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Archive for "Integration"

Community &Coordination &Integration Bill Brieger | 06 Mar 2014

iCCM needs collaboration among varied stakeholders

CAM02760Integrated community case management (iCCM) of common illnesses, as we learned at the just completed evidence review symposium on iCCM in Accra, Ghana, requires a number of key inputs ranging from adequate procurement and supply of commodities, well stated supportive policies and human resources from the district to the clinic to the community.  One input, the collaboration among stakeholders needs constant reinforcement.

Although the project was not iCCM, an implementation research study in 8 sites in Africa that added a package of interventions to existing ivermectin distribution illustrates the need for stakeholder concurrence and collaboration. This 3-year community directed intervention (CDI) Tropical Disease Research Program effort (UNDP/World Bank/Unicef/WHO) was designed to add a package of interventions to the community’s ‘portfolio’ each year in a step-wise manner.  These included antimalarials for community case management, insecticide treated nets, vitamin A and drugs for directly observed treatment of tuberculosis.

While ultimately the community directed approach to distributing these commodities resulted in better coverage in intervention districts than facility based service provision in the control areas, an important lesson from the project occurred in the start-up process the very first year. In fact no real commodity distribution took place that year as originally planned.

What the teams learned is that while community distribution of ivermectin had been taking place for at least 10 years in most of the districts, not all members of the district health teams (DHT) were fully aware of what the onchocerciasis focal person was doing.  It had been hoped a bit naively that the DHT member in charge of immunization and vitamin A, the DHT focal point for malaria and the DHT member in charge of TB/Leprosy would gladly join their onchocerciasis colleague in making their services available through community volunteers.

CAM02763In reality the advocacy process took up the whole first year before other DHT members could be convinced that it was safe and appropriate for community members to take charge of a package of basic health commodities. In some locations, the TB/Leprosy program managers were never convinced.

Even at start-up of onchocerciasis programs in the late 1990s it took much convincing of health workers to ‘allow’ communities to handle drugs like ivermectin. When introducing a larger package through CDI, it became necessary to start this process of convincing and seeking collaboration anew.

A basic iCCM package of ACTs, RDTs, ORS, Zinc and amoxicillin may not appear as complicated as the CDI package added to ivermectin distribution, but in truth a lot of stakeholder advocacy work is still needed.  We learned at the Accra meeting that at minimum malaria and child health programs need to collaborate to provide the basic package and the funding that does with it.  Different programs may in fact have different policies and guidelines. Different donors and different sections of the Ministry of Health must be willing to bring their efforts and resources together and share. This is as much a political as it is a technical process, and scientific evidence that health care interventions delivered in the community save lives may not be enough to overcome politics and vested program interests.

The 300+ delegates to the iCCM symposium are returning home over the next few days.  Hopefully the momentum of the conference will carry them on to engage in collaboration, not only with their colleagues who also attended, but also with those who did not attend and benefit from the sharing of evidence and experience.  It will take a team of people with varied interests to make iCCM a success.

Integration &Treatment Bill Brieger | 03 Mar 2014

iCCM – collaboration for commodities

The integrated Community Case Management Symposium (iCCM) in Accra, Ghana this week provides an ideal opportunity to examine the practical issues of getting the commodities to manage cases of malaria, pneumonia and diarrhoea at the community level.

cropped-iCCM-web-banner6Ordinarily one would expect the medicines needed for iCCM would be obtained through a country’s normal essential drug management system. ACTs, ORS, amoxicillin, etc., should be available through the regular primary health system of a country to all front line health facilities. It is from this frontline facility that community health workers (CHWs) delivering iCCM would normally receive training and stocks/supplies.

The reality is that many front line facilities experience frequent stock-outs. They cannot meet the demands for their own clinic services, let alone provide supplies for community volunteers. Whether it is an issue of financial resources or political will, lack of essential medicines makes it difficult to guarantee child survival more than 25 years after UNICEF, WHO, USAID and other partners launched various initiatives to save children’s lives.

Currently countries are placing hopes in international financial programs such as the Global Fund to solve their commodity needs and scale up to prevent child deaths. In particular opportunities to develop a basic iCCM infrastructure and obtain appropriate malaria commodities are potentially available through Global Fund malaria grants. Child health program managers must work with national malaria control program staff to access this resource.

The Global Fund’s new funding mechanism is based on the national malaria strategic plan. If that plan does not address iCCM, it is unlikely countries can use their ‘envelop’ of funds for that purpose. Regardless, the Global Fund support will provide only malaria commodities. Where can counties get ORS, zinc and amoxicillin, especially if they do not have well-funded national medical stores/essential drugs program.

The RNMCH* Trust Fund with support from Norwegian and British aid agencies is being established and may help provide these pneumonia and diarrhoea commodities in stocks large enough to scale up iCCM. USAID child health projects also include diarrhoea and zinc. The long term sustainability of iCCM based on donor assistance is questionable. We are far from eliminating malaria, and there is no serious discussion of eradicating diarrhoeal diseases and pneumonia.

A pilot project to improve access to quality child illness case management that is being designed in Bauchi State, Nigeria demonstrates the challenges of coordinating commodities. Some were available through a World Bank Malaria Booster Program under a malaria plus package concept. USAID was providing ORS and zinc to child health projects. The US President’s Malaria Initiative could provide ACTs and RDTs, but the local governments and medicine shops involved in the project would have to buy amoxicillin through their normal wholesale channels. Getting the right mix of medicines at the right time in the right amounts to the right places is not easy.

Collaboration among different disease and health programs is always a challenge, but in the short term, program managers in both malaria control and child health need to work together to tap all available resources for iCCM. In the long run donors need to address health system strengthening so countries can manage their own essential drug programs successfully.

*Reproductive, Neonatal, Maternal and Child Health

Integration &Partnership Bill Brieger | 22 Nov 2012

Exploring integration between Neglected Tropical Diseases and Malaria Control Programs

Oladele Olagundoye MD, MPH, an Atlas Corps Fellow at the Corporate Alliance for Malaria in Africa (CAMA), GBCHealth, New York, provides a perspective on the recently concluded Neglected Tropical Diseases meeting in Washington….

yola-cdd-helping-a-community-memebr-to-fix-an-itn-to-the-wall-sm.jpgThe Neglected Tropical Diseases (NTDs) community convened at the World Bank for a 2-day conference tagged “Uniting to Combat NTDs: Translating the London Declaration into Action” on November 17 – 18, 2012 in Washington DC. The objective was to provide a forum where all stakeholders in the fight against NTDs can identify the priorities, discuss the challenges and suggest strategies towards achieving the World Health Organization’s (WHO) targets to control and eliminate at least 10 NTDs by 2020.

Leveraging on the London Declaration of January 30, 2012 by leading pharmaceutical companies, donor agencies and non-governmental organizations (NGOs), to supply the drugs required for preventive chemotherapy (PCT) and the treatment of NTDs, the participants identified three priority areas necessary for the actualization of the WHO’s 2020 targets:

  1. Bridging the estimated $US 4.7 billion funding gap by sustaining international commitments and increased domestic funding for NTDs by endemic country governments.
  2. Building the human resource capacity and health infrastructure at the country-level to effectively absorb the increased supply of drugs, and for the scale-up of delivery services.
  3. Effective integration of intervention programs and incorporation of water and sanitation interventions (WASH), to complement the mass drug administration, and intensified disease management of NTDs.

It was encouraged that Malaria & NTDs (Lymphatic Filariasis & Dengue fever) programs should integrate their services, because the scale-up of vector control interventions (LLINs) will benefit the populations served by both programs. However, a critical barrier limiting this collaboration is the suspicion by malaria programs that NTDs managers intend to leverage on the availability of more funding for malaria programs, to achieve specific NTDs targets.

I recommend that program managers for malaria and NTDs (LF & Dengue fever) should adopt the partnerships and four One’s approach, which has contributed greatly to the success of WHO’s African Program for Onchocerciasis Control (APOC) –

  • 1 collaboration mechanism
  • 1 budget
  • 1 package of interventions and
  • 1 monitoring and evaluation framework

Community &Integration &Treatment Bill Brieger | 10 Nov 2012

Can Community Health Workers Provide Quality Integrated Community Management of Febrile Illnesses?

A Case study of Community Health Workers in Two Selected Local Government Areas of Akwa Ibom State, Nigeria. A Poster Presentation at the 61st Annual Meeting of the American Society of Tropical Medicine and Hygiene, 11-15 November 2012, Atlanta.
Bright C. Orji1, William R. Brieger2, Emmanuel Otolorin1, Jones Nwadike3, Edueno V. Bassey4, Mayen Nkanga5 1Jhpiego/Nigeria, Abuja, Nigeria, 2The Johns Hopkins University, Baltimore, MD, United States, 3Dunamis Medical Diagnostic Services, Lagos, Nigeria, 4Etebi Health Center, Esit Eket, Akwa Ibom State, Nigeria, 5Akwa Ibom State Ministry of Health, Uyo, Nigeria

The World Health Organization has recommended improved quality of care as key elements in strengthening health systems in poor resource countries, Engagement of Community Health Workers (CHWs) can reduce challenges such as weak public sector, human resource constraints, and variable quality of the private sector. Efforts to improve access to quality case management of febrile illness in Nigeria included the engagement of Community Health Workers (CHWs) to use Rapid Diagnostic tests as a component of home management of malaria, dispense ACTs and manage pneumonia and diarrhea.

checklist.jpgThis current effort monitored and measured the performance of CHWs in providing quality management of febrile illnesses in two selected LGAs. The authors trained one hundred and fifty-two CHWs and developed simple quality performance standards (one-page tool) for CHWs providing community services in Akwa Ibom State, Nigeria. All 152 trained CHWs providing malaria, pneumonia and diarrhea case management were monitored and assessed using the standards. The tool has 37 performance criteria (PC) to measure CHW knowledge, skills and competence in 3 sections: History taking and Examination; Conducting RDTs for Malaria; and Illness Management.

Trained assessors observed CHWs providing services. Each correctly performed criterion was scored 1 point. Four rounds of assessments were conducted at an interval of two months from June 2011 – March, 2012. During Round 1 CHWs achieved an average of 19 (52.2%) PC. This rose to 25 (67.5%) PC at Round 2; 28 (75. 6%) at Round 3 and 30 (81.1%) and (p = 0.00). PC that needed most improvement included reinforcement on checking RDT expiry date, entering results on records, and safe disposing of sharps.

CHWs can provide quality case management of febrile illness in the current efforts to reduce annual deaths of people at risk while contributing to the achievement of targets numbers 4, 5 and 6 of the Millennium Development Goals (MDGs). In conclusion CHW supervisors can use this tool to enhance the quality of services provided by the CHWs and improve CHW training.

Elimination &Integration &Morbidity &Mortality Bill Brieger | 25 Apr 2012

Investing and Sustaining: Lessons from Rwanda on World Malaria Day

Rwanda on track to zero deaths from malaria by 2015

By Dr. Corine Karema

Today, April 25th, the world will be commemorating Malaria Day as stipulated in the Abuja Declaration of 2000. Just like the previous years, Rwanda will join the rest of the world in commemorating this day by highlighting achievements in controlling Malaria while also renewing commitment of achieving zero targets of malaria related deaths by 2015.

The theme for this year’s World Malaria Day is “Sustain Gains, Save Lives: Invest in Malaria”, a theme that is testimony to the renewed global commitment of finding lasting solutions for eliminating Malaria from our midst.  For Rwanda, a country that has registered significant progress in combating Malaria, this commitment is a shared vision for which we attach greater value.

Coming up with sustainable and investment solutions for Malaria control is a new discourse which underlines the importance of continued investment in combating this disease with the view of propelling malaria-endemic countries along the path of achieving the health and poverty related Millennium Development Goals by 2015. Here in Rwanda, the battle against Malaria has not been an easy one. It has called for strategic interventions, committed leadership of our government and support from development partners to register progress that we see today across the country.

I will share with you some of the outstanding achievements we have registered over the past years, many of which are captured in the recently released 2010 Demographic Health Survey (DHS). The recent scaling up of interventions has made significant progress:

  • reductions in morbidity by 87% from 1,669,614 malaria cases in 2005 to 212,200 cases in 2011 and
  • reduced mortality by 76% from 1,582 deaths in 2005 to 380 deaths in 2011.

dscn7129asm.jpgThis reduction is as a result of scaling up of preventive measures especially coverage and use of long lasting insecticidal nets (LLINs) which according to the 2010 DHS results…

  • 82% of households have at least one LLIN
  • 72% of pregnant women slept under their nets and
  • 70% of children under-five years were using bed nets

Previously and as the case is in most developing countries, Malaria is treated based on signs and symptoms. However, Rwanda is one of the few countries in the world today where up to 94 percent of Malaria cases are laboratory through microscopy or rapid diagnostic tests at all levels of health care structure including the community level.

The involvement of Community Health Workers (CHWs) in early diagnosis and treatment of children Under-five years has also had an impact on malaria incidence throughout the country as currently 95% of children are tested and treated for malaria within 24 hours of symptoms onset.

In addition, Malaria control activities have been integrated and decentralized at all levels including –

  • a strong CHWs network which facilitates community involvement and participation,
  • the community health insurance scheme also known as Mutuelles de Sante and
  • a strong Health Management Information Systems (HMIS) including the web based community health information system (

The above interventions are strengthened by use of mobilisation and sensitisation campaigns using different channels of communication. The advocacy and social mobilisation is oriented towards intensifying different efforts to sustain the gains made as the country moves towards pre-elimination phase of malaria as outlined in the new Malaria Strategic Plan (2012-2017).

To emphasize on the importance of the World Malaria Day, this year’s event will be held during the scheduled Rwanda Malaria Forum that will be held in Kigali in mid June 2012. The Forum will bring together malaria experts from international community who will deliberate on the challenges African countries and in particular, Rwanda, face in malaria control and how to overcome them.

The recommendations of the forum will guide our sector in finalizing the new Malaria Strategic Plan that outlines Rwanda’s strategies from malaria control to pre-elimination phase by 2017. A series of activities to run for a week have also been planned to reach community levels where different interventions of promoting awareness on preventive measures will be discussed with input from community leaders.

Therefore, as we mark this day in Rwanda, we take pride of our achievements but also remain mindful and conscious of the challenges ahead a in realising the ambitious target of having a Rwanda that is free from Malaria.

The Author is Head of Malaria and Other Parasitic Diseases Division Rwanda Biomedical Center/IHPDPC, Follow: Twitter @ckarema

Community &Integration Bill Brieger | 23 Nov 2011

Bhutan: Community Action Groups – Building local participation for improvement in public health

Participants at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop shared their country experiences on community participation.  Below is a summary of experiences shared by participants from Bhutan, which shows how we can integrate malaria activities into broader community development efforts.

dscn5601-sm2.jpgBhutan is a small country of 39,000 km2 with a population of 634,982. It is bordered by large countries – China to the north and India to the south. The northern reaches of the country are in the Himalayas and have high elevation and cooler climates thus there is no malaria transmission in this region (4 districts). The middle section of the country is considered at risk for seasonal transmission (9 districts) and the southern zone bordering India is considered endemic (7 districts).

One of the main community participation methods in public health, including malaria control and elimination, is the formation of Community Action Groups (CAGs). In the rural communities, these groups have been formed at the village level in four southern districts in Bhutan from 2009 to 2011. The CAG initiative aims to create community ownership of health activities, stimulate decentralization of health work to the grassroots level, and to motivate and build capacity for local leadership. CAG members receive a three-day training which covers sanitation, community motivation, nutrition and child care. The training, meeting costs and monitoring of the CAGs are funded by Global Fund.

Members of the CAG are elected by the community:

  • Chairperson (Tshogpa): this representative is paid by the Government for a five year term
  • Secretary: this is a Village Health Worker, who provides the message delivery on preventive and curative services and are involved in LLIN distribution. These workers attend training on communication methods and receive refresher training.
  • Allied sector representative
  • Water caretaker: this person has strong community ties
  • Female representative
  • Religious group member: this is typically a monk

The CAGs discuss priorities and develop a community action plan. The groups meet quarterly with monitoring every six months and reports are sent to block level with feedback going up to the national level.

One CAG has been successful in achieving sanitation improvements. CAGs are also seen as a platform for multi-sector involvement. A challenge of this strategy is the high turnover of village health workers because they are no incentives. In the future, Bhutan hopes to increase the number of districts with CAG groups, but the source of funding is not yet available.

[Thanks to Yeshi Nidup, Tshewang Phuntsho and Cara Smith-Gueye for the presentation and this summary.]

Health Systems &Integration Bill Brieger | 27 Aug 2011

Malaria and Mental Health

Some time ago we were studying local perceptions of what constitutes malaria illness in eastern Nigeria and came across some syndromes during focus group discussions that verged on mental health problems.

dscn3913-brakina.jpgHeavy/strong malaria or Oke Eya was attributed to too much work, too much exposure to the sun, too much thinking (worrying), or drinking too much wine. This form of malaria was evidenced by senseless talk, appearance of being mad, high fever, and strong headache.

Shaking malaria or Eya Mbaka Ise was also thought to be caused by too much thinking, charms (witchcraft), drinking too much alcohol, or taking drugs like hemp. The person suffering this form of malaria would exhibit abnormal talk and behavior, headache, and appear restless.

It is not uncommon for communities to call many conditions by the local name for “malaria”, but if mental illness is involved, it is not a simple mater of letting a rapid diagnostic test help one decide whether to use artemisinin-based combination therapy or antibiotics.

Though not speaking specifically of malaria, Prince and colleagues in the Lancet noted that, “The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury.” Furthermore, they explained that, “Conversely, many health conditions increase the risk for mental disorder, and co-morbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis.”

Severe malaria itself can also lead to mental health problems.  Specifically Bangirana et al. highlighted the problem that, “Cerebral malaria results in short- to long-term cognitive impairments in many of its child survivors. Although some of the risk factors for impairments have been identified, no attempts have been made to address the plight of those who develop cognitive impairments.”

So far there is no Global Fund for mental health programs.  This puts an extra burden on those programs that receive international support to ensure that they deliver their malaria, TB and HIV services in the context of an integrated primary health care that can address the total person, especially the poor and vulnerable.

Integration &Mosquitoes Bill Brieger | 08 Jul 2011

Ivermectin against malaria: novel idea, but can it be scaled

Several news sources have picked up on a new article in the American Journal of Tropical Medicine and Hygiene that reported when communities take annual ivermectin doses for controlling onchocerciasis and lymphatic filariasis, they may also be protecting themselves or their neighbors from malaria. Specifically the researcheds reported that ivermectin Mass Drug Administration (DA) “reduced the proportion of Plasmodium falciparum infectious Anopheles gambiae sensu stricto (s.s.) in treated villages in southeastern Senegal.”

The process works the same way that ivermectin treats head lice in that when insects take a bloodmeal from someone who has swallowed the drug, the medicine kills the insect. Sarah Boseley points out that some of the attractions of ivermectin are that it has been safely used in humans for 30 years and that it is inexpensive.

The Merck company has been supplying ivermectin (under its brand name Mectizan) free through the Mectizan Donation Program (MDP) to the African Program for Onchocerciasis Control for 16 years.  Over time coverage has reached over 100,000 villages in 18 African countries. Annual distribution in Africa contrasts with more frequent distribution in the smaller focal transmission points in Latin America where the diseases has almost been completely eliminated.

MDP reports that, “Currently, more than 70 million treatments are approved for onchocerciasis in Africa and Latin America and 80 million for lymphatic filariasis in Africa and Yemen each year.” That is a lot of free medicine and one of the largest and far reaching corporate social responsibility programs known.

Back to Senegal – the researchers found that the effect of ivermectin on mosquitoes lasted up to two weeks. They also raise the question of whether more frequent ivermectin distribution in onchocerciasis or filariasis MDA communities during the main malaria transmission season would be feasible.  Possibly a small scale operations research proposal could be submitted to the Mectizan Expert Committee.

cdi_report_08.jpgOf importance is the fact that the Community Directed Treatment with Ivermectin (CDTI) approach utilized by APOC projects has been tested and found quite accommodating to the addition of other Community Directed Interventions (CDI) such as community case management of malaria, ITN delivery and use monitoring and Vitamin A distribution among other basic health services.

The availability of tens of millions of exra ivermectin doese in communities where MDA is already occurring is unknown at present, let alone the feasibility of starting free ivermectin in malarious areas that have no onchocerciasis or filariasis.  In addition, for onchocerciasis, the idea time for distribution is before the rainy season so that microfilariae loads are seriously reduced before the black fly vectors emerge. This timing may not benefit malaria control fully.

Regardless of the unknowns, it is encouraging that people are thinking of synergistic ways to control the various endemic diseases that inflict suffering on poor communities.

Integration &Mosquitoes Bill Brieger | 21 Dec 2010

Two for One – ivermectin and mosquitoes

Suppose that when mosquitoes bit you, they died. The possibility that a human blood meal can kill mosquitoes sounds far fetched, but has been observed as a by-product of mass community mass drug administration (MDA) of ivermectin for lymphatic filariasis in Senegal.

Researchers in Senegal compared villages where MDA was performed with a control set of villages and concluded that, “Ivermectin MDA significantly reduced the survivorship of An. gambiae s.s. for six days past the date of the MDA, which is sufficient to temporarily reduce malaria transmission. Repeated IVM MDAs could be a novel and integrative malaria control tool in areas with seasonal transmission, and which would have simultaneous impacts on neglected tropical diseases in the same villages.”

This is not the only time links have been made between malaria and lymphatic filariasis. A good example was community distribution of insecticide treated nets were provided in Nigeria, which curtailed the mosquitoes that carried both diseases.

In MDA programs for filariasis control “The goal is to treat 80% of the eligible, at risk population yearly, for at least 5 years, in order to interrupt transmission and prevent children from becoming infected.” The window of opportunity for collaboration between MDA and malaria control programs is therefor, very focused.

A smaller scale study reported in July of this year found that, “In mosquitoes feeding on volunteers given ivermectin the previous day, mean survival was 2.3 days, compared with 5.5 days in the control group (P < .001, by log-lank test). Mosquito mortality was 73%, 84%, and 89% on days 2, 3, and 4 in the ivermectin group." Since ivermectin started as a drug for veterinary parasites, it is useful to note that similar results on mosquitoes were found after cattle were given ivermectin. Researchers from Michigan State University* reported that, "Most (90%) of the An. gambiae s.s. that fed on the ivermectin-treated cattle within 2 weeks of treatment failed to survive more than 10 days post-bloodmeal. No eggs were deposited by An. gambiae s.s. that fed on ivermectin-treated cattle within 10 days of treatment." The authors concluded that, "Treatment of cattle with ivermectin could be used, as part of an integrated control programme, to reduce the zoophilic vector populations that contribute to the transmission of the parasites responsible for human malaria." community-ivermectin-distribution-in-buea-cameroon.jpgIvermectin distribution of course has been the major strategy of the the African Program for Onchocerciasis Control (APOC) for the past 15 years.  APOC’s efforts will continue much longer than those of lymphatic filariasis in over 100,000 communities throughout the continent.

More attention to joint planning and coordinating of malaria and other disease control efforts should be synergistic and mutually beneficial for the populations, who according to APOC, live beyond the end of the road.


Equity &Integration &Procurement Supply Management Bill Brieger | 27 Oct 2010

Health Posts – meeting rural needs

People living in rugged rural terrain often go without formal health services. The population may be remote and even migratory, as some herd cattle.

dscn0659a.JPGAngola is working to ensure that at minimum there are Health Posts staffed by trained nurses to provide services beyond the municipal/district headquarters. And since onchocerciasis is common in many of such areas, we are also talking about providing integrated disease control and health care ‘beyond the end of the road,’ as advocated by the African Program for Onchocerciasis Control.

Life for these nurses is not easy as there is usually just one staff member to run the post. Also this situation means that male nurses predominate – one reason why it is presumed that antenatal care may not be easy to provide.

dscn0699-sm.JPGA visit to such a health post recently showed that not only was the nurse enthusiastic, but that he could provide some of the basic components of antenatal care in all but name.

The post had a good supply of sulphadoxine-pyramethamine that is required for intermittent preventive treatment of malaria in pregnant women. There were other medicines and supplements routinely given pregnant women such as ferrous sulfate and de-worming drugs.  The nurse even had a fetal stethoscope.

Strengthening these rural outposts is a priority for malaria control and health equity. These rural populations do not even have access to medicine shops as found in some areas.

Regular supplies of nets, RDTs, ACTs and SP will guarantee that all parts of Africa can work toward reducing malaria deaths by 2015.

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