Category Archives: Leadership

Does Malaria Meet the Criteria for Eradication?

World Malaria Report 2015 CoverWhat it is that makes a disease “eradicable,” or more correctly what makes it possible to eliminate malaria in each country leading to the total eradication world-wide. Bruce Aylward and colleagues identified three main sets of factors by drawing on lessons of four previous attempts to eradicate diseases (including the first effort at malaria eradication in the 1950s and ‘60s).[1]

  1. biological and technical feasibility
  2. costs and benefits, and
  3. societal and political considerations

So far smallpox is the only success because as Aylward et al. pointed out biologically, humans were the only reservoir and on the technical side a very effective vaccine was developed. The eradication campaign was promoted in clear terms of economic and related benefits. While the early malaria eradication efforts started with political will and recognition of the potential economic benefits of malaria eradication, the will was not sustained over two decades. On the technical side at that time there was only one main tool again malaria, indoor residual insecticide spraying, and mosquitoes quickly developed resistance to the chemicals. Are we better able to meet the three eradication criteria today?

Today’s technical challenges are embodied in intervention coverage problems. The World Malaria Report of 2015[2] (WMR2015) explains that the problem is most pronounced in the 15 highest burden countries, and consequently these showed the slowest declines in morbidity and mortality over the past 15 years. Use of insecticide treated nets and intermittent preventive treatment for pregnant women hovers around 50%, while appropriate case management of malaria lags well below 20%, a far cry from the goals of universal coverage. A further explanation of the technical challenges as outlined in the WMR2015 lies in “weaknesses in health systems in countries with the greatest malaria burden.”

The economic benefits criteria should be most pronounced in the high burden countries, but these are also generally ones with low personal income. Ironically, the WMR2015 points out that it is the high costs of malaria care and the malaria burden that further weaken health systems. More investment is needed in order to see more economic benefits.

Biological challenges to elimination are also identified in the WMR2015. Examples of existing and arising biological difficulties include –

  • Plasmodium vivax malaria which requires a more complicated regimen to affect a cure.
  • “Since 2010, of 78 countries reporting (insecticide resistance) monitoring data, 60 reported resistance to at least one insecticide in one vector population.
  • “P. falciparum resistance to artemisinins has now been detected in five countries in the Greater Mekong subregion.” Historically chloroquine and sulfadoxine-pyrimethamine resistance spread from this area and now artemisinin resistance marks a ‘Third Wave” of resistance emanating from the region.[3]
  • “Human cases of malaria due to P. knowlesi have been recorded – this species causes malaria among monkeys in certain forested areas of South-East Asia,” and so far human-to- human transmission has not been documented.

On the positive side greater political support to elimination efforts has been expressed by the African Leaders Malaria Alliance (ALMA) who met at the African Union Leaders Summit in Addis Abba early in 2015 and resolved to eliminate malaria by 2030.[4] This call to action was backed up with an expansion of ALMA’s quarterly scorecard rating system of African countries’ performance to include elimination indicators.[5]

In conclusion, political will exists, but needs to be backed with greater financial investment in order to produce economic benefits. Time is of the essence in taking action because biological and technical forces are pressing against elimination. 2030 seems far, but we cannot wait another 15 years to take action against these challenges to malaria elimination.

[1] Aylward B, Hennessey KA, Zagaria N, Olivé J, Cochi S. When Is a Disease Eradicable? 100 Years of Lessons Learned. American Journal of Public Health, 2000; 90(10): 1515-20.

[2] World Health Organization. World Malaria Report 2015. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, 2015.

[3] IRIN (news service of the UN Office for the Coordination of Humanitarian Affairs). “Third wave” of malaria resistance lurks on Thai-Cambodia border. August 29, 2014. http://www.irinnews.org/report/100549/third-wave-of-malaria-resistance-lurks-on-thai-cambodia-border

[4] United Nations Secretary-General’s Special Envoy on MDGs. African Leaders Call for Elimination of Malaria by 2030. Feb. 3, 2015. http://www.mdghealthenvoy.org/african-leaders-call-for-elimination-of-malaria-by-2030/

[5] African Malaria Leaders Alliance. ALMA 2030 Scorecard Towards Malaria Elimination, December 2014. http://alma2030.org/sites/default/files/sadc-elimination-scorecard/alma_scorecards_poster_english.pdf

Leading by Example: Senegal’s Minister of Health supports the “Zero Malaria! Count Me In!” campaign

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

iwd_squareInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the second feature on women fighting malaria.

Pr. Awa Marie Coll Seck, the former Executive Secretary of the Roll Back Malaria Partnership pursues her fight against malaria in her own country, Senegal, as Minister of Health. Known for her smooth diplomatic skills and experience in policy formulation, she leads an aggressive reform striving to eliminate all deaths due to malaria in Senegal.

Pr. Awa Marie Coll Seck, Minister of Health and Social Action, Senegal

Pr. Awa Marie Coll Seck, Minister of Health and Social Action, Senegal

As global leadership increasingly realizes that the international strategy demands a strong local response and the most active engagement of beneficiaries, Senegal’s Minister of Health walks the talk. The Zero Malaria! Count Me In! campaign aims at creating a movement around the importance of accountability and individual responsibility when it comes to putting an end to this preventable disease. Malaria elimination demands the coordinated efforts of all sectors of society.

As the Minister of Health pledges to build capacity within health facilities so that they are able to properly manage simple and severe cases of malaria, the Zero Malaria! Count Me In! campaign insists on the necessary parallel commitment that Senegalese people need to make in order for the country to reach its malaria elimination objective.

Since the past decade, the country has made tremendous progress and reduced malaria mortality by 62%. Over 6.5 million of insecticide treated mosquito nets were distributed throughout the country and lifesaving medicines are now available in public health facilities free of charge.

Women being the primary caretakers of their families, International Women Day is the perfect occasion to celebrate the leadership of Senegalese women throughout the country, without whom, malaria elimination could never become a reality.

Thank you Minister for leading by example and proving that actions speak louder than words.

Happy International Women Day to all!

*****

Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

ALMA – long time no see

Since African Leaders Malaria Alliance (ALMA) was formed nearly two years ago, we hear only occasionally about its efforts to rally political will.  The last major news came in August 2010 at the 15th African Union Summit when leaders pledged a commitment to malaria in the context of maternal and child health. ALMA still maintains a website and a blog with recent and occastional postings, but generally its activities have been somewhat off the radar of the major media outlets.

Now during the during the 16th African Union Summit in Addis Ababa ALMA has resurfaced in public view. The occasion was award of recognition to four heads of state for their support of malaria programs. Recipients of the 2011 ALMA Award for Excellence are the heads of state of Guinea, Kenya, Uganda and Tanzania.

Although currently comprised of only 35 heads of states, ALMA notes as progress that, “Of the 45 malaria-endemic countries in Africa, 62% have removed tariffs on anti-malarial medicines, 42% have removed tariffs on LLINs, and 31 countries have taken measures to curtail the use of oral artemisinin-based monotherapies,” as reported by the Malaria Policy Center.

In addressing the Group, the UN Secretary General praised them for working toward the goal of Universal Coverage, He explained that, “The African Leaders Malaria Alliance is breaking down barriers, forging partnerships and getting supplies to families in record time. This is remarkable progress. We need to encourage it and use the response to malaria as a model for battling other illnesses and social ills.”

This is a challenging time for leadership in the fight against malaria. Not all heads of state have been watching the store as it were, since several Global Fund grants have been suspended on their watch due to corruption, often by government agencies serving as grant recipients.  Uganda, one of the four awardees of this year’s ALMA Excellence Awards, has had its own brush with the Global Fund.

Kenya was one of the countries covered in a 2008 study by the Global Fund of conflict of interest within its Country Coordinating Mechanism. Kenya was also singled out in an Office of the Inspector General Report to the 21st GFATM Board Meeting as one of the countries that had implemented less than half of the recommendations arising from its audit.

The East African Magazine recently published an African Presidents’ Index that ranken leaders on such factors as press freedom, corruption, democracy and human development. The ALMA award recipients ranked as follows out of 52:

  • Guinea – 29th at 42% score and a grade of F 
  • Kenya – 16th at 53% and a grade of C
  • Uganda – 20th at 50% and a grade of D+
  • Tanzania – 10th at 60% and a grade of B-

Hopefully the recognition by ALMA for malaria achievements will have an overall positive effect on leadership and political will in all areas of governance and human development.  Progress on one issue (health) and one disease (malaria) alone can not have a long lasting effect on defeating poverty and enhancing dignity of life in Africa.

Fifty Years – independence and malaria in Africa

dscn7335-sm.JPGThe New York Times points out that “17 African countries, including Nigeria, gained independence in 1960.” Apparently there are few major commemorations. The Times quotes Ibrahima Thioub, a Senegalese historian, who said, “It’s tough to mobilize people for celebrations, because the flowers of independence have faded. The last 50 years have not at all met the people’s hopes and expectations.”

Have these 50 years brought Africa any closer to independence from malaria? It was during those years in the late 1950s and early 1960s when most countries were gaining independence that the first effort to eradicate malaria failed. We have had twelve years of rolling back malaria now – are the critical factors in place to ensure that eliminating the disease is feasible now?

The New York Times article addresses critical factors – ranging from weakness of institutions like parliaments to gaps in civil society engagement – that would impede  public health and social welfare programs including malaria control. African intellectuals quoted in the article bemoan that “democracy is held hostage by elites,” and the public accepts that “power is a matter of essences, a heritage, something in the blood, that what is normal for a state is unlimited monarchy.”  While both power and malaria may be ‘in the blood’, the former does not appear to be as easily transmissible or shareable, making the latter all the less easy to control.

The Times notes that, “… there is the reliance on heavy inflows of foreign aid, which equaled a quarter to nearly a third of government spending in countries like Burkina Faso, Cameroon and Mali in 2008.” Clearly this includes inputs from the Global Fund, The World Bank Booster Program and the US President’s Malaria Initiative (PMI). What aspects of health programming are not covered by aid is often paid out of pocket by the public, which is already impoverished by diseases like malaria.

Although there have been recent worries about both the level of donor funding moving forward and the willingness of countries to sustain programs should donor funding collapse, there are some positive signs from the donor side.  The US Government is increasing its malaria focus beyond the 15 PMI countries to include at least Burkina Faso, Burundi, Nigeria, Democratic Republic of the Congo and Sudan, and the Global Fund is embarking on a new ‘grant architecture.’

Known as ‘single stream funding’ the new Global Fund grant architecture “will shift the Global Fund towards a more program-based approach, with significantly improved harmonization and alignment, improving its support of holistic health planning and implementation,” to each principle recipients. This should simplify management, provide continuity, and reduce transaction costs – so even if funding does not increase as desired, there still may be savings and efficiencies for the allocated resources.

There are signs that we may get closer to independence from malaria this year as strides are being made to achieve universal coverage of malaria interventions. It may take another 50 years to see whether malaria can truly be eradicated. Hopefully when many endemic African countries will be observing their 100th year of independence, malaria will have become a thing of the past.

USAID – new director confirmed

The US Senate has given the development community a holiday gift. The indo-Asian News Service reports, “The Senate unanimously on Thursday confirmed the nomination of Shah, 36, and some three dozen other officials nominated by President Barack Obama before taking its Christmas break.”

Rajiv Shah has training in medicine and economics and has worked with the US Department of Agriculture. This gives him a broad development perspective and hopefully will ensure nutrition issues are not forgotten, “having championed Obama’s global food security initiative.”

Shah has also worked with the private and the NGO sectors, important partners in USAID’s work.

When Shah was nominated, President Obama said, “Rajiv brings fresh ideas and the dedication and impressive background necessary to help guide USAID as it works to achieve this important goal.”

There are those who are worried that fresh ideas alone may not be enough to guide an agency with such wide scope. NationalJournal.com remarked that, “Then there is the question of seasoning. While development junkies trade war stories of remote missions and malaria like currency, Shah has almost zero field experience. He may be the smartest guy in the room, but he doesn’t have that wellspring to draw on.”

During confirmation hearings Senator Richard G. Lugar posed a question about the future of the successful disease control programs initiated by the US Government in recent years. Shah explained that …

The welcome increase in funding for health assistance since 2000, particularly for combating HIV and malaria, has largely been targeted to African countries where disease and overall poor health conditions have had substantial socio-economic impact. That said, there are still tremendous unmet health and development needs in these countries. The Administration is committed to a broad Global Health Initiative that takes account of the range of health and development needs and, if confirmed, I look forward to working with Congress on this important issue.

The United Nations Foundations congratulated the President on Shah’s nomination and reiterated its own priorities which address both disease control and strengthening maternal and child health (MCH) services:

The United Nations Foundation is particularly focused on development goals related to global health, including our efforts to eradicate polio, reduce measles mortality, and eliminate malaria worldwide. In light of the unmet need in the world for maternal health and family planning, I hope that USAID’s new leadership will keep women’s health and international family planning a priority.

A good example of the nexus between malaria control and MCH is the challenge of preventing and treating malaria in pregnancy (MIP). Pregnant women bear a disproportionate burden of malaria that threatens their survival and that of the fetus and the newborn child.  Without strong a antenatal and reproductive health foundation, MIP control cannot reach those in need.

If Shah does have this bigger picture of malaria control in mind, we can hope for a broadening of malaria intervention into MCH programs that go beyond the limits of the 15 countries that constrained the potential impact of the President’s Malaria Initiative.

Nigeria’s NMCP Loses Director at Critical Juncture

The Director of Nigeria’s National Malaria Control Program has been caught up in a new civil service directive requiring that Permanent Secretaries and Directors in Federal Ministries must step down if they have served at that level/position for at least 8 years. This happens regardless of whether the person has reached the official retirement age of 60 years or the maximum service length of 35 years.

According to the Vanguard, many believed that the old system “gave rise to so many abuses that the federal civil service became the engine room of corruption, ethnic domination, sectional cabalism and the nurturing of super-powerful public officers who were used by narrow, entrenched interest groups and external political forces to subvert the Service itself and the spirit of national unity as a whole.”

Ethnic interpretations do abound as the removal from office of Permanent Secretaries appears to affect mostly people from the Northern part of the country.

The Daily Trust explains that  the removal last week of nine permanent secretaries and about 80-100 directors will not address the concern by some workers of having enough high level civil service vacancies to guarantee everyone the promotion he or she desires. “There can never be enough vacancies for every civil servant to rise to director level.”

The move might be a way to deflect an underlying tension on pay. ‘Regular’ civil servants have been complaining that directors and senior officials receive much higher pay. “There are indications that the demand for a pay rise at this time can be explained by a new policy in the civil service,” according to 234Next.com.

So now, moving from politics to malaria, how does this overhaul of the civil service affect Nigeria’s malaria efforts.  Nigeria has just been granted malaria funds for its Round 8 proposal to the Global Fund. The NMCP was named in this grant as a new Principle Recipient.  Nigeria is also in the middle of a massive ITN distribution campaign to achieve universal coverage.  This could not be a worse time to bring in a new Director who may have little or no experience in malaria programming.

Dr. T.O. Sofola, the just retired NMCP Director, is one of the most dedicated civil servants I have met. She has amassed an amazing knowledge base – both practical and scientific – for managing malaria programs in a vast and logistically challenging environment. She will be sorely missed, but we assume that her staff and all the malaria partners will pull together to make sure that the plans and strategies she guided are a success.

A job with a difference

whpgmp.jpg

WHO is recruiting for the position of Director Global Malaria Programme (GMP). The Director is expected 1) to provide strategic and technical direction, 2) to undertake resource mobilization and management and 3) to facilitate Partnerships and Coordination.

Overall the GMP “is responsible for malaria surveillance, monitoring and evaluation, policy and strategy formulation, technical assistance, and coordination of WHO’s global efforts to fight malaria.” While WHO and its GMP are among the partners in the Roll Back Malaria partnership, some partners might be perceived as more equal than others – in part because WHO sees itself as “the foremost global authority on health.”

The GMP is a major source of the latest technical knowledge on all aspects of malaria ranging from case management to insecticides.  The position of Director is such a group certainly demands wide ranging technical expertise, but even more, it requires skills in leadership.  Since malaria control, elimination and eventual eradication requires the broad ranging collaboration among donors, technical agencies and civil society organizations as embodied in RBM, the Director of the GMP needs to exercise his/her leadership role in a special way.

A spirit of collegiality and inclusion is essential for the new Director, since no one agency or person has all the answers to the problem of malaria. Not surprisingly the job posting stresses a “Commitment to collaborate effectively with other key partners.”  We encourage all those with such a commitment to apply.