Category Archives: Partnership

Training Ghana private sector workers to be ‘malaria-safe’

by Emmanuel Fiagbey, VOICES Project – Akosombo, Ghana: April 24, 2012

Volta River Authority (VRA) Heads of Departments and Safety Coordinators become Malaria-Safe Agents

The Volta River Authority, one of the largest body corporates in Ghana with a total workforce of over 3,000 personnel has made yet another move to live up to its motto of “Setting standards for public sector excellence in Africa.” The Authority with its many operational sites of workers and their families located in Akosombo and Akuse in the Eastern Region, Aboadze in the Western Region, Accra and Tema in the Greater Accra Region, Sunyani and Techiman in the Brong Ahafo Region, Tamale, Wa and Bolgatanga in the three northern regions of the country has embarked on efforts to make the authority a Malaria-Safe institution.

heads-of-depts-and-safety-coordinators-who-attended-the-training-program.jpgAs part of activities marking the 2012 World Malaria Day, the Health Dept., Human Resource Dept., and the Project and Systems Monitoring Dept. of the VRA in partnership with the Johns Hopkins University Bloomberg School of Public Health Center for Communication Programs, (JHU-CCP) Voices for a Malaria-free Future project and the National Malaria Control Program, organized a one day training of 15 heads of departments and 30 Safety Coordinators of the Authority at Akosombo with the goal of equipping the officials with the knowledge and skill of operating as Malaria Safe Agents within the authority. Other departments represented at the training included the Environment and Sustainable Development Dept., Engineering Services Dept., Hydro Generation Dept., Thermal Generation Dept., General Services Dept., Real Estates and Utility Services Dept., Northern Electricity Dept., VRA Schools Dept., Corporate Communication Dept. and the Senior Staff Association.

In an opening speech read on his behalf by Mr. William Amuna, Director Project and Systems Monitoring Dept., the Chief Executive Officer of the VRA, Mr. Kweku Andoh Awotwi stated that the position of Safety Coordinators in organizing safety meetings places them in the best position and provides them the best platform to help promote malaria prevention and adoption of effective treatment behaviors among the VRA workforce, staff families and communities around them. “I would like to believe that today marks a humble beginning of the collaboration between the Volta River Authority and the JHU-CCP-Voices project for a more effective and efficient implementation of the authority’s malaria control program.”

In presenting the statistics on malaria cases within the authority, Dr. Rebecca Acquaah-Arhin, Director Health Services Dept. regretted the increase in malaria cases recorded at the authority’s health facilities in the past three years, (2009-2011) which rose from 10,803 cases in 2009 to 16,241 cases in 2011. Dr. Aquaah-Arhin explained that, in spite of the excellent health services the VRA provides to its workers and their families, and also reaching over 2 million inhabitants along the Volta lake, malaria remains a threat to performance and wellbeing. Stating the impact of the disease on the workforce, she noted that in 2009, 2,324 malaria cases were recorded among employees and their dependants. This rose to 2,523 in 2010 and dropped a little to 2,392 in 2011. Malaria, she stressed cost the VRA 82,943.84 Cedis (approximately $52,000) in 2011 alone, “and this is the challenge our partnership with the JHU-CCP Voices project and our Malaria –Safe program must lead us in planning and working to resolve,” she emphasized.

section-of-participants-discuss-the-malaria-safe-strategy.jpgA National Voice against malaria, Dr. Atsu Seake-Kwawu who led the technical session of the training programme stressed that Safety Coordinators could only operate effectively as Malaria-Safe Agents by remaining continually in touch with current relevant information on the causes, prevention and treatment of malaria and most especially the recommended interventions by the NMCP in managing the disease. He called on all Safety Coordinators at the workplace and also in their communities to ensure the recent mass distribution of LLINs produces positive results by ensuring all who have the nets sleep under them every night. “Your role as Malaria-Safe Agents and Safety Coordinators will not be complete if you fail to challenge any health worker, drug distributors etc who will continue to distribute monotherapies such as Chloroquine in your community. ACTs, in particular the AMFm brand must remain your drug of choice for the treatment of all cases of uncomplicated malaria,” he stressed.

The VRA Malaria-Safe Strategy which was presented for discussion by the Country Director of the JHU-CCP-Voices for a Malaria Free Future project Mr. Emmanuel Fiagbey outlined the objectives, barriers, opportunities for applying the strategy and actions the Volta River Authority must sponsor in order to make the organization malaria-safe. Among the key functions of the authority’s Safety Coordinators as Malaria Safe Agents identified during the training workshop were:

  • Incorporation of malaria information dissemination and education into the agenda of safety meetings at the workplace and in the community;
  • Promotion and dissemination of malaria prevention and treatment messages among the workforce, staff families and communities;
  • Facilitation and organization of special workdays to get rid of mosquito breeding sites in workers’ communities;
  • Serving as models in the use of ITNs and adoption of other prevention and treatment behaviours among their community members; and
  • Ensuring involvement of all departments of the authority in the implementation of the VRA Malaria-Safe Strategy in the three strategic objective areas of;
    1. Strengthening the workforce against malaria to reduce the effect of malaria and enhance productivity of every worker.
    2. Empowering mothers/caregivers and children and other dependants of VRA workers to be appropriately engaged in malaria prevention and treatment.
    3. Engaging surrounding communities as partners and beneficiaries in malaria prevention and treatment.

The VRA Malaria-Safe Strategy which was developed with technical assistance from the Johns Hopkins University Center for Communication Programs Voices Project and the Asuogyaman DMAT will be finalized and officially launched in November as a major component of the VRA’s annual safety week celebrations.

A World Bank for the 21st Century (and malaria elimination?)

By the end of this week someone will be nominated to replace Robert Zoellick as President of the World Bank.  Traditionally this nomination has been made by the United States, and it appears that this tradition is likely to be maintained.  The question is whether the traditional nominee – a white, older male of US citizenship – will be able to lead the World Bank in the Twenty-first Century.

The Washington Post today features two articles on this critical rite of passage. Howard Schneider raises, “The question now is whether the bank’s new leader, who could be named in the coming days, can enhance the institution’s role at a time when developing countries are emerging as the engines of world economic growth.” The mixed roles of the Bank – lender, donor, provider of technical assistance – and the emergence of other major and upcoming economic strong houses leads Amar Bhattacharya of the G-24 Secretariat to ask whether there is a clear goal for the institution at this point in time. His answer is ‘No.’

In contrast Michael Gerson sees a positive future because Zoellick’s leadership, he believes, leaves the “rarest of legacies: a multilateral institution with its reputation enhanced. Zoellick acted decisively to help stabilize the finances of struggling nations during the worst of the financial crisis, as well as to provide relief to countries hit hard by a worldwide spike food prices. He has increased transparency at the bank while successfully raising funds to recapitalize it.”

Gerson stresses the Bank’s need to listen to countries that receive its loans or grants since he sees no ‘silver bullet’ emanating from external development or aid experts. He traces as an example the evolution in country needs and requests from Rwanda which asked for emergency food aid in 2007, but a few years later sought investments to increase agricultural productivity and “Now is asking for help building storage facilities, so expanding crop yields are not wasted.”

Schneider does stress that the technical knowledge provided by the Bank is of equal importance as the financial resources it can mobilize. Who then is in the best position to marshal needed technical inputs while at the same time maintaining a humble leadership style that emphasizes that we need to learn from the low and middle income countries themselves?

According to the Washington Post, the current suspected nominees have ranged from Hillary Rodham Clinton and Sen. John Kerry to Susan Rice and Lawrence H. Summers, though for various reasons these have said they are not interested or are unlikely choices.

wb-booster-countries.jpgJeffrey Sachs has let it be known that he is interested in the job, though Schneider notes, “But he says the administration has not approached him.” Sachs is certainly familiar with the needs of low and middle income countries, but would he or the other US candidates take a learning, rather than a prescriptive approach to working with these countries?

Another name breaks the US white male mold – Nigeria’s Finance Minister and Coordinating Minister for the Economy, Dr. Ngozi Okonjo Iweala. CP-Africa recently reported that, “Dr. Okonjo Iweala reportedly recently told the BBC that it is time to open it up to competition and that top jobs at international institutions should be filled on merit.”  They also though that such an appointee would only be successful with support from China.

What is at stake for the malaria community? Currently the World Bank has commitments for malaria control in 21 African countries up to US$ 762.8 million.  This has been used to finance over 73.8 million treated mosquito nets and 25.3 million doses of effective malaria medication over the past five years, a major dent in the overall efforts to scale up malaria control.  Given the current questionable status of Global Fund support, efforts by all other partners including the World Bank are crucial.  Hopefully the new leadership at the Bank will sustain this in line with the commitments of each national malaria control program.

Challenges in signing Global Fund Grants

Our colleagues at the West Africa Regional Network (WARN) of the Roll Back Malaria Partnership have been deliberating on the challenges facing countries in signing their Global Fund Grant Agreements. Many people do not realize that even when the GFATM Board approves a grant proposal, the grant does not become effective until a country prepares plans for implementation.  Only after such are approved, is the grant signed.  Below are observations and concerns from the WARN Secretariat.

Only two countries in West Africa were able to sign round 10 (Sierra Leone and Cap Verde). WARN noted that the countries that did not sign Round 10 or phase 2 of their grant registered significant delays due to:

  • Lack of understanding regarding the conditionality to be fulfilled before the signing
  • Cumbersome administrative procedures and communication bottlenecks between the countries and the Global Fund during negotiations

WARN Recommendations to the countries, Partners and PRs:

  • Secure the support of the network of partners all throughout the negotiations process
  • Involve local partners and WARN in the final grant negotiations with the Global Fund

WARN Recommendations to the Global Fund:

  • Send a team to the relevant countries to explain conditionality and make proposals for immediately resolving problems encountered
  • Send clearly stated correspondences to the countries and RBM partners indicating the planned date or period for the signing, failing which, the Portfolio Manager should provide the countries with explanations for the delay in the signing

It is likely that WARN is not the only region experiencing these problems.  As international funding support for malaria programs is threatened, Global Fund needs to ensure that whatever is available reaches those in need in a timely manner.

Private Sector and Malaria – Many Roles, Many Benefits

progress-and-impact-business-investing-in-malaria-control.jpgThe latest edition in the Roll Back Malaria Progress and Impact Series is “Business investing in malaria control: economic returns and a healthy workforce for Africa. “The report provides an overview of the direct and indirect economic costs of malaria and looks closely at activities by three businesses in Zambia to tackle the malaria problem.

These companies were “able to scale up malaria control quickly and have seen a rapid return on investment. Malaria-related spending at three company clinics in Zambia decreased by more than 75%, and a very conservative estimate showed that the companies gained an annualized rate of return of 28%.” These experiences provided “Strong models … for businesses to take leadership roles in controlling malaria, protecting their workers and their families, strengthening their businesses, and extending programmes into communities.”

In fact there are several different and complimentary business roles for participation in rolling back malaria as seen below …

  • Manufacturers of preventive and treatment commodities
  • Wholesalers and retailers of malaria prevention and treatment commodities
  • Private health service providers: Formal orthodox, Informal, Indigenous
  • Private companies and industries based in endemic areas that aim to prevent and treat malaria among their employees and surrounding communities
  • Private companies and industries that provide donations to or organize malaria programs whether they are based in endemic areas or not
  • Sales of non-malaria products with a proportion/donation to malaria programming, like PRODUCT RED
  • Private companies that donate to malaria programming through their Foundations

The RBM website that features the Progress and Impact Series on Business involvement provides 16 downloadable case studies on the different models outlined above. Several diverse examples follow:

  • The Azalaï Hotels Group in West Africa, an active participant in the United Against Malaria (UAM) campaign, implements programmes to protect its employees with nets and hotel guests against malaria.
  • The ExxonMobil Malaria Initiative protects employees, supports malaria research and enables NGOs to carry out innovative community malaria control efforts
  • The MTN telecommunications group uses its technology and communication platforms to educate communities through radio, television, SMS, billboards and fliers.
  • The Sumitomo Chemical Company not only produces long lasting insecticide-treated nets but has provided technical assistance toward the establishment of the A to Z Textile Mills, based in Arusha and Kisongo, Tanzania, to ensure locally produced net supplies.

Although not featured by RBM, AngloGold Ashanti in Ghana has maintained an indoor residual spraying from for all structures in Obuasi District for five years now. Cases of malaria illness have steadily reduced at the district hospital.  This protects employees, their families and the wider community.

The impact of individual business efforts may affect a community or a region and vary widely from place to place. In order for greater impact to be felt, national malaria control programs need to identify all potential and actual business partners and bring them into national partnership forums so that collectively the private sector impact on malaria will be most strongly felt.

Peace Corps Senegal

Thanks for the recognition of the efforts of Peace Corps Volunteers worldwide in malaria prevention. PC Volunteers and our partners here in Senegal pioneered the universal bed net coverage and malaria prevention education approach that has now been adopted by PMI and the Senegalese national malaria control program.

Already 7 of the nation’s 14 regions have achieved true universal coverage, including a pre-distribution house by house sleeping area/bed net census, village distribution and education events, and post-distribution hang checks. There is much left to do, but Senegal has made tremendous progress, and Peace Corps Volunteers have been at the center of the fight.

Looking forward as the agency celebrates 50 years, Peace Corps across Africa is developing a comprehensive campaign to replicate and adapt the experiences of PC/Senegal to the other two dozen PC programs on the continent.

Thanks again for recognizing the important role that our Volunteers can and will play in the effort to reduce malaria in Africa.

Chris Hedrick
Country Director, Peace Corps/Senegal
www.pcsenegal.org

Promoting world peace – controlling malaria

the United States Peace Corps is celebrating its 50th anniversary this year.  Volunteers have been working in malaria endemic countries since the beginning of the program. Here we will share a few recent Peace Corps malaria activities. We encourage current and former volunteers to share with us their experiences and lessons learned in controlling malaria.

peacecorps_gov.jpgIn Zambia the Peace Corps has partnered with a local NGO called Youth Activists Organization to bring advocacy messages and educational materials to the community level. Peace Corps Senegal reports that …

Peace Corps Volunteers in all regions of Senegal are leading efforts to prevent malaria, the leading cause of child mortality in Senegal. Volunteers are providing malaria prevention education and have led insecticide treated mosquito bed nets distribution campaigns that have become a model for the rest of Senegal. These efforts are leading to the first large scale universal bed net coverage in the history of Senegal, aiming to significantly reduce malaria caused disease and deaths.

Individual volunteers have written about their experiences, as seen in the following account from Senegal

I worked with three phenomenal community health workers to organize and distribute nets to every family. In the weeks leading up to the distribution, we surveyed all of the families, counting their sleeping areas and numbers of nets in good repair. Working over three days, we traveled house-to-house distributing nets. The chief of Goudel Comi was overcome with gratitude. 

Peace Corps volunteers have even been the subjects in malaria research. One study examined self-reported adverse events associated with long term antimalarial chemoprophylaxis in over 1700 Peace Corps Volunteers. Another study monitored mefloquine resistance in Peace Corps Volunteers.

The Peace Corps even enters into classrooms in U.S. schools from grades K-12 to offer curricular ideas and share experiences from the field. Students can simulate the role of a Peace Corps Volunteer working to prevent the spread of the disease.

The success of malaria control ultimately rests in and with the community. Peace Corps Volunteers are strategically placed to help make sure this happens.

Can Southern Sudan Vote for Independence from Malaria?

As the New York Times in describing preparations for the independence vote in Southern Sudan points out today, “With little more than a week to go until the vote, ballots have been printed, voters registered and campaign rallies held. A countdown clock is posted in the capital, Juba, and foreign officials are flying in for the occasion.”

According to the Times The United Nations Development Program (UNDP), which is responsible for demobilizing various armed forces in the area,may have ” grossly mismanaging the money and may have even intentionally misled donors as to the program’s success.”

The UNDP is also responsible for the Global Fund Round 7 Malaria Grant in Northern Sudan. It may be doing a better job with its malaria assignment. The most recent grant progress report rated them well with a ‘B1’, but raised the concern that, “The cash absorption rate during this reporting period is only 56% of the budget. This is attributed to delays in procurements.”

sdn_mean-ss-line-2.jpgThe North has a mix of malaria transmission situations, while the South is squarely in the endemic zone (as seen in map to right). When the South votes soon for Independence, what will be their own chances of becoming independent from malaria?

The Round 7 Malaria Grant in the South is managed by PSI. The Grant started 2 years ago and currently also rates a ‘B1’. At the most recent grant progress report dated October 2010, the following were achieved:

  • 86% of ITNs had been distributed
  • 10 BCC media campaigns had been implemented and over 6000 community organization staff had been trained, exceeding targets
  • Only 17% of targeted children had been treated with ACTs in the community
  • Health facilities exceeded expectations in terms of maintaining ACT stocks

The progress report concludes that, “Strengthening the capacity of the health system to
deliver health services including malaria interventions have fallen behind set targets, due to late SR selection and contracting, and the PR focusing on the LLIN mass distribution campaign. Nevertheless, results seem to be gaining on set targets.”

Southern Sudan is not without malaria partners. For example, PSI has been working Southern Sudan since “January 2005, distributing Serena long-lasting insecticide-treated nets (LLIN) through the commercial sector … (and providing) support to the Ministry of Health (MOH), Government of Southern Sudan, and county health departments to prevent and treat malaria.” The IRC has trained “villagers to recognize and treat young children for malaria, diarrhea and pneumonia has helped to reduce child deaths by 81 percent in one area of Southern Sudan.”

USAID is also working to help tackle the malaria problem in Southern Sudan. The area has been one of three ‘non-focus’ countries – that is not formally under the US President’s Malaria Initiative (PMI). Two of these countries, Nigeria and Democratic Republic of the Congo, have been added to the formal PMI roster. One wonders whether the fate of malaria control in Southern Sudan rests on the election outcomes.

The BBC quotes a Southern Sudanese nurse who compares the upcoming referendum, “.. as a mother giving birth to twins – once the labour pains are over, the two children can grow up as friends .” We know that malaria during ‘pregnancy’ and during ‘infancy and young childhood’ are threats to survival. We hope that all donors will continue to work for the survival of these Sudanese ‘children’ and bring about a true independence from malaria.

United Against Malaria and CECAFA: Protecting fans through football

Guest Posting by Bremen Leak, Voices for a Malaria-Free Future, Bamako Office Johns Hopkins University – Center for Communication Programs

uam-cecafa-sm.jpgThe 2010 FIFA World Cup South Africa may be over, but Africa is still fanatic about football.

That’s why the United Against Malaria partnership—forged ahead of the World Cup to raise awareness about malaria through football—continues to fill stadia and airwaves across the continent with critical messages about malaria prevention and treatment. Today it’s the humanitarian face of the CECAFA (short for the Counsel of Eastern and Central African Football Associations), organizer of Africa’s oldest football tournament and the year’s biggest football competition since the World Cup.

A 12-team tournament lasting 16 days, the CECAFA Challenge Cup has drawn as many as 60,000 fans per game since its started on Nov. 27 in Dar es Salaam, Tanzania. These fans are primarily men, considered the decision-makers and breadwinners of Tanzania.

To reach this key demographic, Voices for a Malaria-Free Future, through Johns Hopkins Bloomberg School of Public Health—a founding partner of UAM, has joined forces with CECAFA and local beverage maker Tusker to bring attention to the region’s deadly malaria statistics, one football game at a time.

In Tanzania, for example, malaria claims some 80,000 lives each year—almost one in ten of all malaria-related deaths in Africa. In the long run, those deaths rob football clubs of talent, vitality, and World Cup victory, which is why CECAFA’s chair, Leodegar Tenga, announced last week that CECAFA and UAM “shall be partners forever, until we eradicate malaria.” As a result, five additional CECAFA football federations have since joined the campaign.

The official support of CECAFA and the tireless efforts of Tenga have helped UAM continue to educate fans, inform the media, and engage business and political leaders. As the opening ceremony began, Tanzanian President Jakaya Kikwete joined Tenga on the field to greet the UAM ball boys during the opening ceremony.

Throughout the tournament, UAM banners will fly on the field and in the parking lot. Players, ball boys, team escorts, and officials will wear UAM T-shirts or uniforms. And all printed programs will feature simple messages labeled “winning moves to beat malaria, protect your family, stay healthy, and save money.” These include sleeping under a long-lasting insecticide-treated net every night, visiting a health center for malaria testing and treatment when sick, and encouraging pregnant women to seek antenatal care.

More information on UAM and CECAFA may be found online at www.unitedagainstmalaria.org and www.cecafa.net

Malaria and HIV 2010

Another World AIDS Day has come and passed. Sarah Boseley has commented on the information overload that comes this time of year on the disease and the range of basic health programming and valiant efforts to control it. This led to thoughts on whether there are any new developments concerning the connections between Malaria and HIV.

A quick look at the most recent PubMed listings for “Malaria AND HIV” mostly yielded sentences with the common theme of “AIDS, TB and Malaria” that considered the big disease funding efforts and the combined global burden of disease but few new insights on how each disease affects the other. Some interesting examples were uncovered.

On the biological side, Jiang and colleagues in the journal Vaccine (2010 Nov 23;28(50):7915-22) observed that, “Malaria and human immunodeficiency virus type 1 (HIV-1) infection overlap in many regions of the world.” Using mouse models they found that, “important implications for the development of a new form of bivalent vaccine against both HIV-1 and malaria.”

On the programming side, Lugada et al. examined how “Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases,” in rural Kenya, and reported on a campaign that provided, “HIV counseling and testing, 60 male condoms, an insecticide-treated bednet, a household water filter for women or an individual filter for men, and for those testing positive, a 3-month supply of cotrimoxazole and referral for follow-up care and treatment.” (PLoS One. 2010 Aug 26;5(8):e12435)

Reid reported on how injections for suspected malaria cases in drug shops and stores Tanzania and other rural African settings sets the stage for HIV and other infections. The need to prevent such practices can help both diseases. (Rural Remote Health. 2010 Jul-Sep;10(3):1463)

Noting that, “Co-infection of human immunodeficiency virus (HIV) with malaria is one of the pandemic problems in Africa and parts of Asia,” Oguariri and co-investigators examined, “the impact of pyrimethamine (PYR) and two other clinical anti-malarial drugs (chloroquine [CQ] or artemisinin [ART]) on HIV-1 replication.” They showed that, “10 μM CQ and ART inhibited HIV-1 replication,” while “10 μM PYR enhanced HIV-1 replication.” This is important news for malaria case management in areas with high HIV prevalence. (Virus Res. 2010 Nov;153(2):269-76)

While these studies individually may not be earth-shaking, they do point to the continued need for partnership between Malaria and HIV control programs – common interests do exist together with the common desire to save lives.

Sierra Leone – nets without the Global Fund

Widespread efforts to scale up insecticide treated net ownership to meet 2010 Universal Coverage targets are underway in most endemic countries of Africa.  The majority have been using their Global Fund grants to make this leap, supplemented by contributions of other partners.

What happens when a country does not have Global Fund resources at this time? Current efforts in Sierra Leone to reach its nearly 6 million citizens provide a lesson on how to cope.

The AFP has reported on a “20-million-dollar campaign to distribute mosquito nets has been funded by the World Bank, the British Department for International Development (DFID), the Federation of the International Red Cross, the United Methodist Church and other health partners.” These partners are “attempting to get insecticide-treated mosquito nets into each household in the country and to ensure their proper use,” using a house-to-house campaign, which is challenged by poor road conditions.

VOA quotes Lianne Kuppens of Unicef in Sierra Leone who said, “”We have roughly 6 million people and we have 3.2 million bed nets already in the country as we speak. So it’s the first time ever that we are going for universal coverage of bed nets.”

Kuppens also noted that ITN use by children below 5 years of age was below 25%, a problem exacerbated by net mis-use – “nets often find their way into the marketplace or are used as fishing nets or shower scrubs. Vegetable growers use mosquito nets to protect cabbages and carrots from harmful bugs.”

VOA also reports that the campaign has a strong “hang up” component that is using “Street theatre, community radio and religious leaders (to) help convince people that hanging their nets over their beds is better in the long run than selling them or catching fish with them.”

round-7-grant-performance-summary.jpgBut back to the Global Fund …

Sierra Leone’s experience with the Global Fund (GF) may certainly be influenced by its status as a post-conflict country.  The Principal Recipient of the current Round 7 Grant, the Ministry of Health, has, according to GF progress reports, experienced some management challenges.

The Round 7 grant has been running for 2 years and just recently received a “conditional Go” for Phase 2 funding.  ITNs were a small piece of this grant that aimed more at improving malaria treatment.  By 30th April 2010 the grant had distributed only 277,093 of a targeted 312,498 nets for young children and pregnant women.

While the GF does not attempt to strengthen health systems directly, it certainly makes it possible for countries to use grants for their own health system strengthening efforts. More countries should take advantage of this potential. In the meantime, partners should continue to pull together as is the case in Sierra Leone to ensure Universal Coverage.