Category Archives: Invest in Malaria Control

Malaria funding may never be enough, but better program management should be possible

The World Malaria Report shows that malaria cases are up, and even though there are fewer reported cases in 2017 than 2010, the number is greater than 2016. So once again high burden countries are being targeted. Today this focus is on “High Burden to High Impact”, but in 2012-13 it was the “Malaria Situation Room” that also focused on 10 high burden countries.

Progress was being made up to around 2015-16, it then started to reverse. The challenge was not just funding. As the WHO Director General noted in the foreword to the 2018 World Malaria Report (WMR), “Importantly, ‘High burden to high impact’ calls for increased funding, with an emphasis on domestic funding for malaria, and better targeting of resources. The latter is especially pertinent because many people who could have benefited from malaria interventions missed out because of health system inefficiencies.”

Over the years there have never been enough pledged funds to fully achieve targets, but as funding has never reached desired levels, attention is now being drawn more and more to the source of that funding (more emphasis on domestic/endemic countries) and especially how the health system functions to use the funds that are made available. In 1998 during one of the early meetings establishing the Roll Back Malaria Partnership, a speaker stressed that malaria control could not succeed without concomitant health systems strengthening and reform. That 20-year-old thought was prescient for today’s dilemma.

First, what is the funding situation? As outlined in the World Malaria Report …

  • In 2017, an estimated US$ 3.1 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners – an amount slighter higher than the figure reported for 2016.
  • Governments of endemic countries contributed 28% of total funding (US$ 900 million) in 2017, a figure unchanged from 2016.
  • Funding for malaria has remained relatively stable since 2010
  • To reach the Global Technical Strategy 2030 targets, it is estimated that annual malaria funding will need to increase to at least US$ 6.6 billion per year by 2020

The question remains – does investment lead to results. The WMR shows, for example, that “Between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs/LLINs), were reported by manufacturers as having been delivered globally. This represents a substantial increase over the previous period 2012–2014, when 465 million ITNs were delivered globally”.

At the same time the report states that, “Households with at least one ITN for every two people doubled to 40% between 2010 and 2017. However, this figure represents only a modest increase over the past 3 years, and remains far from the target of universal coverage.” Is it simply a matter of funding to reach the other 60% of households, or are there serious management problems on the ground?

Then there is the issue of using nets. The WMR traces new ownership and use from 2010 to 2017, and we can see that overall the proportion of the population at risk who slept under a net increased from around 30% to 50%, but only 56% of those with access to a net were sleeping under them. This can be attributed in part but not completely to the adequacy of nets in a household.

We should ask are enough nets getting to the right places, and also are efforts in place to promote their use. Behavior change efforts should be a major component of malaria program management. Even the so called biological challenges to malaria control have a human element. Monkey malaria transmission to people results from deforestation. Malaria parasite resistance to medicines comes from poor drug management on individual and systems levels.

The target year 2030 will be here before we know it. Will malaria still be here, or will countries and donors get serious about malaria financing AND program management?

On World Malaria Day the realities of resurgence should energize the call to ‘Beat Malaria’

Dr Pedro Alonso who directed the World Health Organization’s Global Malaria Program, has had several opportunities in the past two weeks to remind the global community that complacency on malaria control and elimination must not take hold as there are still over 400,000 deaths globally from malaria each year. At the Seventh Multilateral Initiative for Malaria Conference (MIM) in Dakar, Dr Alonso drew attention to the challenges revealed in the most recent World Malaria Report (WMR). While there have been decreases in deaths, there are places where the number of actual cases is increasing.

Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.

On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.

Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).

The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.

In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.

While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.

Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.

Malaria Day 17 Years Later: Documenting and Investing to End Malaria

The first time the global community observed a day devoted to tackling the problem of malaria was April 25th 2001. This was agreed upon at the African Summit on Roll Back Malaria held in Abuja, Nigeria in 2000. The first seven annual observances were titled “Africa Malaria Day,” and recognized that the largest global burden of the disease affects people on the African continent. As thoughts moved toward elimination, the importance of addressing all endemic communities resulted in the first “World Malaria Day” in 2008.

Thus on April 25th 2017 we are observing the 17th Malaria Day overall and the 10th anniversary of World Malaria Day. This observance has been complimented over the years with a malaria day for the Southern African Development Community and for countries in the Americas.

Each year Malaria Day has had a theme or themes to help focus education and advocacy. Regardless of the theme, the special day has been a time to mark progress and rally partners from the global to community level to continue the fight against the disease. The list below shows some of the issues/themes raised on the past Malaria Days. As noted, in some years advocacy efforts dealt with more than one key idea, though all are not presented.

  • 2001 – Africa Malaria Day 2001: The First Africa Malaria Day; Malaria – A Crisis With Solutions; A Malaria Free-World
  • 2002 – Mobilizing Communities to Roll Back Malaria
  • 2003 – Insecticide Treated Nets and effective malaria treatment for pregnant
  • women and young children
  • 2004 – A Malaria-Free Future: Children for Children to Roll Back Malaria
  • 2005 – Unite against malaria: Together we can beat malaria
  • 2006 – Get Your ACT Together: Universal Access to Effective Malaria Treatment is a Human Right
  • 2007 – Leadership and Partnership for Results
  • 2008 – Malaria, A Disease without Borders
  • 2009 – Counting Malaria Out
  • 2010 – Counting Malaria Out; (and in the Africa Region) Communities engage to conquer malaria!
  • 2011 – Achieving Progress and Impact
  • 2012 – Sustain Gains. Save Lives. Invest in Malaria
  • 2013-15 – Invest in the Future: Defeat Malaria
  • 2016-17 – End Malaria for Good

In sum these themes emphasize the importance of access to malaria interventions, documenting that access, using the data to stimulate more investment ultimately leading to an end (elimination) of malaria. The most recent World Malaria Report (2016) provides several important examples of the progress so far.

  • Households with least one ITN increased to 79% in 2015
  • 53% of the population at risk slept under an ITN in 2015 in Africa increasing from 30% in 2010
  • The proportion of suspected malaria cases receiving a parasitological test in the public sector increased from 40% in the WHO African Region in 2010 to 76% in 2015
  • In 2015, 31% of eligible pregnant women received three or more doses of intermittent preventive treatment in pregnancy (IPTp) among 20 countries with sufficient data, a major increase from 6% in 2010

In addition to noting progress, the report also points out gaps in appropriate care seeking for malaria, attendance at antenatal care clinics, and adequate numbers of nets for a household. As implied in the IPTp data, there is the additional problem of obtaining timely and accurate date to document progress and/or gaps. Looking at the Malaria Day themes around investing, we know that unless one can show investors results, it will be difficult to “End Malaria for Good.”

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..