Funding &Health Systems Bill Brieger | 01 Feb 2009
Global Fund Gap – implications for high burden countries
We have commented on the consternation expressed over the shortfall of money to fund the current crop (Round 8 ) of Global Fund applications. It is useful to bring this problem to life looking at an actual grant proposal that is held in limbo. Unfortunately Nigeria is one example – unfortunately because Nigeria probably has the highest burden of malaria.
Specifically the GFATM notes Nigeria’s Round 8 Application stands in limbo because certain …
Round 8 proposals … have been approved by the Board in principle and will be presented to the Board for funding approval, according to the comprehensive funding policy and as / when funding becomes available. The Global Fund Secretariat will be working with countries to find efficiencies in all Round 8 proposals to bring the total approved (Phase 1) funding for Round 8 at or below US$ 2.75 billion and to reduce the amount of Phase 2 funding (to be addressed during the Phase 2 renewal process).
The actual funding requested in Nigeria’s Round 8 proposal was nearly $600 million, of which $334 million was for phase 1. These figures look large in relation to the $74 million allocated for the Round 4 Malaria grant (which had been combined with Round 2), but when one considers the population of 140 million people combines to only about $4 per person, which is small considering the cost of nets, ACTs, logistics, health systems strengthening and the like.
One needs to remember that Nigeria has over 800 ‘health systems’ if one counts the 774 Local Government Areas (LGAs) (districts), 36 states (plus one Federal Capital Territory) and federal system of tertiary level facilities. The NGO and private sectors may even represent their own systems in the eyes of some. Constitutionally each level has its distinct health responsibilities, and LGAs are where primary health care and most of malaria services are delivered through government and a variety of formal and informal private channels.
It is these front line LGA ‘systems’ that need the most strengthening. While people may question the way LGAs spend their fundes, most of which come from federal subventions (read oil money), the reality is that the bulk of their expenses are recurrent ones, especially personnel. Infusions of support from the Global Fund, World Bank, DfID, USAID and others will only create a critical mass of malaria control action if these LGAs are strengthened and then correctly manage malaria commodities and resources.
Delayed funding for high burden countries like Nigeria not only delays critical systems building but also delays saving of lives. 2010 is so close and yet so far away.
Health Systems Bill Brieger | 05 Jan 2009
Is there ‘enough’ government to eliminate malaria?
Fareed Zakaria in today’s Washington Post quoted, “Samuel P. Huntington, the greatest political scientist of the past half-century, who died on Christmas Eve,” as saying, “‘the most important political distinction among countries concerns not their form of government but their degree of government.'” The implication, therefore is that …
So many of the world’s problems — from terrorists in Waziristan to the AIDS epidemic to piracy in Somalia — are made worse by governments that are unable to exercise real authority over their lands or people.
Money does not solve the problem. Sue Lloyd-Roberts of the BBC reported that, “Oil has provided hundreds of billions of pounds in revenue for the government since it was discovered in the Nigerian Delta 50 years ago and yet the country boasts some of the poorest communities in West Africa. Elections are rigged by money and guns and corruption pervades society from the top down.” People she interviewed explained that it is not just the billions of dollars embezzeled by government leaders over time but that, “The idea that there is a huge pot of black gold out there for the taking has distorted everyone’s values.”
‘Smaller’ pots of money may have a similar effect. When it became likely that Kenya might not secure Round 8 Global Fund support, “A Kenyan official (said) the government will investigate allegations of corruption in programs funded by a U.N.-backed agency to treat patients with AIDS, malaria or tuberculosis.” The Medical Services Minister said that, “The Geneva-based Global Fund to fight AIDS, Tuberculosis and Malaria said it suspects that some lists of patients treated in earlier programs were fictitious.”
Larger trends may be at work. The Washington Post looked at the world’s demographic future and explained that, “Sub-Saharan Africa — which is afflicted with the world’s highest fertility rates and ravaged by AIDS — will still be racked by large youth bulges … In recent years, most of these countries have demonstrated the correlation between extreme youth and violence. If that correlation endures, chronic unrest and state failure could persist through the 2020s — or even longer if fertility fails to drop.”
Failing states cannot eliminate malaria. Cholera and now likely malaria are killing people in Zimbabwe. Refugees in the continuing crisis in eastern Democratic Republic of Congo are exposed malaria and other diseases, and in the Niger Delta of Nigeria poverty, unemployment and instability amidst great oil wealth threaten health and social infrastructure.
Greater attention to poverty alleviation and youth employment will be crucial for stabilizing and strengthening governments so that they can address poverty-associated endemic diseases like malaria.
Community &Health Systems Bill Brieger | 04 Jan 2009
Hospitals, hospitals, hospitals – but can they conquer malaria?
Nigeria Health Watch calls our attention to numerous news headlines highlighting hospital construction …
- Benue okays renovation of 10 hospitals
- Lagos completes 100-bed children’s hospitals
- Nigerian in Britain Hopes to Build Hospital in Homeland
- Afam Onyema’s singular goal: to build a hospital in Nigeria
- Foundation laying ceremony of the much publicized American Hospital to be built in Abuja
- China to aid Nigeria’s health-care with hospital complex
… and makes the observation that, “While all these are important to some extent … no building has ever saved a life. However … it is convenient for politicians to brag about these.”
Although hospital emergency/casualty wards are often used for treatment of severe malaria, it is at the primary health care (PHC) level where the main attacks against malaria take place. What role do buildings play in the PHC process?
When PHC was getting off the ground as official health policy in Nigeria in the late 1970s, the effort had three main components – infrastructure, personnel and community. Infrastructure for the local government (district) level consisted of a web of facilities ranging from comprehensive health centers and health centers to health clinics and health posts. Personnel needs for PHC were to be met by new cadres of staff whose titles, though varying over time, all contained the word ‘community’ – community health officers, community health assistants, community health supervisors, community health extension workers.
These new cadres of staff, while linked to or based in the facilities, were expected to work in and with community members. The formation of village, district, ward and other levels of health and development committees that included both a representative selection of community members and leaders as well as health workers and staff from other sectors, formalized, in theory, the link between the front line staff and the community.
Many new PHC health facilities were built over the past 30 years, especially in the more rural and underserved sections of Nigeria’s 774 local governments. These new buildings alone did not guarantee services. For example, several new PHC structures in the more remote rural areas of Oyo State mainly provided shelter for goats and sheep for their first 10-15 years.
Eventually as more trainees graduated from the community health worker courses, there were attempts to staff the facilities, as few professional nurses would not work there. Ultimately local governments found that these community health workers were in fact a cheaper substitutes for nurses, pharmacists and other professionals, and thus, the community side of their work was often not fully realized.
With the advent of major malaria financing in Nigeria from the Global Fund, DfID, USAID, the World Bank and some NGOs, it may be possible to see the PHC system spring to life and ensure that the combination of facilities, personnel and community actually deliver malaria treatment and prevention services at the grassroots as hoped for 30 years ago.
Health Systems Bill Brieger | 22 Dec 2008
Can Nigeria Eliminate Malaria?
Earlier this month the New York Times expressed the concerns of many in and out of Nigeria when it said “That the president of Africa’s second-wealthiest country and its biggest oil exporter had to travel abroad for minor treatment speaks volumes about the state of services in Nigeria. The average Nigerian lives on less than $2 a day and has no reliable access to electricity, clean water or adequate health care.”
Nigerians were excited about the election of Barack Obama in the US, but what of their own leaders? Low expectations were visible when the New York Times quoted a accountant in Lagos: “’What can we do? We just have to fold our arms and accept what our leaders do.’ Patrons near him nodded in resignation.” Are people also just folding their arms and watching efforts to control malaria in the country?
What can be done in this environment? The Siemens company is now in court for extensive bribery activities. The New York Times also reports that Siemens “made $12.7 million in payments to senior officials
in Nigeria for government contracts,” and explained that, “Siemens bribed wherever executives felt the money was needed, paying off officials not only in countries known for government corruption, like Nigeria …”
Ironically and fortunately, and unlike other countries such as Uganda, Nigeria has not been implicated in corruption over the management of its Global Fund monies. Nigeria did almost lose its first GFATM malaria grants because of slow progress toward its self-selected performance indicators and did lose a GFATM HIV grant basically for just not spending the money in a timely fashion to achieve goals. Because of slow performance in its Rounds 2 and 4 malaria grants, Nigeria was unable to secure approval for its GFATM malaria proposals for Rounds 5-7. Finally Round 8 was approved in principle, but hangs in limbo for actual funding. These experiences speak to broader health systems inefficiencies.
Being Africa’s most populous country, Nigeria faces both opportunities and challenges. The vast supply of highly qualified human resources is the opportunity – the challenge is a system that may not enable these human resources to apply their knowledge and skills to solve common health problems.
A major system challenge is the 3-tiered health system wherein Federal, State and Local Governments each have constitutionally designated health care responsibilities. The Federal is best organized to meet policy and procurement challenges, but it is at the State and more especially the Local Government levels where actual malaria program implementation happens. The Private Sector and NGOs also play a major role, too. These non-governmental partners are involved in a national coordinating forum, but such mechanisms are rare at the State level and below.
Local Governments (LGs) that have the prime responsibility for primary health care delivery, which includes malaria services, have the weakest infrastructure, and these number 774. Formerly the National Primary Health Care Development Agency provided technical assistance to Local Governments, but in recent years its focus has narrowed to selected wards at the level below the LG. Until the LG health system is strengthened, it is unlikely that Nigeria can defeat malaria.
With advocates like Nigeria Health Watch things might change: “But times have changed. Nigerians will no longer be taken on wild goose chases about … “who awarded which local government what contract to build primary health care centres” … or “… which health committee colluded with which company to equip teaching hospitals with MRI scanners“…. We expect health to be measure in health terms …. and not by buildings or by machines.”
Eradication &Health Systems Bill Brieger | 21 Dec 2008
Eradication – even guinea worm is not easy
The Carter Center has been one of the major players in the guinea worm eradication effort for the past two decades. Eradication is not an easy task, but some characteristics of the guinea worm help in its demise. The Carter Center explains that …
Humans are a Guinea worm’s only host, so spread of the disease can be controlled by identifying all cases and modifying human behavior to prevent it from recurring. Once all human cases are eliminated, the disease will be eradicated. Today, cases of Guinea worm disease are down more than 99% since 1986, making it poised to be the next disease after smallpox to be eradicated.
The nearly invisible crustacean that serves as the intermediary host stays put in ponds during the transmission season, so it is only human movement that is of concern. Guinea worm was probably the first problem recognized as a neglected disease in part due to the fact that it infected neglected rural people. These people are not extremely mobil, and improved village water supplies can go a long way to eliminating the disease as well as improving the economic status of villagers.
Guinea worm was to be the test disease or indicator for the success of the United Nations Water Decade (the 1980s). While the annual number of cases world-wide has decreased from 3.5 million to less than 5,000, the disease has resisted eradication efforts for over 20 years. If a disease with a relatively simple life cycle and some obvious locally implementable solutions cannot be eradicated so easily, what of malaria?
Ernesto Ruiz-Tiben of the Carter Center notes that, “Hopefully Guinea worm will be the first parasitic disease ever eradicated. If and when that happens, we will have done it without a drug and without a vaccine to treat or prevent the disease. If we can do that, it will be one of the greatest achievements in public health.” Even with nets and drugs and insecticides and hopefully, vaccines, there is long ways to go for malaria.
Finally though, if guinea worm is relatively simple to eradicate, why has it persisted for 13 years past its planned demise in 1995? Some of the same problems facing malaria eradication plagued efforts against guinea worm, and these are in large part challenges of health systems resource management – for example, ensuring that funds for well construction were targeted at endemic villages, not politically expedient villages, planning to distribute simple cloth water filters before the transmission season, not during, enabling village health volunteers to report cases promptly and health workers to respond promptly to guarantee case containment.
Until there is support for improvements in health system functioning, any disease will be difficult to eradicate.
Health Systems &Human Resources Bill Brieger | 10 Dec 2008
Training – as important as commodities
New tools are said to be the answer to the question of malaria eradication. Even with the not so new tools available – ACTs, RDTs, IRS, LLINs, IPTp, IPTi – progress toward elimination can be made if health workers are trained in their appropriate use. Ssekabira and colleagues found that training improved some aspects of malaria case management such as reduced treatment of people testing negative in the lab, but they also pointed out that there needs to be integrated ‘team based’ training around all these tools in order to achieve success.
In their focus on training for improved malaria case management SSekabira’s group learned that ‘integrated’ means getting all clinical and laboratory staff on board as well as ensuring adequate procurement/supply of drugs, equipment and supplies, supportive supervision and especially adequate human resources to be trained, deliver services and supervise. This is a tall order, but alternative is bleak.
The advent of large scale donor funding of malaria control in the past six or so years began with a focus on malaria commodities. Concern was expressed to achieve coverage targets – 60% in 2005, 80% in 2010 – which was thought to be possible only if enough drugs, supplies and materials were made available to endemic countries. In this context, countries were reluctant to ‘waste’ their donor dollars and euros on health systems strengthening, human resource development and operations research. SSekabira’s efforts show these seeming peripheral elements actually provide a crucial framework without which all the malaria commodities in the world will really go to waste in storerooms and warehouses.
The use of Rapid Diagnostic Tests (RDTs) provide a simple example of the commodity vs. integrated approach. Harvey et al. reported that, “Manufacturer’s instructions like those provided with the RDTs … are insufficient to ensure safe and accurate use by CHWs. However, well-designed instructions plus training can ensure high performance.”
Training resources exist, as for example Jhpiego’s Malaria in Pregnancy Resource Package, which is freely available online. Management Sciences for Health has training tools for the procurement and supply management. Greater use of such tools is needed so that the billions of dollars and euros spent on commodities will actually save lives.
Health Systems &Vaccine Bill Brieger | 12 Nov 2008
Creating health systems to support malaria vaccine research
Various announcements have been made this week of a huge upcoming malaria vaccine trial among 16,000 African children. The Seattle Times describes the major health systems investments that have been underway to support this research trial.
The massive vaccine trials will be conducted in Burkina Faso, Gabon, Ghana, Kenya, Malawi, Mozambique and Tanzania. Dr. Christian Loucq, director of the Malaria Vaccine Initiative, said the project has been working over the past year to upgrade laboratory, computer and other equipment in those countries, train technicians, and even help develop local equivalents of the U.S. Food and Drug Administration to ensure the trials are properly monitored.
This is a indirect acknowledgment of the broader health systems challenges that create bottlenecks for implementing existing interventions such as long lasting insecticide treated nets, artemisinin-based combination therapy and intermittent preventive treatment for pregnant women. The success of these current interventions is essential for bring malaria levels close to elimination levels in endemic countries so that when an effective vaccine arrives, it will be able to carry malaria control efforts to the next level – eradication.
GlaxoSmithKline, one of the vaccine trial partners, has an active malaria support program that addresses malaria prevention and treatment activities in 8 African countries and so is very likely aware of the systems challenges facing implementation of existing interventions. The researchers are also realistic about their own challenges because they have been involved in malaria vaccine trials since 2003. The PATH Malaria Vaccine Initiative, the other partner in this endeavor, has other vaccine candidates in the pipeline ‘in case’.
Ultimately, the researchers realize that “even if their vaccine does not succeed, the widespread investment needed to conduct the trials means that Africa will be left with better communications, research and other infrastructure that could be used in the search for vaccines against other diseases such as AIDS.” What is needed though is ongoing, more thorough and concerted attention to improving health systems to deliver malaria and other primary health care interventions, not just building systems when and where a special research project is planned.
Better access to and use of health systems strengthening funds from the Global Fund is one step in this direction.
Health Systems &Procurement Supply Management &Treatment Bill Brieger | 25 Oct 2008
When does treatment become control?
The introduction of Artesunate-Amodiaquine in M’lomp village, Senegal has been monitored over time by Sarrassat and colleagues.Their efforts were motivated by experiences in Thailand, South Africa and Zanzibar, where a decrease in malaria morbidity was observed following the introduction of artemisinin-based combination therapy (ACT).
Decreased incidence has been postulated as an effect of artemisinin-based medicines’ ability to kill gametocytes and reduce transmission (Drakeley et al.; Nosten et al.; Carrara et al.; Barnes et al.; Battarai et al.).
Sarrassat’s team also observed a decrease in the incidence rate and repetitiveness between 2001 and 2002. They were worried that lower rainfall might also have contributed to the findings, especially since treatment coverage was less than ideal.
Ultimately Sarrassat et al. concluded that, “In sub-Saharan countries, in order to optimize the impact on malaria morbidity, ACT deployment must be supported, on the one hand, by a strengthening of public health system to ensure a high ACT coverage and, on the other hand, by others measures, such vector control measures.”
A home management strategy has been one recommendation to improve the ability of health systems to increase ACT coverage. Generally though timely procurement and supply procedures are required to make ACTs available for the whole population at risk. In order to do this, health systems need strengthing as Sarrassat suggests.
Health Systems &IPTi Bill Brieger | 22 Oct 2008
IPTi and EPI – healthy links
Recently we highlighted some lessons that malaria control efforts could learn from immunization program management, and observed that this was important because malaria control interventions such as ITN distribution have often been linked with immunization campaigns. Another link is use of the Expanded Program for Immunization (EPI) services as a delivery mechanism for intermittent preventive treatment for infants (IPTi).
Pool and colleagues have reported on the acceptability of EPI as a channel for IPTi delivery in Tanzania. The researchers concluded that, “In this setting, IPTi delivered together with EPI was generally acceptable. Acceptability was related to prior routinization of EPI [emphasis added] and resonance with traditional practices. Non-adherence was due largely to practical, social and structural factors, many of which could easily be overcome.”
For example, mothers would have preferred drops instead of tablets for their infants. As with vaccines, mothers knowledge about the whole process was vague and generally consisted of an understanding that the process promoted health rather than controlled specific diseases. Structural factors related to poverty. Despite potential limitations, EPI appears to be a good platform for IPTi delivery.
A review of the Demographic and Health Survey for Tanzania shows that the country has maintained a full immunization coverage rate of around 70% over the past 4 surveys (12 years), but that in the most recent survey (2004) at least 90% of infants had at last one EPI contact. This again speaks well for incorporating IPTi into an existing system that reaches most infants.
The DHS does show some other factors in EPI coverage that would also affect IPTi and reinforces structural factors as a concern. There was lower rural than urban immunization coverage. More educated and wealthier parents were more likely to get their infants immunized that less educated and poorer ones. DPT3 coverage in 2004 was only 75% for those in the lowest wealth quintile compared to 96% among those in the highest quintile.
These wealth/access disparities are no reason to dissociate IPTi from EPI, but they do emphasize the need for overall health reform so that disease prevention interventions equitably reach all children and families.
Health Systems &Mortality Bill Brieger | 15 Sep 2008
As more children survive, can health systems cope?
UNICEF reports that, “Fewer children under the age of five are dying today than in past years, according to the latest data from UNICEF. Globally, the number of young children who died in 2007 dropped to 9.2 million, compared to 12.7 million deaths in 1990.”
UNICEF explained that, “As we are more successful in some ways, the task is a little harder. As coverage of basic services gets higher, the most underserved populations are sometimes the most difficult to access. To ensure further declines in child mortality in the future, UNICEF is calling for a greater focus on newborn and maternal health, as well as strengthening basic health systems in areas where young children are at risk.”
Reduced malaria deaths are part of the scenario. “Malaria in these parts (high burden) of Africa could however be substantially reduced using currently available tools. Examples of successful control are occurring in Africa where areas previously known for their high endemicity have become areas of relatively low transmission over about 10 years, including The Gambia, Zanzibar and some parts of Kenya. This reduction in malaria is often unrecognized by public health services or clinicians yet is a practical reality.”
Likewise Chambers et al. noted in April 2008 that, “Last month, WHO reported that cases of malaria in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children aged less than 5 years.2 Ethiopia, meanwhile, saw reductions of 51% in deaths and 60% in cases in the same age group. These remarkable outcomes were achieved through expanded access to malaria control, primarily long-lasting insecticide-treated bednets and artemisinin-based combination therapies.” The head of WHO’s Global Malaria Program was quoted as saying, “This is the first time we have seen these results with the new tools.”
Questions arise – how will the health system respond if large scale donor interventions in high burden areas continue to make improvements as seen in Rwanda, Ethiopia, Kenya, the Gambia and Zanzibar? Below are some possibilities. What do you think will happen?
- Replacement mortality will claim children if health systems do not address malnutrition and unsafe water supplies
- More surviving children may influence fertility decisions assuming the health system makes family planning commodities more readily available
- The health system will become complacent and relax malaria control efforts before achieving elimination, leading to rebound malaria mortality
Our recent discussions about health systems issues require that health system strengthening must be taken seriously if gains against malaria are to be sustained.