Tropical Health Matters

Nigeria has been classified as one of the main high burden malaria endemic countries.  The World Bank Booster program notes that the per capita investment in malaria is disproportionately low in largest high burden countries, and this threatens progress across the continent.

The results of this low level of per capita investment were highlighted by Oresanya and colleagues recently when they reported that, “Household ownership of any net was 23.9% and 10.1% for ITNs.” Furthermore, “Utilization of any net by children under-five was 11.5% and 1.7% for ITN.” The Abuja targets look a long way off from Abuja and environs.

One of the key “predictors of use of any net among under-five children … [was] the presence of a health facility in the community.” The implication is that the high burden malaria problem is not only characterized by low relatively investment in malaria control, but a similarly low level of investment in the health system through which malaria interventions can be delivered.

This assumption is reinforced in a report by Michael Reid in the WHO Bulletin stating that, “Despite several attempts at reform over the past 30 years, Nigeria still lacks a clear and coordinated approach to primary health care.” In only two years during the 30 years since the Alma Ata Primary Health Care (PHC) Declaration has the Nigerian budget for health exceeded 5% of the total, despite the formulation and reformulation of PHC policies and the training and re-training of front-line health care workers.

Recently we reinforced the point that malaria control must have a strong health system to reach all in need with life saving interventions. One wonders whether the challenge of high burden malaria countries can be addressed without major health care reform. Reid provides other disheartening documentary and interview evidence:

• Nigeria has never learnt or developed any system of authentic and full-scale community health care before Alma-Ata or after it
• The world health report 2000 ranked Nigeria 187 out of 191 countries for health service performance
• Infant mortality rates have been deteriorating from 85 per 1000 live births in 1982, 87 in 1990, 93 in 1991 to 100 in 2003

Reid notes a tendency to blame the problem in part on a colonial legacy of two health systems – one for the elite and the other for the poor.  Other countries with fewer resources than Nigeria have overcome this legacy. Is it a matter of political will?

“Peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources,” according to Schellenberg et al. (2008). These peripheral facilities in Nigeria and primary health care for that matter, are the constitutional responsibility of local government in Nigeria. A visit to many of these in Akwa Ibom State last month found shortages of staff and medicines, lack of basic furniture, damaged roofs, abandoned rooms, lack of water supply and light, and staff quarters overgrown by weeds. It would appear that in high burden countries the neglect of PHC is the same as the neglect of malaria control.

Major new funding for HIV and Malaria has been coming in over the past eight years. The question is how that funding has not only impacted on the two diseases, but what has it done to the health systems that are expected to deliver disease control services?

From the beginning of RBM, partners and planners has stressed that malaria cannot be rolled back outside the context of health sector reforms and improvements.  Except for the possibility of ITN distribution campaigns, malaria control activities such as case management with ACTs and delivery of IPTp via directly observed treatment, require a strong, accessible and affordable primary health care system.  The issue of home management is tackled in the context of the health system training, supplying and supervising community volunteers. Even campaigns are run from a base in the district health department and linked with child immunization activities.

To some extent we have seen negative effects on the health system with new malaria funding when there is donor pressure to achieve and report quickly on performance – parallel procurement and distribution systems have been set up as well as parallel monitoring and evaluation processes, but ultimately the delivery of malaria control services requires that primary health services – facilities and staff – function on the ground.

In contrast critics have pointed to HIV/AIDS programming as creating its own structures resulting in internal brain drain within countries – pulling staff and resources away from the basic health system in order to reach treatment and coverage targets. A recent publication, Seizing the Opportunity of AIDS and Health Systems, explores this issue through three country examples. The report focuses on health information, supply chain and human resources in Mozambique, Uganda and Zambia. Concerning information system the report summarizes the situation thus:

In each of the three countries donors draw information from parts of the health information system and from national monitoring and evaluation systems. Meanwhile, all three donors have their own donor-specific reporting requirements in all three countries. The proliferation of information systems results partly from donors’ own priorities and accountability requirements. But it also reflects weak government coordinating structures for health information system management. And it reflects the ill-equipped, underfinanced state of national AIDS councils.

There is evidence of functional antiretroviral supply chains, but not a strengthening of the overall supply chain within countries. “In all three countries, the Global Fund, PEPFAR, and the MAP have worked with governments to develop supply chains for antiretroviral drugs. The supply chains are still fairly small, however, often serving 300 facilities or fewer. They rely largely on public structures. Yet they generally function more smoothly than the much larger government-managed supply chains for other essential medicines.”

In addressing human resources the report says that donors have focused more on in-service training of existing workers than on helping enlarge the pool of health staff. Because of better salaries and benefits in donor-supported programs, health staff have been pulled away from the public sector, thus weakening the health system. The report concludes by saying …

As PEPFAR, the Global Fund, and the MAP work to extend the reach and effectiveness of their HIV/AIDS programs, they will continue to find that country health system weaknesses create barriers to program expansion. To surmount those barriers they should finance programs in ways that increase the abilities of country health systems to provide broad quality health services, while doing the least possible harm to those systems. But to create greater incentives for donors to seize this opportunity, actions by country governments are also urgently needed. Earmarked funding for HIV/AIDS is evidently here to stay. The approach recommended here will ensure that donor funds bring the greatest possible benefits to country health systems while also achieving desired AIDS-specific outcomes.

We might add that benefits to the country health systems will ultimately also benefit efforts to control malaria.

Jeffrey Sachs has again called on the world to get serious about malaria. In Scientific American he explains why, “The challenge of controlling the disease in Africa by 2010 is fundamentally organizational, not technical.” While partners seem to be in agreement on the basic strategies and interventions, health systems needs remain, including these mentioned by Sachs:

• harmonization among partners in all sectors
• transparency, efficiency and accountability of implementing country governments
• unprecedented coordination of financing, training, monitoring and logistics
• raised production levels of basic commodities to hundreds of millions of units
• training for tens or hundreds of thousands of community health workers on malaria control

These challenges appear daunting, but Sachs implores partners that, “The consequences of organizational failure, on the other hand, would be almost too painful to behold.”

The Global Fund has been encouraging countries to include health systems strengthening (HSS) components in their proposals for quite some time. This has sometimes been framed as separate grant sections and at others as integrated into disease-specific sections. After six rounds only 1% of funds were distinguished as HSS.

Past Global Fund e-forum discussions have addressed HSS and noted the low priority given to this element, the challenge of weak systems in recipient countries and the inability of health systems to reach communities and households where intervention is most needed.  A current forum contribution, for example, looks at how Nigeria was in the process of laying “foundations of what could have been one of the best public health infrastructures…in Africa” with primary health care in the 1980s and 1990s, but “these infrastructures and gains are almost totally lost.”  Is HSS fighting an uphill battle?

The GFATM directs the Technical review Panel (TRP), “in reviewing a disease component which contains a cross-cutting HSS section, the TRP may recommend for funding either: a. The entire disease component, including the cross-cutting HSS section; b. The disease component excluding the cross-cutting HSS section; or c. Only the cross-cutting HSS section if the interventions in that section materially contribute to overcoming health systems constraints to improved HIV, tuberculosis and malaria outcomes.” The reality is that some countries such as Ghana never benefit from HSS in their malaria grants.

People have often looked to the World Bank to address systems and infrastructural issues. This has not always happened in such a way as to impact on specific health programs. Now the Bank says its “new strategy is about strengthening health systems in developing countries while complementing the efforts of other organizations contributing billions of dollars to combat diseases such as HIV/AIDS and malaria.” In order to avoid the pitfalls of a single disease focus approach, “the Bank is shifting its focus to not only funding vaccines and medicine but doing so in a way that ensures a health system is capable of delivering vaccines, medicine, and general health care to more people.”

According to its second annual report, PMI is also paying attention to health systems as follows” “The PMI is organized around four operational principles based on lessons learned from more than 50 yearsof U.S. Government efforts in fighting malaria, together with experience gained from implementation of PEPFAR, which began in 2003. The PMI approach involves: •Use of a comprehensive, integrated package of proven prevention and treatment interventions; •Strengthening of health systems and integrated maternal and child health services; •Commitment to strengthen national malaria control programs and to build capacity for country ownership of malaria control efforts; and •Close coordination with international and in-country partners.”

Just as partners are in agreement about the major malaria control interventions for scale up to 2010 and beyond, we also hope they agree and coordinate their efforts to strengthen the health systems that not only will deliver these interventions, but also will hopefully sustain them.

Even if adequate stocks of ITNs/LLINs were available for ALL people in malaria endemic communities, as the UN hopes … Even if there were supplies of ACTs to treat ALL people who suffer from malaria … even when effective vaccines become available … if human beings themselves continue to disrupt countries and health services (what the New York Times has termed “self-inflicted wounds”) – within and across borders – malaria will not be eradicated.

In a letter to the editor of the American Journal of Tropical Medicine and Hygiene colleagues from the US Centers for Disease Control and Prevention (CDC) and the Kenya Medical Research Institute (KEMRI) take stock of the health care situation as Kenya tries to return to normal after months of violence sparked by the national elections in December.

“It is possible that the health impact of Kenyas chaos could ’ linger well beyond a political rapprochement. We may see increases in mental illness, substance abuse, and unemployment in response to the violence, which may lead to new public health challenges for the country. Disruptions in food supply, immunizations, medications, and health services could affect people’s health for months, and perhaps years, to come. For example, the national malaria control program, which had made notable progress over the past 5 years, now faces the challenge of delivering life-saving antimalarial drugs and long-lasting insecticide-treated bednets in a country where the roads are far less secure. Gains in HIV care and prevention may also have been compromised. An undisrupted supply of drugs and reliable access to clinical care are essential for the health of the 180,000 HIV-infected people receiving antiretroviral therapy. The influx of tens of thousands of internally displaced people to areas of the country already struggling with ongoing public health challenges, such as malaria and HIV, could place an unsustainable weight of health needs on an already fragile public health infrastructure. In addition, future research collaborations and their associated gains in capacity building for the country could be limited by reluctance of research partners to locate projects in Kenya.”

The New York Times today also reports on the post-election situation and efforts to begin national and community healing in Kenya. The Kenyan government, facing an economic and food crisis arising from the conflict, is encouraging people to return to their farms, even in ethnically conflicted areas, with promises of food, tool, new houses and cash. “To make its plan work, the government has said, there must be genuine ethnic reconciliation,” which is the real challenge. Political jockeying and an over-bloated cabinet do not help, according to the NY Times.

As CDC/KEMRI staff remind us, 30 years of collaboration for improving the health of Kenyans can be nearly destroyed in a few days. Clearly conflict prevention and resolution need to be considered among the key strategies for eliminating malaria from the world.

Back in December, an editorial in The Lancet praised the first two operational years of the US President’s Malaria Initiative (PMI). Various supporters and critics were quoted as favoring the approach that was heavy on basic malaria control interventions and light on consultants.

At the same time, PMI leaders themselves recognized that many national health systems with which PMI works are weak and need strengthening. There was also recognition that PMI must work with the broader health system in order for its interventions to have the broadest effect on maternal, child and even national health. Clearly there is little value pouring funds and commodities into national health systems that cannot absorb or manage them.

The editorial did point out that the current US effort includes support for procurement, supply, education and monitoring, which are essential components of efforts to strengthen a health system. Although sometimes criticized for selecting countries that already have other international malaria support, PMI views this also in the context of systems strengthening. For example, countries have the option of including health systems strengthening components in their Global Fund proposals (though this aspect need MUCH more attention).

Spending all money on high priced consultants is certainly a problem. Spending some money on reasonably priced consultants that can address health systems bottlenecks is a good investment.

Tanzania has been noted for its high levels of antenatal care (ANC) attendance. Four out of five health facilities offer ANC. Over 94% of pregnant women attend ANC offered by a trained provider including nurse/midwifes, other clinicians and MCH Aids. It appears that 95% of these attend ANC two or more times, making it theoretically possible for Tanzania to achieve the RBM target of 80% of pregnant women receiving two doses of Intermittent Preventive Treatment (IPTp). National Policy has supported IPTp in ANC for over six years. Unfortunately the DHS also shows less than 22% of pregnant women receiving two doses.

Tarimo (2007) offers some explanations for this “IPTp Gap” in the East African Journal of Public Health. ANC clinic exit interviews revealed that only 60% of women received IPT and some of the reasons for the gap. A key problem was unavailability of sulfadoxine-pyrimethamine (SP) for IPTp. About 40% of those who actually received SP did not take it as directly observed treatment in the clinic for reasons including not wanting to take it on an empty stomach and aversion to sharing drinking cups with other women. Who knows what they did with the SP when they got home?

Finally while 90% were aware of IPTp, only 30% knew the correct timing and dosage. Thus, they were not even in a position to make educated demands on service providers for timely and adequate provision of IPTp. These problems represent a clear failure of the health system: failure to stock SP, failure to ensure conducive conditions to take SP and failure to educate clients thoroughly.

We have previously raised the question about community delivery of IPTp, which while effective in increasing coverage, raises concerns about reducing utilization of ANC and delivery services. But what do we do when the health service is clearly squandering an opportunity to deliver this live saving intervention through ANC?

An policy forum article on implementation science in Science Magazine is quite timely considering the recent criticism appearing in the Los Angeles Times about large scale funding for single purpose disease control programs. Some of the discussion focused on the need to strengthen health systems, support human resource development and retention and integrate into broader public health programming. Questions about how this can be done fall in the realm of implementation science as described by Madon et al.

The Global Fund has issued a response to the original article, which was commented on in the LA Times on 20 December. Although the authors criticize the Global Fund for not providing convincing data to challenge their claims of health system damage, both the original article and the rejoinder rely on the claim that 1) more time is needed to see the effects of this relatively young effort (5 years only) and 2) available statistics from international organizations do not yet reflect actual Global Fund achievements, such as massive distribution of ITNs.

Implementation science as described by Madon et al. requires a more rigorous approach. They bemoan the fact that “Instead, planners often assume that clinical research findings can be immediately translated into public health impact, simply by issuing ‘one-size-fits-all’ clinical guidelines or best practices without engaging in systematic study of how health outcomes vary across community settings.”

The article in Science further explains that, “implementation science creates generalizable knowledge that can be applied across settings and contexts to answer central questions. Why do established programs lose effectiveness over days, weeks, or months? Why do tested programs sometimes exhibit unintended effects when transferred to a new setting? How can multiple interventions be effectively packaged to capture cost efficiencies and to reduce the splintering of health systems into disease-specific programs?” It is answers to these questions that international donors including the Global Fund and the Gates Foundation need to address.

The new series in The Lancet, “Who Counts?”, has serious implications for malaria programming and funding. Without being able to count the expected decreases in morbidity and mortality, program managers will lack the credibility to ask for continuing support. Ngozi Okonjo-Iweala and Philip Osafo-Kwaako explain that, “First, without adequate capacity for obtaining statistics, assessment of the magnitude of the development problems to be faced is often impossible. Second, if we get the numbers wrong, tackling development problems effectively is difficult.” They conclude that, “Governments and donors must view reliable data as an important tool in the development process, and must invest both financial and human resources in strengthening their statistical systems.”

Philip Setel and colleagues in the first of the “Who Counts?” series raise the question, “How much longer support for efforts to expand immunisation, and confront AIDS, tuberculosis, and malaria will last is questionable if counting the lives saved, and providing direct evidence of reduction of deaths due to these causes—particularly in the poorest of the poor—remains undone?” They worry that few countries in Africa have the capacity to measure the indicators for achieving the Millennium Development Goals, including those related to malaria and its effects on maternal and child health.

AbouZahr et al., in the fourth article in the series note that with new funding sources like GAVI and GFATM “pay particular attention to the importance of monitoring and evaluation, and could represent new opportunities to strengthen country capacities in vital statistics.” To this end the Global Fund provides a Monitoring and Evaluation Toolkit to grantees and their partners. This supports GFATM’s emphasis on performance based funding.

In the area of childhood immunizations GAVI is also “results oriented” and helps strengthen health systems to collect accurate country data. GAVI also has a Monitoring and Evaluation Technical Advisory Group. More Specific malaria monitoring and evaluation resources can be obtained from the Roll Back Malaria Monitoring and Evaluation Reference Group.

Two big challenges exist in order to make viable malaria M&E possible. First there is need to ensure that the existing health information system data collection processes – the forms, the registers, the summary sheets, the surveys – adequately and appropriately address key malaria indicators. Secondly, like in the HIV/AIDS ‘three ones’, there needs to be a unified malaria M&E system from community to national level that is used by all programs and partners – public, private and NGO.

The collapse of health and other social infrastructure is a common outcome of conflicts such as civil wars. In such settings one does not talk about ‘health sector reform’ glibly, but must consider the whole issue of health sector rebuilding. Two post-conflict countries are currently included in the US President’s Malaria Initiative (PMI), Angola and Liberia. Both are also recipients of GFATM malaria grants. What do lessons about malaria control can we learn from administering these two programs?

The situation in Angola is summed up succinctly by the PMI country assessment. “Angola recently emerged from almost three decades of civil war that severely impacted its development, particularly the health sector. It is estimated that 80% of the health facilities were looted or destroyed during the war and that the existing health system covers only about 30% of the Angolan population, with even lower utilization rates.” The national surveillance system “has limited human and financial capacity and lacks nationwide coverage, standardized procedures for the collection and analysis of data, and an effective communication system to ensure timely reporting.”

In addition to limited laboratory facilities, the PMI assessment found procurement problems. “Given that many key agencies and systems are not yet in place or fully functional, the GFATM proposal proposes that procurement functions be carried out by WHO while providing for support not only for the program of activities under the NMCP but also for strengthening the system in general.” To address these challenges, PMI and GFATM recipients have been working on coordination efforts over the past two years, according to GFATM. In addition GFATM recommends moving away from an external Principal Recipient and that the “PR shall present a revised plan that reflects the gradual transfer of responsibilities to the NMCP staff. A plan with measurable targets for the capacity-building activities should be agreed upon.”

Recently the US President expressed concern to the Liberian President about the continued death of Liberian children from malaria and indicated that PMI would be setting up shop soon. The GFATM Grant Performance Report of August 2007 for Liberia observed that, “The internal audit section has however not been able to conduct these audits in Liberia due to staff shortage as well as the situation of insecurity prevailing in the country.” Human resources for health are scarce generally in much of sub-Saharan Africa, and are exacerbated in post-conflict settings. In Liberia, GFATM noted that, “There is no M&E expert dedicated to this project.” It was further observed that, “There are some tensions existent in regards to having a non-local entity (UNDP) as PR.”

The selection of a non-indigenous Principal Recipient is not uncommon, but in post-conflict settings, lack of strong civil society organizations and weak government bureaucracies may be a factor. The Report further states, “There are very few active donors in Liberia and most organizations are struggling for funds. There is as a result little organized effort for harmonization of programs and requirements.

As of the August 2007 Report, Liberia was behind target in terms of staff training and number of service points supported for malaria case management, though they appear to be on target for reaching pregnant women and distributing ITNs. ITN distribution may be done outside the formal health system, but case management requires a fairly well organized public and private sector, even when volunteer community-based workers are involved.

Some of the health systems and implementation problems mentioned above may not appear terribly different from those faced by other Sub-Saharan countries, and maybe it is a matter of scale. Key lessons appear to be a need for collaboration and coordination among the often few donors on the ground and efforts to build and re-build local capacity. Citizens of these countries have suffered enough and do not need ‘wars’ among donors and recipients and certainly must win the war against malaria.

Kiszewski et al. paint a stark picture of the potential funding gaps for malaria control programming in endemic countries. Based on data available between 2000-03, the authors found that only 4.6% of approximately $1.4 billion of projected annual funding needs were available from domestic sources in African countries. With notable exceptions including Cameroon, Malawi and South Africa, most countries could contribute less than 2-3% of the total malaria programming needs, e.g. 0.1% in Kenya, 0.5% in Mozambique, 1.1% in Nigeria and 2.6% in Mali. Even if domestic contribution (which includes out-of-pocket expenditure) doubles, triples or quadruples, the gap will remain.

Obviously there are large scale donor programs addressing this gap but none can do it alone. Recently around 55% of support from the Global Fund to Fight against AIDS, TB and Malaria has gone to sub-Saharan Africa and roughly a quarter of total GFATM funding has been allocated for malaria projects. This needs to be viewed in light of the fact that $7.7 billion has been committed by GFATM over the six annual rounds of funding to date. GFATM hopes to more than double its annual commitments, but this will not meet the malaria resource gap.

The US President’s Malaria Initiative hopes to work up to a $300 million annual contribution to 15 sub-Saharan countries. The World Bank’s Malaria Booster Program is targeting specific countries with good size grants, such as $180 million for Nigeria over 5 years. The Bill and Melinda Gates Foundation is funding major malaria research and expand use of existing tools. UNICEF has mobilized funds and bilateral donors to make a major contribution to meeting needs for insecticide-treated nets. NGOs in industrialized countries have been supporting this with net fund raising campaigns. An innovative taxation on air travel has brought UNITAID into the malaria arena. But is this enough?

The big challenge is sustaining funding levels. Although the GFATM is developing mechanisms for a rolling continuation of grants with good performance, grants that don’t perform or are mismanaged can be canceled. A key factor in determining performance is the strength of the health system. Kiszewski and colleagues do acknowledge that ‘program costs’ such as training, communications, monitoring and infrastructure account for 14.1% of the malaria funding needs.
The GFATM itself stresses health system strengthening (HSS) through monitoring and evaluation tools and that “funding for HSS activities can and should be applied for as part of disease components.”

Some HSS problems are deep and chronic as pointed out by MSF who has documented the health worker crises in many African countries. Therefore the question remains, will donors commit not only to addressing the malaria resource gap on a sustainable basis, but also to strengthening the underlying health system which is crucial for managing those malaria resources?