was wrong to say – as, were he alive today, he almost certainly would say – that there was every reason to believe that it could do so.”

The political factors described by Gill that have ‘created’ modern famines are also likely to affect development work as it relates to malaria. Ironically Ethiopia, the scene of this famine narrative is also one of the success stories in malaria control. Were he here today James Grant might look at the unfolding malaria story and find support for his optimistic views of development.

That said, the ultimate success of malaria control rests in free, open societies where equitable access to all malaria interventions is possible for all citizens.

AIDSPAN has produced another valuable issue of the Global Fund Observer (GFO) that reports and analyzes the challenges of implementing Global Fund grants. Three of the main articles address serious gaps in various areas of programming.

The first gap is one of funding. As we discussed recently, even with an overall increase in pledges to the GFATM, the amounts are inadequate to achieve goals. The inability to raise funds at all level shows serious weaknesses in commitment and planning. AIDSPAN notes consequences of this such that for example …

In fact, though, this week’s pledges provide only $2.9 billion for Rounds 10, 11 and 12. The current estimate of the cost of Phase 1 of Round 10 is $2.0 billion. So the prospects for adequately funding Rounds 11 and 12, and Phase 2 of Round 10, are currently bleak, unless funds significantly in excess of this week’s pledges end up being raised.

The second gap is in oversight of procurement and supply management (PSM). “Deficiencies in the oversight of procurement and supply management (PSM) arrangements may be exposing Global Fund grants to unnecessary and unacceptable risks. This is one of the conclusions of an audit report released by the Fund’s Office of the Inspector General (OIG) in April 2010.”
Some of the main PSM deficiencies as summarized by GFO are –

• weak forecasting of requirements for drugs and health product
• weak technical specifications for procurement
• absence of, or weak, procurement policies and procedures
• poor inventory management
• poor storage and transportation facilities at national and sub-national level
• weak procurement planning resulting in frequent emergency procurements and
• inadequate management information systems

The third major gap reported in the GFO is lack of civil society participation in County Coordinating Mechanisms (CCMs) for global fund grants. The article highlights the Civil Society Action Team’s recent report. This report documented the fact that while persons affected by the three diseases in theory have representation on CCMs, they often do not take part in the real decision making.

In particular, “civil society representatives often lack the capacity and expertise to fully engage in CCM processes and to properly represent their constituents.” Lack of participation threatens the relevance and acceptability of programs.
These gaps focus on weaknesses basic health systems management processes and competencies. It is not enough to point out these gaps. Serious efforts are needed to strengthen health systems. Unless these three gaps are closed, partner interest in pursuing the noble goals of disease control and elimination will be threatened.

Eric Goosby of the President’s Emergency Plan for AIDS Relief, or PEPFAR, has likened the effort to get more funding for HIV/AIDS control in the current economic climate as “swimming upstream.”

Even so, The Global Fund reported that the United States pledged “US$4 Billion to The Global Fund to Fight AIDS, Tuberculosis and Malaria for the period 2011-2013. The pledge is the largest ever by a donor to The Global Fund and represents one of the largest increases by an individual donor country to the Global Fund for this replenishment period.”
The increases did not satisfy all. The New York Times reports that, “AIDS activists vented open frustration, both with the overall result and the American contribution.” The challenge remains that even with heightened funding, the actual amount was just barely able to “reach even its lowest ‘austerity level’ fund-raising target of $13 billion — the amount (The Global Fund) had said it needed just to keep putting patients on treatment at current rates,” according to the Times. This echoes recent reports of inadequate funding to meet malaria targets.

On a positive note, contributions by corporate partners are increasing. The Global Fund announced that, “Chevron Corporation (NYSE:CVX) today announced that it will commit an additional $25 million to The Global Fund to Fight AIDS, Tuberculosis and Malaria, raising its 6-year investment in the organization to $55 million. This is now the largest contribution from a single corporation.”

Finally, Dr Goosby explained that …

The battles against malaria and tuberculosis will also suffer, but the effect on AIDS is easier to measure. Malaria waxes and wanes with hot weather and local spraying. The TB epidemic echoes the AIDS epidemic because so many people have both, but TB can be cured in six months, which shrinks case counts rapidly.

When the Abuja targets for Rolling Back Malaria were enthusiastically set ten years ago people did not perceive that finance would be a major problem. Even at the subsequent ATM conference in Abuja in 2006 there was more emphasis on capacity building to deliver interventions.  People argue that the global financial crisis could have been predicted, but that does not help us meet current disease control promises and shortfalls.

New donors are needed – greater corporate participation will help as will increased contributions by upcoming economic power like China who pledged $US14 Million.  Also greater commitments by endemic countries themselves will be needed to sustain efforts.

While Robert Snow and colleagues have some good news to report – an increase in malaria funding by 166% since 2007 – the overall message of their article in The Lancet is that we are well below financial targets to maintain the level of malaria control expected for achieving RBM’s 2010 goals.  This is particularly true in countries where P. vivax predominates.

This “60% global shortfall in funds for malaria control” combined with less than effective roll out of malaria interventions, as we recently discussed, bodes ill for achieving MDGs.

According to The Lancet article a major part of the problem is not adequately targeting the poorest countries and sustainability of funding: “More efficient targeting of financial resources against biological need and national income should create a more equitable investment portfolio that with increased commitments will guarantee sustained financing of control in countries most at risk and least able to support themselves.”

The BBC quotes the authors as saying that not only does the funding shortfall increase the risk on malaria resurgence, but could also mean that the nearly $10 billion invested since 2002 would be in vain.

Why would be take the risk of turning this second international push toward malaria elimination into a repeat of the first eradication effort? Aside from the overall inadequacy of funding, the issue of targeting countries is crucial.  Do existing funding mechanisms ensure that support for malaria control and elimination actually goes where there is most need, and are endemic countries themselves contributing as much as possible to support and sustain these efforts?

Global Fund monies flow to countries that can write the best proposals, not necessarily those in most need. US government support for malaria then ties in with existing donor support like the Global Fund in order to add that extra push for achieving targets. Neither of these efforts begin from the question of where is there the most need.

On top of this, though lip-service is given to health systems strengthening, it has not received priority attention by countries, such that we are faced with procurement, supply and implementation challenges that threaten what funding is available.

It is time for the Roll Back Malaria Partnership to rethink how best to support progress along the pathway to elimination and not just let the funding chips fall where they may. Lets put the country road maps to good use.

The UN Millennium Development Goals Summit is underway in New York. The New York Times reports on one aspect of development, guaranteeing regular supplies of electricity. For example …

In Nigeria, a major oil exporter with a population of about 155 million people, 76 million do not have electricity, (Fatih Birol) said. “If only 0.4 percent of their oil and gas revenues were invested in power production, they would solve the problem,” he said, “so it’s not just a question of money, it’s how the money is managed.”

Electricity is not the only issue that requires greater investment.  African countries have also been asked to designate 15% of their national budget for health, but as the New Vision explained, “UGANDA cannot allocate 15% of the national budget to health as agreed by the African Union (AU), a government minister has said.”

We need to recognize that all MDGs are interrelated. Malaria and electricity, for example, have connections.

• Rapid Diagnostic Tests need to be stored at cool temperatures at national, regional and district health stores, and so air conditioners and fans are needed
• When villages are electrified people can close doors to mosquitoes at night and use fans – and with light, children can read their school books on how to prevent diseases like malaria
• Electricity ensures that laboratories run more efficiently and computers are able to analyze monitoring and evaluation data for enhance decision making
• When schools of nursing, medicine, etc. have electricity, students can learn about malaria using the latest technology and access the internet to gain more knowledge on the disease

These direct and indirect connections between malaria and electricity demonstrate that endemic countries need to invest their resources to control and eliminate the disease. The MDGs are not something that stop in 2015. The projected gains in health and development status must be sustained beyond 2015 if malaria is to be eliminated – hopefully the political will to invest in health will be sustained, too.

First the good news. Roll Back Malaria’s “Saving Lives with Malaria Control: Counting Down to the Millennium Development Goals” report provides encouragement when one reads that, “it is estimated that in the past 10 years, scaling up malaria prevention has saved the lives of nearly three quarters of a million children in 34 malaria-endemic African countries, 85% of these in the past 5 years alone.”

This is the latest report in RBM’s Progress Series and indicates that, “the results suggest that if current scale-up trends are maintained until 2015, another 1.14 million African children’s lives will be saved between 2011 and 2015.”

On the other hand, RBM warns that, “if funding were to cease in 2010 and prevention efforts were to fall, an estimated 476 000 additional children would die in that same period.” Is it possible that a greater focus on future eradication of malaria could distract from saving lives now and reaching the 2015 Millennium Development Goals?

The New York Times reported three years ago that, “challenging global health orthodoxy, Bill and Melinda Gates called for the eradication of malaria.” According to the Times, the Gateses labeled this call to action ‘audacious,’ while some partners called it ‘inspirational,’ ‘noble but quixotic’ and even ‘harmful.’

Now the Seattle Times reports that Bill and Melinda Gates are, “revamping the scientific agenda with their eyes on the controversial goal they set three years ago: driving malaria to extinction”

Justifying the focus, the Seattle Times indicated that, “Although total eradication of the disease may be as much as forty years away, it’s important to start work on drugs and vaccines that could take a decade or more to bring to the field, David Brandling-Bennett, leader of the Gates Foundation’s malaria programs.”

The implications of “The increased focus on the future means the Gates Foundation is ending its support for some efforts to lessen the disease’s current toll. Those include research to improve treatment of the severe infections that strike children and pregnant women, and that are responsible for most of the estimated 850,000 annual deaths from malaria,” according to the Seattle Times. Fears have arisen that this change by Gates, due to its financial influence, may pull resources away from other malaria research and program implementation efforts.

On the programming side, Gates has pledged 3% of the total Global Fund pledges as of August 2009, which is three-quarters of the funds pledged by all non-governmental organizations (foundations, corporations, etc.). While this is important, it is unlikely that even if Gates does not continue its support for programming, the bigger threat to major malaria funding sources – i.e. governments – is the current weak global economic environment.

We can all agree that Bill and Melinda Gates have influence. Currently they are using it to advocate to other wealthy individuals, corporations and foundations to contribute more toward charitable pursuits. In the area of malaria, they can also advocate with governments – both donor and endemic – to maintain and increase their financial support for malaria control and elimination. By then the new malaria tools deriving from Gates-supported research may be ready to carry elimination into eradication world-wide.

As the G8 Summit convenes in Canada this weekend, there comes a time for reflection and accountability. In fact accountability is the theme for a publication – “The Muskoka Accountability Report takes stock of recent G-8 commitments related to development, assesses the results of G-8 actions and identifies lessons for future reporting.” The report explains that …

In 2005, at the Gleneagles Summit and the United Nations Millennium +5 Summit,G8 countries and the world’s major aid donors made commitments to increase Official Development Assistance (ODA). Based on these specific commitments, the Organization for Economic Co-operation and Development (OECD) estimated that ODA from all OECD-Development Assistance Committee (DAC) bilateral donors would increase by around $50 billion a year by 2010, compared to 2004.

The Muskoka Report notes that ODA increased from $80 billion to $120 billion, with $24 billion coming from G8 countries. But it also explains that this $10 billion shortfall is actually $18 billion in 2004 dollar value. The report notes the following health accomplishments:

• G8 contributions account for $12.2 billion or 78 percent of the total contributions to the Global Fund
• G8 is on track to provide over 100 million insecticide-treated nets
  by 2010
• For the period 2005 to 2009 G8 funding to the Global Polio Eradication Initiative was $1.68 billion

Although the dollar amounts seem large, the Washington Post reports from Toronto that, “Canada announced on Friday a multibillion-dollar initiative to combat infant mortality and improve maternal health globally, but the aid package was far smaller than expected, undercut by a new drive toward austerity that reduced the contributions of wealthy nations.”

An expected package of $10 billion from the G8 may turn out to be only $7.3 billion. “… the plan highlighted how world economic dynamics have made a sudden lurch toward less government spending.”

Oxfam has called the contribution gap between 2005 promised and 2010 realities a ‘bounced check‘ that undermines the G8’s credibility. Maybe this is an accounting trick, suggests Oxfam:

Oxfam also decried the G8’s attempt in their own accountability report to minimize their breach of faith by using 2009 dollars instead of 2004 dollars for the calculation and deducting for lower growth, thus showing only a $10 billion shortfall.

Oxfam calls on the G8 to show the “political will and leadership that at least equals that we saw at Gleneagles.” This involves not only acknowledging that the gap is nearly double the apparent dollar value, but also taking steps to close it.

Save the Children recommends that the Muskoka Summit recommit to funding, but that these “Governments need to do better at the September U.N. Summit on the Millennium Development Goals .” The President of Save the Children observed that while the G8 and upcoming G20 leaders are worried about economic stability …

… both the leaders and the public should understand that global economic growth can never be balanced if the world doesn’t address the tragic circumstances surrounding birth and early life in much of the developing world. Without decisive action, the social costs of global economic downturns will only hit harder and last longer.

The BBC reports today that, “World leaders are due to focus on the nuclear disputes with Iran and North Korea on the second day of the G8 summit in Canada.” Maybe they will eventually come to the realization that global poverty is also a problem for all. As BBC notes, “Mr Obama has called for the group to pull together to promote economic growth, saying that world economies are ‘inextricably linked’.”

Although we do not have a malaria vaccine ready for widespread use, it is instructive to learn about how the Global Alliance for Vaccines and Immunizations (GAVI) plans for its financial future. The BBC Reports that GAVI “needs more than $4bn (£3bn) by 2015. This would enable it to continue existing programmes and roll out new vaccines against diarrhoea and pneumonia. But there are fears donors may want to cut back in the current climate.”

A new development is greater scrutiny by donors. BBC adds that, “In March, the UK pledged £150m to Gavi over 10 years. £10m has already been paid out, but there are plans to review all funding of international agencies – of which GAVI is one – as part of a drive to direct money at only the most effective organisations, a spokesperson confirmed.”

Specifically Britain’s Department for International Development (DfID) announced on 3rd June 2010 that, Full transparency and new independent watchdog will give UK taxpayers value for money in aid.” International Development Secretary, Andrew Mitchell, explained that, “We can’t escape the fact that today’s fiscal landscape is radically different from what has gone before. There is a massive deficit, which it is our number one priority to tackle. Against this backdrop our protected aid budget imposes a double duty to ensure that for every pound of taxpayers’ money we spend, we demonstrate 100 pence of value.”

Mitchell described further plans to move aid away from middle income countries. “We will spend the money on our priorities such as maternal health, fighting malaria, and extending choice to women over whether and when they have children.” Other budget cutting measures were identified. The Global Fund was not mentioned by name in the speech.

He also expressed agreement with the new approach of USAID and said, “Women can hold the key to development in the world’s poorest countries – in education, enterprise, micro-finance and healthcare. Investing in women pays dividends throughout the entire community.”

GAVI’s concerns ultimately have to do with the stability of funding. In its action agenda for achieving Millennium Development Goals (MDGs) UNDP pointed out that, “Well-targeted and predictable aid is a critical catalyst for meeting the MDGs and has produced significant results in Burkina Faso, Mozambique, Rwanda, Uganda and Vietnam by making more resources available for service delivery.”

UNDP also indirectly warns about dependence on aid: “Evidence, however, also suggests that countries need to expand their own domestic resource mobilization and to adjust their budgets to ensure maximum return on their investment.”

This period of economic uncertainly has produced one certainty – soul (and pocket) searching is needed by governments – both of donor countries as well as disease endemic countries – if programs are going to be sustained to the point of disease elimination.

As we get very close to achieving the Roll Back Malaria Partnership’s 80% target for 2010 in prevention and treatment coverage, there is a tendency to worry when people talk of shifting funding priorities. The HIV community is particularly worried that funding for treatment and control may become stagnant or even decrease. As AFP reported from Johannesburg, “Thousands of protesters marched Thursday against what they say is a softening commitment to fighting AIDS in Africa by the United States and other developed countries.”

Government donors are by and far the biggest contributors to global disease control efforts, but foundations and corporations can set trends and attract attention and thus influence priorities. For example, Melinda Gates, speaking at the recent Women Deliver Conference in Washington addressed the issue of maternal and child health:

We are nurturing a vision that is changing the world. Donors will spend more on women and children, and those donations will be tracked. Developing countries will pass rigorous policies for women’s and children’s health, and fully fund their implementation, and health workers will have the tools and training they need.

Rahim Kanani, reporting on Melinda’s talk, concluded that, “With global leaders convening next week in Canada for the G8 and G20 Summits, maternal and child health is now a top international priority.” And quoted Melinda thus: “The whole world will be looking to us for leadership. We need to be ready with a single plan.”
These thoughts are certainly in sync with the current US administrations Global Health Initiative, which seeks an integrated approach to health care. GHI will “help partner countries improve health outcomes through strengthened health systems – with a particular focus on improving the health of women, newborns and children through programs including infectious disease, nutrition, maternal and child health, and safe water.”

Malaria definitely needs to be part of the integrated mix of maternal and child health (MCH) services. Pregnant women are more vulnerable to malaria; even mosquitoes are more attracted to them. Malaria leads to maternal anemia and death as well as intrauterine growth retardation leading to low birth weight babies, who have a poor chance of survival. Research is finding more about possible links between malaria and pre-eclampsia and postpartum hemorrhage.

There ultimately should be no reason to fear a loss of malaria funding given the strong advocacy initiatives built by RBM partners. Even more, efforts of the integrated approach to strengthen health systems will benefit malaria control and elimination, which requires a strong health system.

And in closing we are reminded that the wealthy people behind foundation and corporate giving can be advocates themselves.  As NPR reported, “Microsoft Corp. co-founder Bill Gates and billionaire investor Warren Buffett are launching a campaign to get other American billionaires to give at least half their wealth to charity.” We trust that malaria control within an integrated MCH program will remain part of this charitable urge.

The New York Times points out that “17 African countries, including Nigeria, gained independence in 1960.” Apparently there are few major commemorations. The Times quotes Ibrahima Thioub, a Senegalese historian, who said, “It’s tough to mobilize people for celebrations, because the flowers of independence have faded. The last 50 years have not at all met the people’s hopes and expectations.”

Have these 50 years brought Africa any closer to independence from malaria? It was during those years in the late 1950s and early 1960s when most countries were gaining independence that the first effort to eradicate malaria failed. We have had twelve years of rolling back malaria now – are the critical factors in place to ensure that eliminating the disease is feasible now?

The New York Times article addresses critical factors – ranging from weakness of institutions like parliaments to gaps in civil society engagement – that would impede  public health and social welfare programs including malaria control. African intellectuals quoted in the article bemoan that “democracy is held hostage by elites,” and the public accepts that “power is a matter of essences, a heritage, something in the blood, that what is normal for a state is unlimited monarchy.”  While both power and malaria may be ‘in the blood’, the former does not appear to be as easily transmissible or shareable, making the latter all the less easy to control.

The Times notes that, “… there is the reliance on heavy inflows of foreign aid, which equaled a quarter to nearly a third of government spending in countries like Burkina Faso, Cameroon and Mali in 2008.” Clearly this includes inputs from the Global Fund, The World Bank Booster Program and the US President’s Malaria Initiative (PMI). What aspects of health programming are not covered by aid is often paid out of pocket by the public, which is already impoverished by diseases like malaria.

Although there have been recent worries about both the level of donor funding moving forward and the willingness of countries to sustain programs should donor funding collapse, there are some positive signs from the donor side.  The US Government is increasing its malaria focus beyond the 15 PMI countries to include at least Burkina Faso, Burundi, Nigeria, Democratic Republic of the Congo and Sudan, and the Global Fund is embarking on a new ‘grant architecture.’

Known as ‘single stream funding’ the new Global Fund grant architecture “will shift the Global Fund towards a more program-based approach, with significantly improved harmonization and alignment, improving its support of holistic health planning and implementation,” to each principle recipients. This should simplify management, provide continuity, and reduce transaction costs – so even if funding does not increase as desired, there still may be savings and efficiencies for the allocated resources.

There are signs that we may get closer to independence from malaria this year as strides are being made to achieve universal coverage of malaria interventions. It may take another 50 years to see whether malaria can truly be eradicated. Hopefully when many endemic African countries will be observing their 100th year of independence, malaria will have become a thing of the past.