Tropical Health Matters

Linking health and microfinance is the goal of an opinion piece by Leatherman and Dunford in the current Bulletin of the World Health Organization. While they recognize the real and potential stumbling blocks of equitably and honestly serving the 155 million household worldwide that are serviced by more than 3500 microfinance institutions, they also see evidence that microfinance can have a positive health impact.

Where it occurs, the link between health and microfinance occurs through an organized health education component during member meetings and through individual loan counseling. Areas that have seen positive health outcomes include child nutrition, diarrheal disease control, HIV prevention and malaria, among others.

The malaria example cited by Leatherman and Dunford is a Freedom from Hunger Foundation (FFHF) project in Ghana. The project researched the effect of malaria health education on microfinance clients by comparing them with a group of clients receiving education on diarrheal diseases and a group of non-clients. By the end of the project a greater proportion of the malaria group …

• had appropriate malaria knowledge
• identified groups most vulnerable to malaria
• reported that insecticide-treated nets (ITNs) provide the best protection against malaria
• agreed that pregnant women should use ITNs
• had improved knowledge of malaria complications during pregnancy
• owned at least one bed net
• reported at least one child or woman of reproductive age sleeping under a bed net
• increased in ITN ownership and use

Those who did not have nets complained of both cost and access.  Learning sessions alone could account for knowledge changes listed above, but not necessarily the behavior change. Although FFHF does not claim so directly, the authors set the stage for one to hope that improved living standards afforded by microfinance enabled some to use their knowledge and obtain nets. Otherwise, there would be less reason to justify coupling health education and microfinance.

An indigenous microfinance group in Orissa, India also has tackled malaria. BISWA (Bharat Integrated Social Welfare Agency), a nongovernmental organization tried three interventions with their microfinance self-help groups (SHG): 1) health education on ITN use, 2) health education with free nets, and 3) health education on ITNs that encouraged use of microfinance money to but nets. Nearly 60% of SHG members offered the opportunity to buy ITNs through micro-credit did purchase at least one net, and the majority of those were bought on credit.

Knowledge and access to credit may not be the only factors at work in changed health behaviors. The FFHF group concludes that, “When MFIs provide culturally sensitive education and support to poor women, they not only improve health but also empower women by enhancing their self-confidence and promoting their status in households and communities.”

This hints at what Bamidele has defined as personal agency belief. Personal agency is the multiplication of locus of control and perceived self-efficacy, and he used it as a measure of entrepreneurial spirit of participants in microfinance enterprises in Nigeria. Members of credit societies had greater personal agency beliefs than non-members. This may be why Deji found that, “Membership of cooperative societies is very significant to favorable adoption behavior of women farmers towards agricultural innovations, hence should be encouraged as a strategy for improving the agricultural productivity and livelihoods of the women farmers.”

The FFHF project acknowledged that during the span of intervention their project did not affect malaria treatment behaviors. Finance of course makes a big difference in treatment seeking by poor people as pointed out by Chuma and colleagues. The poor in Kenya used borrowing from friends and relatives and getting medicines or care on credit as major coping strategies. Purchase of medicines on credit from drug shops was also identified as a common practice by Rutebemberwa et al. in Uganda.

Microcredit services may make access to malaria medicines more reliable with a combination of knowledge, financial resources and enhanced personal agency belief – this is an idea that deserves further research.

Roll Bank Malaria (RBM) was launched in 1998, but actual scale up to universal coverage is only happening in 2010. By Comparison, the African Program for Onchocerciasis Control (APOC) took off in 1996 and has been scaled up for several years in all but a few of its endemic countries. Granted, APOC has a relatively smaller target area, but it now regularly reaches over 127,000 African villages with annual doses of ivermectin.

Both programs have in common the need to sustain their scaled up for many years into the foreseeable future if disease elimination is to be achieved.

This need for a long term perspective causes concern when one reads about a threat to continued funding for APOC’s Borno State, Nigeria project, and raises speculation whether malaria efforts may face the same threat a few years down the line.

APOC started with a very clear vision of sustainability. APOC, a government entity (state, province, district, or country) and a non-governmental development agency (NGDO) would enter into a financial and programmatic 5-year partnership to establish community directed treatment with ivermectin (CDTI – see photo of CDTI in Cameroon at right). APOC’s financial contribution would be largest in the first year, when the overall budget would be largest because of start up costs.

Over time, program costs were to reduce, as would costs per person treated because of economies of scale. APOC’s share of the budget would decrease relative to that of the government partner, though the overall budget to maintain the program into the future was expected to be smaller and more manageable to the government partner with some continued support from the NGDO.

Free supplies of ivermectin from the Mectizan Donation Program would continue as long as there was need, but by the sixth year of operation, it was hoped that countries could sustain their own CDTI efforts. Apparently this has not been easy.

Evidence of problems with Borno’s CDTI project surfaced in 2007 at a meeting of APOC’s Technical Consultative Committee where the following report was shared. “Borno has maintained a good geographic and therapeutic coverage. However, the project has the following challenges:

• Non-release of funds by state and LGAs
• Inadequate number of FLHF staff
• Selection and training of more CDDs
• Obtaining funds from the government

IRIN now reports that after 11 years of operation “The (Borno State) government was supposed to provide counterpart funds to run the river blindness programme, but it has not done so, (according to) Borno State’s onchocerciasis coordinator Galadima.” Hellen Keller International (HKI) is Borno’s NGDO partner for CDTI and has been trying to make up the slack.

Unfortunately “HKI funding has been hit by the global recession, says (a representative). ‘Since the recession our donors have turned their attention elsewhere with little consideration for Africa and this affects the volume of funds for intervention projects like the onchocerciasis.’

Project staff complained to IRIN that, “We have been crippled financially due to lack of state counterpart funding. We sometimes find it hard to fuel our vehicles and go for supervision in the affected communities.”

There were hopes that another four years of government funding would put Borno within reach of elimination goals, but project staff lament that, “If the project stops at this stage, the effects will be devastating. It will turn the tide of the success we have achieved which will be quite disastrous.”

Let’s move this scenario forward to 2015 and change the disease to malaria. Let’s assume that talk of funding ceilings by donors has become a pressing reality and countries need to contribute more to sustain malaria interventions and achieve elimination. Let’s hope we don’t wind up again like malaria control did in the 1950s and ‘60s – eliminating the programs, not the disease.

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ps – The IRIN article does have some potential technical problems. It referred to the CDTI as a program to create ‘immunity’  to onchocerciasis, whereas ivermectin actually is a drug to kill the microfilaria of the parasite and keep infection at a low level until such time as adult worms die and transmission in the community stops. There is also concern about the figure of $18 per person treated. Normally at this advanced stage of the program we should be talking in terms of cents, not dollars. These technical problems with the article do not detract from its serious financial message.

Is the malaria house in order? NGOs worry about donor funding ceilings that affect their own funding floors, agencies distributing nets need to unlock store room doors and net recipients look at their ceilings and wonder how to hang their nets. This is some of the news that threatens success of efforts to achieve universal coverage.

One man’s ceiling is another man’s floor – so the saying goes. One would hope that support from the Global Fund, The World Bank, US Government and DfID, among others, would be a sturdy floor or foundation on which governments in endemic countries could build a strong malaria control program.

It becomes evident reading an article posted at World Sentinel that if donors to the Global Fund actually succeed in setting funding ceilings, the financial floor to control malaria in endemic countries will become less stable. Specifically, “NGOs are outraged at developments of the current Board meeting of the Global Fund Board to Fight AIDS, Tuberculosis and Malaria, taking place in Geneva, Switzerland. Many donor governments are promoting the establishment of a ceiling on the next round of disease fight grants to developing countries.”

This ceiling would stifle innovation, dampen country ambitions and cost lives according to the Global AIDS Alliance. We have discussed concerns that not all endemic governments are making a serious financial commitment to malaria control, and if the donors’ ceiling drops and their own floor falls, who will make up the funding gap?

An equally frightening part of the ‘malaria house’ becomes evident “even as donations roll in and millions of bed nets pile up (behind the doors of) warehouses across Africa, aid agencies and non-governmental organizations are quietly grappling with a problem.” But even when these nets are released, they may not be used.

“Data suggest that, at least in some places, nearly half of Africans who have access to the nets refuse to sleep under them,” according to the Los Angeles Times. Why are nets not hanging from all ceilings?

The LA Times article gives some reasons why villagers won’t hang nets in their houses: perceived poor ventilation when sleeping under nets, not being sure how to hang them over sleeping mats, and not viewing malaria as a serious enough threat to warrant the inconveniences of hanging and using one. Clearly education on net use has not often gone together with getting the distribution numbers higher. As Sonia Shah says, nets may be “‘gifts’ that many neither want nor use.”

Maybe if we convince donors and governments that nets and other malaria commodities are being used, they will remove their funding ceilings and give us a chance to eliminate malaria from all houses in endemic countries.

Eliminating malaria, let along eradicating it, does not come cheap. In places like Zanzibar that have seen “prevalence rate come down from 35 percent before 2008 to below 1 percent,” there is worry that success may actually discourage continued support.

Zanzibar is right to worry. As its malaria control program staff observed, “Malaria prevalence was reduced to 1-2 percent in the 1970s, and then people relaxed.” Sri Lanka had similar experiences:

History shows that malaria control efforts must be sustained to be effective. Sri Lanka is an example of a country where malaria roared back after nearly being eliminated in 1963. But those eradication efforts were not sustained and by 1990 there were a quarter of a million cases. Fortunately malaria control was stepped up again and levels have dropped once more to just 673 cases reported in 2008.

Zanzibar’s worries are real. Even though progress is happening, IRIN noted that the malaria program says it has reached only 60% of households with indoor residual spray and 40% of pregnant women with intermittent preventive treatment. Achieving and maintaining targets of 95% and 80% respectively will take continued financial commitments. As a spokesperson net manufacturer Vestergaard Frandsen said, “We can’t afford to let funding backslide and threaten this progress.”

In addition to maintaining interventions, Zanzibar is in a position to show the additional costs of monitoring and documenting elimination. This includes establishing and maintaining its Malaria Early Epidemic Detection System. Again, the Zanzibar malaria control program warns that, “Each district also needs its own surveillance and response team and there is a need for more trained personnel. To set up this system you also need a lot of money.”

Dr. Steven Phillips, medical director of global issues and projects for ExxonMobil is optimistic about the major increases in malaria funding globally, but also is cautious…

You can imagine with the economic headwinds, with the global downturn and also with a lot of competing priorities that donor governments have, the real question is will this level of finance be sustained? And if it’s not sustained what’s going to happen to the progress?

The Global Fund also offers a word of caution: “Despite remarkable progress in the past few years, any reduction in the flow of funding to fight the disease could put recent achievements at risk.” They estimate that $20 billion raised between 2011-13 would meet “72 percent of global need in 2015 for insecticide-treated nets for malaria, but they also are considering less ambitious scenarios like $13 and $17 billion.

In fact, lack of major donor support for low transmission areas like Botswana in Southern Africa points to the need to orient donors to the financial challenges of working toward and achieving malaria elimination. Establishing more focused and intense intervention in some of Botswana’s northern districts as well as epidemic outbreak detection in the eastern areas is not cheap.

WHO pointed out that, “The Government of Botswana is the major financier for malaria control, accounting for more than 90% of total expenditure.” There are unmet financial needs in the areas of surveillance, vector control and human resources. Is this the fate of Zanzibar as the islands become low prevalence areas like Botswana?

Fortunately Zanzibar has a 10 million Euro Global Fund Grant that will last through 2014 as well as PMI support, but not every low transmission area is as fortunate.

There are great expectations for achieving universal coverage of malaria interventions by 31 December 2010. Success at that point in time will be meaningless unless interventions are sustained and new interventions appropriate to achieving elimination some years hence are funded.

RBM’s second report in the Progress and Impact Series provides us with the following data:

• Annual donor support for malaria control has increased dramatically (approximately 10-fold) between 2004 and 2009, estimated to have reached nearly $1.8 million in 2009
• Global production of ITNs has increased 5-fold since 2004, rising from 30 million to 150 million in 2009
• Six of the eleven countries with data collected in 2008 or 2009 showed >50% household ownership of nets, although the highest was 62%
• Averaging across 26 African countries (with 71% of <5 year child population), use of ITNs by children rose from 2% in 2000 to 22% in 2008

What do these figures tell us? First, money and commodities do not translate easily into indicators of success. Even household possession of the commodities does not guarantee use. And the best net coverage results achieved in 2008 or 2009 barely reach the RBM target of 60% for 2005, let along the 80% goal for 2010.

Some malaria community members have become cynical. “‘These are meaningless input measures that tell us only (the UN) is effective at spending other people’s money,’ said Philip Stevens, a health-policy expert at the London think-tank International Policy Network.”

C.Health also reports that, “Richard Tren, director of Africa Fighting Malaria, an Africa and US-based advocacy group, said measuring malaria spending and the numbers of drugs bought did not always mean more Africans had access to them.”

Obviously inputs are needed, but UNICEF reports that “available funds are still far short of the estimated $6 billion needed worldwide for effective malaria control in 2010.”

Partners are anxiously considering that the ‘Decade to Roll Back Malaria‘ comes to a close on 31 December 2010 and hope for success, but so far only Eritrea, Ethiopia, Equatorial Guinea’s Bioko island, Gambia, Ghana, Zambia, the Tanzanian island of Zanzibar and Sao Tome and Principe have scaled up malaria interventions and have observed marked reduction (30-95 percent) in morbidity and mortality indicators.

What can we expect from high burden countries like Nigeria and DRC where over a third of Africa’s malaria occurs? Nigeria is in the midst of distributing over 60 million LLINs, although there is still a gap of 9 million. Preliminary reports shared at a recent debriefing session on malaria progress in Abuja estimated that up to 25% of LLINs were ‘lost’ during distribution in one state.

Clearly nets produced for and acquired by countries is not the ultimate indicator we need to determine a decade’s success. We should not feel guilty about ‘spending other people’s money’ to eliminate malaria, but we should be accountable.

Readers have expressed concern about our recent look at embezzlement of Global Fund Grants.  The Lancet has now published a study that addresses what one might call ‘legal’ diversion of government funds away from health programs.

Lu and colleagues have examined development assistance for health (DAH) across countries and learned how it affects domestic government health spending. Their analysis showed two key findings

• DAH to government had a negative and significant effect on domestic government spending on health such that for every US$1 of DAH to government, government health expenditures from domestic resources were reduced by $0·43 (p=0) to $1·14 (p=0)
• DAH to the non-governmental sector had a positive and signifi cant eff ect on domestic government health spending

In response Sridhar and Woods express “worry that others will draw two rather crude conclusions,” that health funding should not be routed through governments, but rather it should go to NGOs. In defense of this position they offer some realistic limitations – accurate calculation of government expenditures and donor tendency to skew assistance through disease-specific programs.

Ooms and colleagues offer another reason to take the findings of Lu et al. with caution. They see examples of both increases (Rwanda) and decreases (Ethiopia) in government response to increased DAH and encourage us to try to understand what governments may be facing and plausible reasons for their thinking such as …

• Governments compensate for exceptional international generosity to the health sector by reallocating government funding to other sectors
• Governments anticipate long-term unreliability of international health aid by stalling possible increases of recurrent health expenditure, or
• Governments smooth aid by spreading aid across several years

Robert Davis, who provides an invaluable listserve drawing our attention to publications of child survival and health shared these Lancet pieces as well as another interesting article from 2007 on the role of DAH in immunization program achievements. Arevshatian and co-researchers documented that, “Rates of immunization coverage are improving dramatically in the WHO African Region. The huge increases in spending on immunization and the related improvements in programme performance are linked predominantly to increases in donor funding.”

Assuming that the global community shares goals of eliminating diseases like polio, onchocerciasis, and malaria, DAH is needed to address the scale of these endeavors. Governments of endemic countries, if left their own devices, may not have given the same elevated priorities to these diseases as do donors and experts elsewhere, but fortunately neither are they adverse to using assistance to help their people.

Considering the current economic climate where the Global Fund worries constantly about replenishment, countries are right to question whether DAH commitment is really there to back these grand schemes into the future. As we have asked recently, are malaria donors prepared for a second round of universal net coverage in the next three years given the likely durability problems of LLINs?

Here is the reality. In Nigerian states that had not benefited from the earlier rounds of Global Fund support one could rarely find ACTs in government clinics.  Local government budgets for essential drugs were meager, and decisions had to be made whether using a sizable chunk for these expensive drugs was advisable or even feasible. Now with greater expansion of coverage in Round 8 as well as pilot efforts for the Affordable Medicines Facility malaria (AMFm), it is finally looking like affordable ACTs may be accessible at the community level.

Right now our challenges or concerns are not to bemoan the shifting of local government funds away from malaria drugs (which they were not purchasing anyway). We need to build the capacity of all levels of the health system to manage the new resources in a way that lives are saved and the Millennium Development Goals of 2015 are achieved.

… unfortunately the nagging thought remains, will these financial commitments to DAH be sustained?

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

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

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

Kenya’s Saturday Nation reports that the country lost out on appeal for its Global Fund Round 9 malaria and HIV application rejection. “Late last year, Kenya’s (original) application for funding from the Global Fund on Aids, TB and malaria for $270 million was rejected on technicalities and the country’s poor record with the organisation.”

Apparently the rejection of the appeal was two pronged – proposal quality and past performance. First the Nation reports that, “On Kenya’s appeal for malaria funding for example, the panel upholds that the decision made initially by the technical team was sound and saw no need to reverse it.” Then the Nation quotes a Ministry official as saying, “Our under-performance has been the main undoing.”

To date Kenya has received only two malaria grants from the Global Fund – Rounds 2 and 4. Only 17% of the Round 2 funds were ever disbursed for the $27 million grant after start-up in 2003, and apparently the grant ground to a halt after about 3 years, never entering Phase 2.

So far 63% of the $162 million Round 4 grant have been disbursed since inception in 2006. Expenditures are only 60% of disbursement. On last review in November 2009 the grant scored a B2, meaning inadequate performance but potential demonstrated.  The difficulties in performance and new grant success seem ironic since Kenya has recently made major strides in updating its malaria strategy and action plans to better reflect the country’s epidemiological and transmission profiles.

On top of these problems were reports from Kenya early last year that “the Government appointed a taskforce to trace the missing Sh13 billion grant from the Global Fund to fight Aids, tuberculosis and malaria.”

Once grants have been made, the Global Fund’s Office of the Inspector General has a role in monitoring implementation and colating lessons learned to improve GFATM functioning. The most recent report notes that of 17 recommendations made to Kenya to improve the functioning of its grants, none were implemented. General problems across several countries included among others …

• Conflicts of interest with PRs and SRs sitting on CCMs
• CCMs micromanaging grants instead of overseeing them
• PRs not complying with grant agreement clauses
• Procurement not executed in line with best practices
• Weak financial management and internal control of PRs
• Unworkable monitoring/evaluation systems because of unattainable targets and poor data collection procedures (feature attributed to countring including Kenya)

None of the foregoing problems are secret, and yet countries like Kenya cannot seem to get out of the viscious cycle of poor performance leading to new grant rejection leading to funding shortages that lead to more poor performance in their malaria control efforts.  Back in 2008 Kenya went through major efforts to democratize and improve the functioning of its Global Fund governance mechanisms.  Maybe the malaria partnership has not help Kenya accountable for the promises it made?

PS – the Global Fund is not Kenya’s only weak area for international assistance. According to the Nation yesterday, “Kenya has failed the eligibility test for (US) Millennium Challenge aid in each of the past five years because it falls short on governance standards.”

VOA reports that, “the U.S. isn’t backing off its commitment to aid other nations. In fact, the President has asked for increased funding for global development programs to provide humanitarian and economic assistance around the world.”

While the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI) are continuing, they are doing so in the context of a new perspective – global public health.  VOA further notes that …

As part of a new emphasis on global health, the President’s budget will also devote new funding to reduce the number of mothers and infants who die each year from complications of childbirth or pregnancy, poor nutrition, and malaria, tuberculosis, pneumonia and polio. These are treatable diseases, yet they kill millions every year. And rather than the U.S. delivering aid services on its own, it will continue to work with its partner countries to build their capacity to deliver services through strong and accountable institutions. 

A key issue in this approach is health systems strengthening.  It is one thing to provide needed malaria (or HIV) commodities to endemic countries, and quite another for that country to be able to distribute those to people in need, promote proper use and monitor and report back to improve programming. The emphasis on health systems is most welcome and an important evolution in the life PEPFAR and PMI.

The potential for integration with maternal and child health services is an essential part of systems strengthening.  Too often, malaria in pregnancy program coverage has been low because of weak linkages between MCH and Malaria programs.

This pledge to expanding work on global public health should serve as a positive example to other donor countries.  We are still a long way from achieving the annual financial commitments needed to move from malaria control to elimination.

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

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

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

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

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

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

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

Please review and comment on these messages …

Overarching Message

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

Message 1

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

Message 2

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

Message 3

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

Message 4

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

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