Category Archives: Invest in Malaria Control

Malaria Funding Allocations by the Global Fund and the Need to Mitigate Risk

The Global Fund Observer (aidspan) has provided information on the 2017-19 allocations by the Global Fund to Fight AIDS, TB and Malaria. Here we take a closer look at the malaria component.

Overall malaria grants account for $US 3.3b or 32% of total funding for the period. This includes 71 countries as follows:

  • 41 countries in WHO’s Africa Region
  • 6 in the Eastern Mediterranean Region
  • 7 in the Americas
  • 10 in Southeast Asia
  • 7 in the Western Pacific
malaria-fund-allocation-2017-19

2017-2019 GFATM Allocation

The Global Fund Observer also noted that the GFATM board is very much aware of risks to these grants. An example comes from the management pharmaceuticals. Risks can be found along the whole supply chain process. The GFATM found that, “artemisinin-based combination therapies (ACTs) are more commonly targeted for theft or illegal diversion than are antiretrovirals (ARVs) or medicines for opportunistic infections (OIs).”

In fact the GFATM has identified 40 high or very high risk countries, most of which overlap with the list receiving current grant allocations. Therefore while we praise the provision of needed malaria funds for the upcoming three years, we also call on the Global Fund managers, country coordinating mechanisms, grant recipients and watchdogs in civil society and the media to ensure these grants continue to save lives from malaria.

Disrupting Malaria: How Fyodor Biotechnologies is changing the diagnostics game

Efosa Ojomo, Senior Researcher, Harvard Business School, Forum for Growth and Innovation looks at the new innovation award recipient, the designers of the Urine Malaria Test, and explains how the technology disrupts the system that has made it difficult to reach the average malaria sufferer with appropriate diagnostics and treatment.

In 2015, 214 million people were infected with malaria, 190 million of whom were in African countries. Of those infected, 438,000 died, 91% of who were in Africa. In addition, malaria has significant financial implications on families, companies and countries. Experts estimate that in countries burdened with malaria, the disease is responsible for as much as 40% of public health expenditures, 30 to 50% of in-patient hospital visits, and 50% of out-patient visits.

From a financial standpoint, direct costs of managing the disease is up to $12 billion annually, while the cost in lost economic growth is many times more. Considering the scale of malaria’s impact on Africa, there have been many innovations that have helped curb the spread of the disease, but perhaps one of the most significant is Fyodor Biotechnology’s disruptive Urine Malaria Test (UMT).

UMT-DiagThe UMT, a Significant Malaria Milestone

Fyodor’s UMT is a simple urine test where patients simply pee on a stick in order to find out whether they have malaria. The World Health Organization states that “Early diagnosis and treatment of malaria reduces disease and prevents deaths. Access to diagnostic testing and treatment should be seen… as a fundamental right of all populations at risk.” In other words, if we diagnose early, we will save many more lives and limit transmission.

fyodortableUMT is an inexpensive (introductory price: ~$2 per test to end user) malaria diagnostic test that does not require the expertise of a trained professional. The UMT kit also does not require a lab or special disposal due to its simplicity. It is a three step process that lets patients know, in 20 minutes, if they have malaria.

Why the UMT is Disruptive

The most important hallmark of a disruptive innovation is that it makes complicated and expensive products simple and affordable, enabling many more people in society to benefit from the innovation. The UMT fits this model as the differences between the UMT and existing blood-testing kit below clearly illustrate.

One of the most exciting things about the UMT is Dr. Agbo’s goal to manufacture the product in Africa. “With an investment of $5 million, we can build a fully equipped manufacturing plant in Nigeria. That amount will only get us a building in the United States,” he explained.

Innovation Prize of Africa winners IPA2016winners-1200x590 at Forbes2It is solutions like these that African investors and policy makers need to support in order to get Africa on a path to sustainable economic development. As reported by Forbes, the UMT is an innovative product by Africans for Africans. This is why the UMT is an innovation winner.

(A longer version of this posting appeared on the World Bank Africa Can blog.)

Huambo: Thinking ahead toward investing in malaria elimination

wmd2015logoEight members of the Southern African Development Community are strategizing toward the pre-elimination phase of malaria.  The four frontline states are Namibia, South Africa, Swaziland and Botswana.  The second tier includes Angola, Zambia, Zimbabwe and Mozambique.

Huambo circled Pf_mean_2010_AGOMalaria prevalence varies by province in Angola with greater burden in the north (see map on right). Huambo in the central highlands is the second most populous province at 2 million and in some of the 11 municipalities malaria transmission is low.  This has led provincial health authorities to strategize how to invest in pre-elimination efforts where appropriate while maintaining full prevention interventions where needed.

An analysis of routine health information system (HIS) data is a first step. Rapid Diagnostic tests are part of the basic protocol for case management in all health centers. Data for 2014 was summarized by municipality. Test positivity rates for each municipality are shown in the map to the left. These range from a low of 2% in Katchiungo in the east to 54% Bailundo in the north.

Huambo Municipalities Malaria Test PositivityMore detailed geospatial analysis will be needed looking at variations within municipalities by health center catchment area, but a broad picture emerges that three municipalities in the northern part of the province have higher RDT positivity rates, and require sustained interventions like long lasting insecticide-treated nets and intermittent preventive treatment for pregnant women.

Reactive case detection such as being practiced in Swaziland might be considered in the remaining 8 municipalities after some initial pilot testing. Community based surveys using RDTs and more precise tests like polymerase chain reaction (PCR) could also be tried in order to supplement current HIS data and provide better targeting of interventions.

Hopefully government and partners will invest in helping Huambo test these processes. Huambo could then provide a good model for approaching malaria elimination for the rest if the country and the region.

World Malaria Day 2015 Blog Postings Help #DefeatMalaria

wmd2015logoA special World Malaria Day 2015 Blog has been established. So far nine postings are available at http://www.worldmalariaday.org/blog. Please read and share with colleagues.

1. “Investing in integrated health services to defeat malaria”BY ELAINE ROMAN, MCSP Malaria Team Lead.

2. “Fake antimalarials: how big is the problem?”

BY DÉBORA MIRANDA, Technical Communications Officer, ACT Consortium (UK).

3. “Why antimalarial medicines matter”WMD15_7_Facebook_Final

BY PROFESSOR PAUL NEWTON AND ANDREA STEWART, Worldwide Antimalarial Resistance Network and Laos Oxford University Mahosot Hospital Wellcome Trust Research Unit.

4. “Malaria as an entry point for addressing other conditions”

BY HELEN COUNIHAN, Senior Public Health Specialist, Community Health Systems.

5. “Bridging the Care-Seeking Gap with ProAct”

BY MATT McLAUGHLIN, Program Manager of Peace Corps Stomping Out Malaria in Africa initiative.

WMD15_6a_Facebook_Final6. “Defeating Malaria in Pregnancy”

BY CATHERINE NDUNGU, ELAINE ROMAN AND AUGUSTINE NGINDU, Jhpiego.

7. “Intermittent Preventive Treatment, a Key Tool to Prevent and Control Malaria in Pregnancy”

BY CLARA MENÉNDEZ, Director of ISGlobal’s Maternal Child and Reproductive Health Initiative.

8. “Widespread artemisinin resistance could wipe out a decade of malaria investment”

BY TIM FRANCE, Asia Pacific Leaders Malaria Alliance.

9. “The long walk to a malaria-free world”

BY DAVID REDDY, CEO Medicines for Malaria Venture.

Investing in Antenatal Care to Defeat Malaria

For many years malaria in pregnancy (MIP) was the proverbial neglected step-child of malaria control programs. Partly this was due to structural problems – the challenge of coordination between different units and departments within a ministry of health – malaria programs and reproductive health programs in separate and parallel divisions.

Another reason for neglect may lie in the fact that it is been difficult to achieve the MDG 5 as outlined in the United Nations’ 2014 Millennium Development Goals Report. One still finds that worldwide, almost 300,000 women died in 2013 from causes related to pregnancy and childbirth. Maternal death is mostly preventable and much more needs to be done to provide care to pregnant women.

Maternal death prevention includes providing pregnant women 3 or more doses of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) and ensuring women have AND sleep under insecticide treated bednets (ITNs) during antenatal care (ANC). Unfortunately recent Demographic and Health Surveys (DHS) and Malaria Information Surveys (MIS) from endemic countries show slow or stagnating progress in reaching Roll Back Malaria goals of 80% coverage of pregnant women with these interventions. Recent DHS/MIS have found that only 15% of recently pregnant women got two doses of IPTp in Nigeria, with only slightly better coverage in Burkina Faso (46%). Now that targets have shifted to three or more doses, the coverage challenge is even greater.

TPI pregnancy-2The irony is that these same DHS reports show that a large proportion (>90%) of pregnant women in malaria endemic countries of Africa get registered for ANC. In order to achieve full coverage of IPTp pregnant women should attend ANC at least four times, but the recommended minimum of four ANC visits is difficult to achieve. According to WHO, “The proportion of pregnant women in developing countries who attended at least four antenatal care visit has increased from approximately 37% in 1990 to about 52% in 2012 but, in low-income countries, only 38% of pregnant women attended four times or more antenatal care during 2006-2013.”

In their article, “The quality–coverage gap in antenatal care: toward better measurement of effective coverage,” Stephen Hodgins and Alexis D’Agostino offer an explanation. They point out that it is not the number of ANC contacts alone that matters; it is the content of each visit that is equally important. They explain that a “coverage gap” exists when women who attended ANC four or more times did not receive the elements of basic package of services spelled out in the concept of Focused Antenatal Care (FANC).

Specific findings from Hodgins and D’Agostino’s DHS review showed that, “Blood pressure and tetanus toxoid performed best, with median quality–coverage gaps of 5% and 18%, respectively. The greatest gaps were for iron–folate supplementation (72%) and malaria prevention (86%).” Simply put, the lesson is that attending ANC does not equal receiving lifesaving maternal health services.

Many factors affect the quality of ANC services ranging from the major gaps in availability of trained health workers at the frontline in endemic countries to poor procurement and supply systems for even the cheapest drugs like SP. Even when health workers are in place, their understanding of and attitudes toward using SP for IPTp may be inadequate. These issues are where the gap between attending ANC and receiving needed services emerges. We will not be able to defeat malaria in pregnancy until we invest in strengthening the whole ANC system and pay better attention of women’s health.

Monitoring Net Use: Ensuring a Major Investment Pays Off

wmd2015logoJohn Orok, the Director of Akwa Ibom State’s Malaria Control Program in Nigeria, and colleagues have shared with us the follow-up survey results following a mass LLIN distribution campaign in his state in late 2014. Unless we monitor our investments in nets, we will not “Defeat Malaria.”

While long lasting insecticide-treated nets (LLINs) have made a major dent in the incidence of malaria in Africa, LLINs need to be replaced at intervals. Akwa Ibom State Ministry of Health (SMOH) conducted a mass net distribution in 2010 during which 1.8 million LLINs were handed out in the 31 Beneficiary hang her Net 2015local government areas (LGAs/Districts). An estimated 2.7 million nets were acquired with Global Fund support for replacement distribution in November and December 2014. In an effort to learn about the outcome of the exercise, the SMOH organized a follow-up household survey in all LGAs in January 2015.

The state formed a technical working group which developed a checklist and interview guide for to gather follow-up information on the number of households that acquired nets, hung the nets, slept under the nets, their reasons for not using nets and sources of information about nets. Interviewers were recruited for each LGA and trained to use the checklist and recognize appropriate net hanging and use. Twelve interviewers were assigned to each Ward of each LGA.

Who Sleeps Under LLINs in Akwa Ibom StateA total of 2,696,476 net cards were issued to households based on approximately two nets per household, and 2,626,966 nets (97.4%) were redeemed. Retention rate in the sampled households was 97.1%, while hanging rate of those retained was 71.8%%. Overall 69.6% household members reported that they slept under a net the previous night. A greater proportion of pregnant women (92.1%) reported using nets compared to children below 5 years of age (82.3%) and other household members (63.3%). Main reasons for not using nets included feeling hot (44.5%), inability to hang the net (19.7%) and concern about the chemical used to treat the net (11.4%).

Akwa Ibom is located in Nigeria’s highest malaria transmission zone, and hence there is need to use LLINs throughout the year. The contrast with 2013 DHS, where only 14.1% of residents overall slept under an LLIN, results is stark and implies that net use may likely decline as nets age beyond an ideal replacement schedule of every 2-3 years. Even 1-2 months out from a campaign there are people who are not hanging and using nets. Continuous systems for community level education and reinforcement and health system-based routine distribution for periods between campaigns are needed to ensure this major investment in controlling malaria pays off..