Tropical Health Matters

A variety of malaria and related issues have arisen over the past two days. A media coalition for malaria elimination formed in Ghana. A Nigerian NGO stresses the importance of addressing malaria on Nigeria’s 60th Independence Day (October 1). An innovative technology foundation is supporting various malaria and NTD treatment and diagnostic research efforts. Click on links below to read the details.

Media Coalition for malaria control and elimination launched

A Media Coalition comprising of selected journalists and editors, has been launched in Ghana under the umbrella of the “Zero Malaria Starts with Me” campaign to eliminate malaria by 2030. The Coalition, which aimed to enhance the quality and quantity of malaria coverage, and support broader advocacy efforts, was launched at a workshop in Accra organized by the National Malaria Control Programme (NMCP), in collaboration with the African Media and Malaria Research Network and Speak Up Africa, an advocacy and communication Organisation based in Senegal.

The workshop brought together media personnel from across the regions, who nominated their Regional Executives, with two National Co-Chairpersons coming from Greater Accra. The Members of the Coalition, made a firm declaration of their commitment towards the elimination of malaria in Ghana by the year 2030, by championing the fight, taking responsibility for their roles through proactive, regular, accurate, and high-quality media output of news on malaria.

Chinwe Chibuike Foundation Set To Flag-off Full Scale Malaria Eradication Program On Independence Day

A Nigeria indigenous and international non-governmental organization, envisioned to create a conducive environment towards the accessibility of healthcare facilities and improved educational opportunities, has joined the fight against the bizzare challenges of Malaria. The renowned Nigeria-USA humanitarian organization, Chinwe Chibuike Foundation is collaborating with other organizations to flagoff a full scale malaria eradication exercise tagged “Nigeria at 60 Malaria Eradication Project”, on the 1st of October 2020.

According to the founder and President of Chinwe Chibuike Foundation, Ms Gloria Chibuike, during an interview session with Pulse TV few days ago, she noted the forthcoming Nigeria At 60 Malaria Eradication Program will be different and of more impact, especially with the full scale approach and introduction a new Malaria repellant Band.

While emphasizing on the extensive features of the project, Ms Gloria described Malaria as one of the biggest problems in Africa at the moment, considering the increased number of recorded deaths and infection. She narrated that the discovery of the new malaria repellent band was timely and off-course very efficient, especially with testimonies from few persons who have already tried the brand.

Drugs and Diagnostics: Malaria and NTDs

The Global Health Innovative Technology (GHIT) Fund announced today a total of 1.37 billion yen (US$13 million*) to invest in seven partnerships to develop new lifesaving drugs and diagnostics for malaria, Buruli ulcer, Chagas disease, leishmaniasis, schistosomiasis, and soil-transmitted helminths (STH). This includes three newly funded projects and four that will receive continued funding. The RBM Partnership is planning on how to monitor and provide technical support for ITN programs. Click the links within each section to read details.

As of September 29, GHIT’s portfolio includes 50 ongoing projects: 26 discovery projects, 16 preclinical projects and eight clinical trials (Appendix 3). The total amount of investments since 2013 is 22.3 billion yen (US$211 million).

Support the Improvement of Operational Efficiency of ITN Campaigns

The Alliance for Malaria Prevention (AMP) is a workstream within the RBM Partnership to End Malaria. With malaria indicators stagnating and intense pressure to improve access and use of effective ITNs, WHO has renewed focus on stratifying vector control strategies in countries. Along with the introduction of new, more expensive ITNs, countries are now challenged to determine where they should deploy different ITN types to manage insecticide resistance within limited funding envelopes, as well as to identify more efficient ways to implement mass ITN distribution.

Countries that have accessed AMP technical assistance have significantly improved their capacity to modify and update strategies and tools to increase ITN access, use and accountability. They have also continued to identify further gaps and look for effective ways to address them. Now AMP planning to support update and finalization of ITN tracking tool, aligned with priorities across major partners (GF, PMI, RBM).

 

The Global Fund sixth Replenishment Conference will take place in October 2019 to raise new funds and mobilize partners toward ending AIDS, TB and malaria by 2030 in alignment with the Sustainable Development Goals. The target is to raise at least US$14 billion “to help save 16 million lives, avert 234 million infections and help the world get back on track to end these diseases.”

It is not exactly clear how much of this US$14 billion would be pegged for malaria, especially since there are cross-cutting health systems strengthening components to many grants. That said, the total seems to pale in light of the 2018 World Malaria Report estimated investment needs of US$6.6 billion alone for malaria from 2020 onward.

Of course the Global Fund is calling on the private sector to “mobilize at least US$1 billion to step up the fight.” It is not clear whether this should be included in the US14 billion or in addition.

The RBM Partnership notes that “Accounting for more than half of all external resources and 44% of total malaria funds available, the Global Fund represents the leading source of funding for malaria prevention and treatment.” Such non-Global Fund external resources have come from partners like the World Bank, the US President’s Malaria Initiative, DfID and a host of other bilateral, NGO and corporate sources. The implication is that at most 15-20% of current financial investment in malaria has been borne endemic countries.

RBM also highlights that at the recent African Union meeting, “African Heads of State and Government adopted the 2018 African Union Malaria Progress Report which was prepared by malaria experts from countries in Africa…” This means that the leaders acknowledged that malaria investments and significant achievements already made “are under threat and accelerated action is needed now to get countries back on track.” This led the current chair of the Africa Malaria Leaders Alliance, His Majesty King Mswati III of the Kingdom of Eswatini, to say, “It will take significant resources to achieve malaria elimination.  Now, more than ever, we must boost our domestic resources from both the public and private sectors.”

Analysis in the ALMA Scorecard shows in the fourth quarter of 2018 most countries have acquired the needed funds to finance malaria commodities. The analysis does not point out the source of these funds. The 2030 target is only 11 years away. Serious national planning, political will and advocacy are needed not only to prevent resurgence of malaria to pre-RBM days, but also to reduce and eliminate a disease responsible for so much economic loss and loss of life.

The history of community intervention in Burkina Faso dates back to immediately after the declaration of Alma Ata in 1978. The first community health experiments were carried out in 1979 with the support various development partners with an aim of reducing maternal and infant morbidity and mortality difficult to access health districts where village birth attendants where been trained, equipped and supervised. Today as a matter of policy, Burkina Faso aims at improving the quality of health services and increasing access to health services through community-based health workers (CBOs), civil society organizations (CSOs), non-governmental organizations (NGOs) and associations implements community intervention strategies. with the full participation of communities.[1]

Burkina Faso’s draft strategic plan for community health states that, “Community Health is a multi-sectoral and multi-disciplinary collaborative enterprise that uses public health science and some social science approaches to engage and work with communities. Its purpose is to optimize the health and quality of life of all people who live, work in a given community. It is based on community needs, understanding and community priorities for health.”¹ Community participation is seen as central to achieving universal health care.

The Ministry of Health¹ notes that there has been community participation as part of cost recovery (Bamako Initiative). Communities are part of the management committees set up at the level of the first-level health facilities so that the populations thus participate in the management of health facilities, through these committees. “In recent years, there has been renewed interest in community health with a strong mobilization of civil society through NGOs and associations. Community components are integrated into many health programs. This new dynamic has led to significant progress and positive results in the areas of the fight against HIV, tuberculosis, reproductive health (family planning, health of young people and adolescents), malaria, malnutrition, vaccination, etc.”

The Ministry reports that, “Indeed, the community actors have contributed to the achievement of the results obtained through the implementation of community-based health services, which however remain to be rethought not only in its vision but also to be in phase with that of the universal health coverage. For a better involvement of these actors in the achievement of the health objectives, the main challenges remain their motivation, the reinforcement of their capacities and the collaboration with the agents of health.”¹ Systematic evaluation of such results remains to be done.

While there have not been systematic assessments of these participatory processes in community health, researchers did take a close look at the levels and types of community participation attained in water and sanitation projects in Burkina Faso. The following lessons have implications for involving Burkina Faso communities on PHC:[2]

• Users and Neighborhood groups have a lower level of participation than city and government stakeholders
• It is possible that the social structures and traditions in Burkina Faso do not encourage a more participative approach
• Further study of power structures in Burkina Faso may determine why participation is lower than expected
• There is a significant decrease in participation levels during the design and selection steps of planning as opposed to the earlier stages of problem identification and definiing objectives, and the later stages of option selection and action planning – a question of planning styles dominated by experts

These issues raise questions about the social and cultural aspects of the planning process and about leadership and governance. It would seem that ‘experts’ also need education about how to work with communities.  There are also concerns about the level of community education employed to help community members and CBOs make informed choices. The authors raise another important question concerning expectations that communities will take ownership in the running of projects when in fact these Users have only been asked about their problems and then been informed about a solution.

In another sector the World Food Program developed a diagnostic and planning approach based using community participation and conducted training and practical exercises on “Community-Based Participatory Planning.” The exercise brought many community actors together to identify food security issues such as land degradation, lack of economic activities for residents in the non-agricultural season and floods that block access to health and other services. participators discussions identified community resources to address these issues and demonstrate resilience.[3]

A recent Global Fund grant to Burkina Faso was entitled, “Strengthening health systems and scaling-up of integrated community case management interventions.”[4] Community-based organizations (CBOs) involved in control of the three diseases commonly addressed through integrated Community Case Management (iCCM) – malaria, diarrhea and pneumonia. The program was also expected to strengthen the community workforce be ensuring adequate numbers of functional CHWs. The project received a high level of regular reporting by CBOs (100%), but less than ideal from individual CHWs (83%). This was in spite of the fact that they achieved recruitment targets for ‘functional’ CHWs. Interestingly the biggest problem for the CHWs was the extremely low availability of essential supplies with which they could work (13%). The grant demonstrated the challenges of involving CHWs in more focused activities as opposed to a broader community agenda. Reorganization of the CHW program in the last few years has created a standardized curriculum so that there are two CHWs per village who respond to a variety of community needs ranging from reproductive health to disease control. The problem of adequate supplies and materials to do their work continues, though.

While Burkina Faso has established the basic participatory structures in the form of committees and community agents, the Ministry of Health is concerned that Community participation is low.¹ Lessons from other sectors show possible reasons and solutions and inter-sectoral collaboration, one of the hallmarks of PHC should be used to address the challenges. the MOH of course has its own ideas (listed below) about the root causes of this problem and having identified the following, it should be encouraged to continue efforts to strengthen the roll of the community in PHC:

• lack of social capital (capacities of communities to work together effectively, to identify problems, to prioritize and take charge of them)

• weak involvement of communities in the whole process of implementation.

• greater focus on community diagnosis of needs, assets, and priorities, to develop appropriate intervention strategies, planning, implementation, evaluation

• lack of capacity (skills, human resources, material and time) of community implementation actors,

• lack of accountability of the stakeholders responsible for the implementation of community-based initiatives (CBIs)

• lack of a multi-sectoral approach in the resolution of health problems

Insufficient strategies to combat social exclusion and to take into account specific groups also constitute a barrier to community participation

Partners worry that there is difficulty sustaining CBIs and demotivation of actors (CHWs, facilitators), which can allow morbidity and mortality to remain high in the community. Clearly, investment in strengthening community participation will go a long way in saving lives and promoting health.

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[1] Ministere De La Sante. Draft Strategie Nationale De Sante Communautaire Au Burkina Faso 2019-2023. September 2018

[2] McConville J, Kain J, Kvarnstrom E, et al. (2014) “Participation in sanitation planning in Burkina Faso: theory and practice”. Journal of Water Sanitation and Hygiene for Development, vol. 4(2), pp. 304-312. http://dx.doi.org/10.2166/washdev.2014.125

[3] Ouedraogo, Celestine (2016). Promoting Community-Led Resilience and Development Solutions in Burkina Faso. World Food Program. https://www.wfp.org/stories/promoting-community-led-resilience-and-development-solutions-in-burkina-faso

[4] Global Fund (2017). Burkina Faso BFA-S-PADS Grand Performance Report. https://www.theglobalfund.org/en/portfolio/country/grant/?k=d8f34742-0d57-410c-b5ba-39615edc5785&grant=BFA-S-PADS

The new Astana Declaration says that, “We are convinced that strengthening primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals.” The Declaration outlined a vision, a mission, and a commitment. An opportunity to discuss how to implement this existed at the two-day conference in Astana Kazakhstan celebrating the 40th anniversary of the seminal Alma Ata Declaration.

Ironically the opportunity was not fully grasped. There were many sessions that shared country experiences ranging from finance to information technology.  Youth who will carry PHC forward for the next 40 years gave their opinions and thoughts. Lip-service as well as actual case examples of community involvement were featured. What we did not hear much of was the specifics of how countries, moving forward, will actually implement the commitments spelled out in the document.

One colleague who has worked with the sponsoring agencies was of the view that since much advanced input and work from many partners and countries had gone into the new Declaration, which was already nicely printed, they were reluctant to provide the slightest chance that debate would be reopened.

As they say, fair enough (maybe), but even if one takes the Declaration as a done deal, the matter if implementation needs to be addressed. There was ample criticism that the Alma Ata Declaration was not properly implemented.  This was in part because academics and development agencies jumped the gun and pushed, with focused financial backing, what would be called selective primary health care that was more agency driven, not community directed as envisioned at Alma Ata (now Almaty) in 1978.

In order not to repeat those mistakes and give full voice to the community and key constituents, at minimum the implementation strategies of the pre-agreed Declaration should have been discussed in specific terms. Sure many ideas and examples were aired, but there was no attempt to focus these into workable strategies.

But was the community even there in Astana to take part in strategizing? One community health worker from Liberia received much attention because she was the odd one out. Sure, there were plenty of NGOs, but not the real grassroots of civil society, although the youth involvement aspect of the conference approached that. Some of these NGOs and agencies had themselves been part of the selective PHC agenda.

There was plenty of talk about us involving them, especially when it came to community health workers (CHWs). CHWs should first be integrated into community systems to ensure they are accountable to communities. Then there should be an equal partnership between community systems and health systems. Otherwise CHWs get lost as just front line laborers.

Of course it is never too late. Regional gatherings may be a better forum that can discuss implementation in a more socially,  economically and culturally appropriate way. Let’s hope we don’t look back in another 40 years and with the Astana Declaration had been better and more faithfully implemented.

The 30^th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

Kate Klein as part of her Master of Science in Public Health program in Social and Behavioral Interventions at the Johns Hopkins Bloomberg School of Public Health undertook a study of the potential for private sector involvement in malaria prevention in Ghana. She shares a summary of her work here. During her practicum in Ghana she was hosted by JHU’s Center for Communications Programs and its USAID supported VectorWorks Program. Her practicum she was also supported by the JHU Center for Global Health, and she presented her findings in a poster at the CGH’s Global Health Day on 30^th March 2017. Her essay readers/advisers were Dr. Elli Leontsini (Department of International Health) and Kathryn Bertram (Center for Communication Programs).

Malaria is endemic in all parts of Ghana and significantly burdens families, communities, and economies. Malaria remains a leading cause of morbidity and mortality in Ghana; it accounts for eight percent of deaths in the country (The Global Fund, Ghana). It was also responsible for about 38% of outpatient visits, 27.3% of admissions in health facilities, and 48.5% of under-five deaths in 2015 (Nonvignon et al., 2016). In Ghana, the estimated cost of malaria to businesses in 2014 alone was estimated to be US$6.58 million, and 90% of these were direct costs (Nonvignon et al., 2016). Malaria leads to reduced productivity due to increased worker absenteeism and increased health care spending, which negatively impact business returns and tax revenue to the state (Nabyonga et al., 2011).

Although long-lasting insecticidal treated nets (LLINs) are a well-documented strategy to prevent disease in developing countries, most governments, including Ghana, lack the resources needed to comprehensively control malaria. The Global Fund (GF), USAID/President’s Malaria Initiative (PMI Ghana), and the United Kingdom Department for International Development (DfID Ghana) are the main donors for the national malaria control strategy and have worked primarily with the public sector (World Malaria Report, 2015). As government funding remains unable to close the funding gap for malaria, there is an increasing need to revitalize the private sector in sales and distribution of this life-saving technology.

Ghana is looking to the private sector to encourage a departure from previous dependence on donor-funded free bed nets. The Private Sector Malaria Prevention (PSMP at JHU) project is being implemented in Southern Ghana to increase commercial sector distribution of LLINs. Three case studies served as a situation analysis and exemplified the potential for the PSMP: a rubber producing company, a mining company and a brewery.

All three had experience in malaria control and prevention but only one had specific experience with LLINs (which dovetailed well with its own corporate strengths in logistics management as exemplified by other bottling companies in Africa). Another supported the idea of adding LLINs to its existing indoor residual spraying and community health education efforts, but needed to consider how to develop the flexibility to engage in multiple malaria interventions.

The third had had the right climate and leadership to be able to partner with PSMP, but recently underwent a takeover by a large multinational brewing company and the resulting period of transition could potentially complicate their participation in LLIN distribution efforts from a budgetary standpoint. Generally these companies had the understanding of the potential benefits to the company of situating malaria control within their structure, and thus being early candidates for adoption of the PSMP.

While the three case study companies recognized the business case for malaria, this was not a unanimous opinion among other five companies interviewed. Their concerns ranged from a preference toward treatment interventions to concerns expressed by employees about the difficulty of achieving high levels of net usage due to an array of complaints surrounding sleeping under LLINs. Some of these others had financial constraints.

Through case studies and interviews PSMP was able to identify various challenges moving forward as well as areas where further clarity must be sought. PSMP learned that several companies are pouring their resources into strong treatment and case management programs, and one challenge will be determining how to push for preventative action, such as LLIN distribution, when treatment mechanisms are so established and bias exists.

For those companies who are making tremendous strides in malaria prevention, bringing recognition to these successes through advocacy will be necessary for encouraging future participation and convincing other similar employers of the benefits of starting their own LLIN distribution programs. Finally, PSMP needs to prioritize clarifying viewpoints on LLIN efficacy and use, with a focus on understanding why employers may hold unfavorable views and what it would take to overturn them.

In the future it will be necessary to move beyond the occupational considerations specific to mining and agro-industrial operations and consider how the work has changed the environment into a malaria habitat and the non-traditional work hours that may create more significant Anopheles mosquito exposures. PSMP should gather specific information on lifestyle, housing, and work environments during future visits with employers so that companies that have the most to gain through LLIN distribution are identified and targeted.

GhanaWeb reported this morning that, “The United Nations General Assembly at its 68th Session, adopted Resolution A/68/L.60, “Consolidating Gains and Accelerating Efforts to Control and Eliminate Malaria in Developing Countries, Particularly in Africa, by 2015” by consensus.”

Likewise the UN itself issued a press release confirming that in a final act the Assembly adopted this resolution in order to call for increased support for the implementation of international commitments and goals pertaining to the fight to eliminate malaria. GhanaWeb reiterated the UN’s message that, “with just less than 500 days until the 2015 deadline of the MDGs, the adoption of this resolution by the General Assembly reiterates the commitment of UN Member States to keep malaria high on the international development agenda.”

The UN Press Release explained that, “The resolution urged malaria-endemic countries to work towards financial sustainability to increase national resources allocated to controlling that disease, while also working with the private sector to improve access to quality medical services.  Further, the resolution called upon Member States to establish or strengthen national policies, operational plans and research, with a view to achieving internationally agreed malaria targets for 2015.”

This effort is consistent with moves two years ago in the 66th General Assembly when it called for “accelerated efforts to eliminate malaria in developing countries, particularly Africa, by 2015, in consensus resolution” (document A/66/L.58) where the “Consolidating Gains …” document was first shared. The draft of the 2012  resolution, according to the UN Press release was sponsored by Liberia on behalf of the African Group, and called on Member States, particularly malaria-endemic countries, to strengthen national policies and operational plans, with a view to scaling up efforts to achieve internationally agreed malaria targets for 2015.

The sad irony of Liberia’s current predicament wherein the Ebola epidemic is rendering it nearly impossible to provide malaria services should give us pause. According to Reuters, “Treatable diseases such as malaria and diarrhea are left untended because frightened Liberians are shunning medical centers, and these deaths could outstrip those from the Ebola virus by three or four fold.”

The new resolution (A/68/L.60) in calling for increases national resources allocated to controlling that disease from public and private sources demonstrates the importance of national commitment to sustain and advance malaria control into the era of malaria elimination. It is now up to local malaria advocates to ensure that their governments, as well as private sector and local NGO partners, follow through to guarantee the needed quantity and quality of malaria services.

In response to donor criticism of human rights issues in one malaria endemic country and because of subsequent possible links with future donor cooperation, a prominent government official of that country was quoted as saying, “We don’t like to blackmail others. It’s very dishonest, very irresponsible and unfriendly of persons to attach behavior of another community to their sharing resources.”  (Reuters) This complaint ironically comes from a country that is on record as having squandered Global Fund resources.

Are donors under obligation to ‘share’ their resources with anyone regardless of their ‘behavior’, not just in the field of human rights, but also financial accountability? No country is forced to share its resources, and while all could do more, remarks like those above from recipients add fuel to the fire of those who would be happy to curtail foreign aid all together.

It is unfortunate that many countries are highly dependent on donors to solve problems like HIV, malaria TB, NTDs and NCDs for the foreseeable future. But a solution to the perceived manipulation by donors would of course be a greater commitment of domestic resources to solve these problems.

One country that is seeking a good balance is Burkina Faso. While the country does receive major support from the Global Fund and the US President’s Malaria Initiative for its fight against malaria, Burkina Faso is stepping up to play its own part.  Government has in recent years steadily increased its financial support to buy malaria commodities from $2 million to over $4 million annually in the past few years.

Relative to donor amounts this contribution may seem small, but the point is the willingness of the government to step up and help its own people. These additional government funds have played a crucial role in filling medicine and commodity gaps that naturally occur when donor supply schedules do not match needs at a given time.

The fight against malaria will be won by having more action oriented governments like Burkina Faso and fewer complainers and embezzlers.

Jhpiego was founded in 1973 to provide technical assistance to countries where the risk of maternal mortality and morbidity was quite high.  While focusing on local capacity building from the start, Jhpiego’s model for technical assistance has evolved.  Burkina Faso first benefitted in 1983 by having health staff attend intensive training at Johns Hopkins Hospital.  Subsequently Jhpiego’s work moved to the field, and some of the early trainees became staff on the ground.

Jhpiego established an office in Ouagadougou in 1996, and one of the earliest projects focused on malaria in pregnancy as part of USAID’s flagship program “Maternal and Neonatal Health” (MNH).  It was during that time that Jhpiego collaborated with partners like CDC to do some of the early testing of the intermittent preventive treatment of malaria in pregnancy (IPTp) in West Africa.  The results of this life-saving intervention were published in the American Journal of Tropical Medicine and Hygiene.

Jhpiego continued to provide technical assistance on malaria in pregnancy interventions and capacity building to the Ministry of Health (MOH) in Burkina Faso through the MNH project and into its successor, USAID’s ACCESS project. Jhpiego worked with partners to update malaria guidelines, training materials, supervisory tools and job aids during this period.

In 2009 USAID presented the Maternal and Child Health Integrated Project (MCHIP) with the opportunity to carry out an integrated package of malaria care and prevention strengthening with the MOH and particularly the National Malaria Control Program (NMCP). Over a period of three years Jhpiego, the lead organization in MCHIP, working with together with partners from the NMCP and MOH, was able to accomplish among others the following:

• Updating Malaria policy and guidelines
• Updating Malaria supervisory tools and training of supervisors
• Updating In-service training materials on malaria and training of health facility staff
• Developing a Strategic communications plan and strategy for malaria
• Forming of curriculum update committee on malaria at national training schools for primary health staff
• Training of US Peace Corps Volunteers to support malaria activities in their communities
• Building the capacity and organizational strengthening for the NMCP itself
• Conducting a situation analysis of rapid diagnostic test acceptance and use
• Undertaking a health systems analysis of the strengths and bottlenecks of malaria program implementation in Burkina Faso

Last week, the Burkina Faso office of Jhpiego hosted the organization’s African Malaria Technical Update Workshop with staff from 15 countries participating. Today Jhpiego is taking its 40^th Anniversary celebrations to Ouagadougou.  Jhpiego will express appreciation to local partners in the fight against malaria and threats to maternal and child health.

Jhpiego has been committed on the ground in Burkina Faso to building national capacity for controlling malaria specifically for over 15 years. The recent award by USAID of its bilateral program “Improving Malaria Care” to Jhpiego last October cements Jhpiego’s commitment to the country and to reducing malaria for another five years.

The latest edition of Global Fund Observer (#218) from AIDSPAN raised a lingering question about the Funds founding principles – what is country ownership and how is it practiced? The thoughts range from the more altruistic – let the country decide what it needs to do and we’ll give the money – to the more crude, though not stated as such – give the country enough rope (money) to hang itself.

Another founding principle involved the Global Fund seeing itself as only a financial mechanism, not a technical one like the World Health Organization or UNICEF.  AIDSPAN demonstrates how over time, while still not providing direct technical assistance, decisions from the Technical Review Panel and the Global Fund Board, among others, can be seen clearly as offering a technical guidance that must be heeded if funds are to flow.

In short AIDSPAN has shown how the Global Fund itself has taken a more directive role, though often based on programmatic evidence and advocacy from those who have a stake or experience. We also need to look at th other side of the coin – within the country, who owns the Global Fund process?

A major overhaul of Country Coordinating Mechanisms (CCMs) some years ago was stimulated by the realization that government agencies are not the sole representatives of their countries and peoples.  While civil society and non-governmental organizations were expected to play a role in CCMs, they were often ignored and rarely had major roles in deciding on and implementing Global Fund sponsored programs in their countries.  Sometimes the advocacy mentioned by AIDSPAN was prompted by CSOs and NGOs not being heard within their own countries.

AIDSPAN mentions changes that the Global Fund has strongly suggested such as having dual track principle recipients (PRs) representing government and the non-governmental sectors.  While this may have represented a somewhat heavy hand from Geneva, the results sometimes reflected the status quo ante and NGO PRs were often relegated to less well funded aspects of programming such as behavior and social change.

Global Fund recipient countries represent a wide diversity of political systems in various stages of evolution.  It would be naive to expect that country ownership really embodies democratic participation of all stakeholders, public, private and NGO, in decision making and implementing on an equal footing – and no one really believes that is fully possible in at present.  Still it is a long term goal and a principle that should guide funding decisions as much as the quality of the technical content of proposed activities.

In the meantime we can look for additional ways and means to hold countries accountable for their health and social programming decisions. A good example is peer influence from the African Leaders Malaria Alliance (ALMA) which regularly publishes a scorecard of progress toward key health indicators. This freely available score card shows for example, in the first quarter on 2013 only six countries meeting the criteria of good financial management set by the World Bank. In the countdown to 2015, only eight countries are on track in terms of breastfeeding coverage.

As AIDSPAN observes, “But one has to acknowledge that, in the process, the concept of ‘country ownership’ is certainly evolving. Perhaps it will evolve further under the new funding model.” We hope the concept evolves along lines of full and equal partnership among all stakeholders within a country – that all sectors and peoples within a country will truly ‘own’ and thus influence the decision and actions around programs supported through the Global Fund.