Tropical Health Matters

Kenya is not only facing increased budget demands to treat malaria using the newer effective antimalarial drugs, it also must deal with expanding habitats for the malaria carrying anopheles mosquitoes.

The East African media organization reported, “The money used last year for malaria was the largest amount ever spent in one year in Kenya on a single disease other than HIV/Aids, and analysts say this reflects both the growing commitment of donors and the government to combat the country’s leading killer.” While donor support such as that from the Global Fund to Fight AIDS, TB and Malaria, can make child doses of Coartem available to the country at cost – about one US dollar – the country must cope with market pricing to meet its total malaria drug needs. This may range upwards to $US 8 per treatment for the consumer. If countries do not forecast and fund their total antimalarial drug needs for both children and adults, cheaper medicines from donor funds may be misused for adult clients who have malaria.
The article also implied that countries may feel resentment because they perceive that that WHO and other donors have forced their hand in adopting new drug policies that favor Coartem among other combination therapies.  Apparently the Pharmaceutical Society of Kenya (PSK) protested that the drug was too expensive. The PSK was worried that this decision to promote Coartem could not be sustained when donor funds wound down.  If countries decide to return to cheaper but less effective alternatives, the small headway made in recent years will be lost. Clearly this should be a wakeup call to donors and the pharmaceutical industry to find cheaper AND effective alternatives.

If the $US 58 price tag for antimalarials in one year was not enough of a challenge, Kenya is also faced with expanding mosquito habitats.  According to The Standard “The discovery of malaria-causing mosquito (Anopheles gambiae) in the Central highlands may have been a surprise to many, but not to climate change experts.” People living in these new malaria territories do not have the acquired immunity that those in endemic areas have, and hence the impact will be great.  While Kenya itself cannot control global climate change, being the home of the UN Environmental Agency, it should be a major advocate for encouraging global cooperation on the issue. In the meantime Kenya will have to budget even more scarce funds for malaria drugs, insecticide treated nets and IRS.

Finally, a third challenge is program management. Although one can empathize about the dilemmas facing Kenya, one needs to draw attention to the fact that the Global Fund does have concerns about how Kenya is managing the support it is receiving to provice malaria treatment. According to the Round 2 Malaria Grant Score Card (2005) which states: “The Program has failed to meet targets inseveral important service delivery areas (SDAs) including distributionof insecticide-treatednets (ITNs) (0% of target) and no data is available for number of people receiving treatment for Malaria, pregnant women receiving IPT (Intermittent Preventive treatment) or Case fatality rate.” the progress report of November 2006 shows some progress on IPT, but not nets and treatments received.

A concerted donor-country effort is needed to meet these triple challenges in a timely manner.

Recently we examined a proposal that financial support from the Global Fund to Fight AIDS, TB and Malaria (GFATM) be used to sustain health systems.  Two decisions by the GFATM Board in April make this proposition seem less like wishful thinking.  The first of these challenging decisions was to attempt to mobilize resources to reach $US 8 billion annually by 2010. This represents a quadrupling of current resource levels and approximately one-quarter of what the partners project as total resource needs to fight the three diseases by that time, i.e. US$ 28-31 billion per year.

The second key decision was the establishment of the “Rolling Continuation Channel” (RCC). The RCC would provide CCMs with the opportunity of applying for continuing funds for existing grants before they expire as distinct from submitting new grant proposals. The caveat is that eligibility would be reserved for high performing grants.

How would malaria grants fare under the RCC regime? The GFATM’s Progress Report 2007 notes that two malaria indicators/targets, ITNs distributed and anti-malarial treatments provided, fall below achievements for TB and HIV targets. To date, malaria grants have the lowest proportion scoring a performance rating of ‘A’, 16% compared to 25% for HIV and 32% for TB grants. If both ‘A’ and ‘B1’ ratings are defined as ‘high performance’, malaria does a little better comparatively (71%), through still in last place after HIV (74%) and TB (84%).

How can malaria grants become stronger performers and thus qualify for RCC? Recently Roll Back Malaria partners have provided concerted assistance to a number of countries to ensure that they submit the strongest GFATM Round 7 grants possible.  At a discussion forum sponsored by the Global Health Council, Dr. Michel Kazatchkine, the new Executive Director of GFATM, talked about the need not only for assistance in grant development, but also in quality implementation when he said that, “I’ve been saying when talking about partnerships that we need those not only to design the grant and be the best request possible but also to help it being implemented.”

Dr. Kazatchkine suggested that a better coordinated “reservoir of technical assistance” be made available.  The job of technical assistance is actually not within the mission of the GFATM, and so the onus to ensure that malaria grants succeed, and thus be eligible for RCC, falls back on partner groups like RBM. One could call such inputs the ‘hidden costs’ of GFATM grants. Hopefully all countries and donors will recognize that contributing to the GFATM is only one side of the coin, and that grants once awarded may not be sustained without extra resources needed for technical implementation support.

The Global Fund to fight Against AIDS, TB and Malaria (GFATM) has to date awarded only about one-quarter of its resources to malaria grants. A new publication entitled Partners in Impact Results Report from GFATM summarizes key activities and performance up through December 2006. There may be some argument about the relative cost of HIV versus Malaria interventions, but as we see from further analysis of grant performance, malaria grants could benefit from more funding to address health systems issues that challenge good performance.

The first two charts seen here summarize concerns presented in the 2007 Results Report. As of December 2006, 215 grants had reached Phase 2 renewal status. A smaller proportion of malaria grants have achieved the higher status “A” and “B1” classifications concerning performance than HIV or TB grants. Furthermore, when one compares grant performance against targets set by the grants themselves, once can see that Malaria Interventions (ACT and ITN distribution) are less likely to achieve their targets than HIV (ARV distribution and Counseling & Testing, for example) ot TB (DOTs). Clearly Malaria Grant recipients need additional funds and technical assistance to improve their performance.

This brings up another interesting issue. The Results Report also summarizes performance by type of Principal Recipient. NGOs and Civil Society Organizations receive 30% of funding but according to the third chart below, their grant performance is better than government agencies or the UNDP. Although a direct connection cannot be made from the data in the report, this finding suggests that Malaria Grants might benefit from greaer involvement from the NGO sector. In the meantime, technical assistance for malaria grants is needed not only for developing better proposals in Round 7, but more importantly for ensuring that the existing grants perform better and thus justify continued malaria investments in those countries.

Ooms, Van Damme and Temmerman have recently argued that country support from the Global Fund to Fight against AIDS, TB and Malaria (GFATM) should address health workforce gaps so that the situation “Medicines without Doctors” does not lead to misuse or non-use of live saving drugs. The authors express how that the existence and commitment of the GFATM signifies the possibility of sustaining a commitment to funding a health workforce that poor countries cannot achieve due to varying challenges ranging from budgetary problems to the brain drain. This takes sustainability to a different level and involves all countries, especially the richer industralized ones, in sustaining health for all.

These authors focus more on human resources for HIV/AIDS. What are the special workforce needs for malaria? For example, there is need to have adequate staff who understand how to procure, manage, prescribe and counsel on ACTs.  In-service training (IST) may be part of the picture, but quality training is needed. This brings to mind a story about ‘jamboree training’ described by one colleague where over 300 district health staff were assembled and told everything about the GFATM project in just a couple days in order to meet promised training targets, which in turn one hoped would enable the meeting of ACT distribution targets. Workforce enhancement needs to be multidisciplinary – pharmacy, clinical, records, disease control and health education staff have different but interrelated roles to ensure that malaria interventions are planned, delivered and monitored. Districts not within the current scope of the GFATM project often do not get training on current or new national malaria guidelines, and the human resources in private sector are often left out.

Fortunately, attention to Health Systems Strengthening recommended by Ooms et al., is addressed in guidelines to countries applying for Round 7 of the GFATM. This may not solve the problem.  GFATM is not an unrelenting spigot of funding.  Securing a project does not guarantee that it will run for the proposed five years. As the end of the second year approaches, projects are reviewed, and if they are not performing – i.e. meeting indicators, they are not renewed for Phase II.  Similarly, just because a country wins a grant one year does not guarantee it will be lucky in securing future and continuing grants as Ooms et al. would hope. GFATM is ‘performance based.’

Clearly the global community has responsibility for preventing death and disability arising from malaria and other tropical diseases.  The GFATM offers hope, but is not yet the magic solution.  Of course this does not mean that we should accept the current reality, but instead should try to push the boundaries of the commitment to eliminating malaria by both endemic and donor nations.

This is the season when Central Coordinating Mechanisms in many countries are busy writing proposals for Round 7 of the Global Fund for AIDS, TB and Malaria. Many of the most endemic countries in Africa experienced failure in their Round 6 Malaria proposals. The Roll Back Malaria Partnership’s Harmonization Working Group has done commendable work to provide comprehensive technical assistance through two recent workshops to assist certain African countries to develop stronger proposals. The fear is that these new and improved proposals may face the same fate as last year’s group if more attention is not paid to the bottlenecks that have prevented achieving performance indicators in previously awarded malaria grants.

Much of technical assistance to date to GF grants has taken the form of proposal drafting assistance. Although CCMS are free to include in their proposals provision of technical assistance, few do. Until recently grants reached the Phase II renewal process with troublesome implementation bottlenecks ranging from poor procurement systems to inadequate monitoring and evaluation. It was estimated that nearly 40 countries were facing these implementation bottlenecks in 2006. Recently the Global Fund has inaugurated an Early Alert and Response System to identify these problems. The question is who will help provide TA for projects that are already in progress? Without addressing the existing bottlenecks, not only will current grants be lost, but new proposals will reviewed with a strike against them.

During the past year the US Government recognized the inhibiting effect these bottlenecks were having for both Phase II renewal and the success of new proposals. At present the US provides over one-quarter of all funds to the Global Fund, and does not want to see that investment lost when timely technical assistance could turn a project around. The challenge has been getting CCMs to request the technical assistance, but where they have, as was the case of the Nigeria Malaria Grant, it has helped. More countries are encouraged to take advantage of existing technical assistance channels as well as to write into their new proposals funds for getting technical assistance as they implement their programs.

A theme of non-governmental actors in the battle against malaria was echoed by two politicians recently. One stressed the importance of NGOs at the national level, while the second emphasized the role of non-governmental players on the international scene.

Alhaji Umaru Musa Yar’Adua, one of Nigeria’s presidential candidates, asked civil society groups in the country to brainstorm and produce a framework for monitoring the implementation of government projects, according to ThisDay. The candidate observed that, “Some of our health policies like the free malaria treatment is based on this policy and it is (sic) working efficiently,” although success overall in health and social programs requires a partnership between government and civil society, especially in monitoring and guaranteeing efficiency. Just last year Nigeria added a coalition of NGOs concerned about malaria to the constituencies electing representation to their Global Fund Country Coordinating Mechanism (CCM). A greater role for these constituents in grant implementation is needed in Nigeria and elsewhere.

Great Britain’s Prime Minister Tony Blair delivered the closing speech at World Economic Forum in Davos. Blair emphasized that, “Into the void between identifying an issue’s importance and securing the means of acting on it, has increasingly stepped the non-governmental and non-state actors. The resource of the Gates Foundation is being put to the eradication of Malaria – a preventable disease which kills one million a year.”

The long term solution to malaria control will ultimately rest on a partnership between government and non-governmental actors, and even leadership by the latter. Part of the reason why malaria eradication failed in the 1950s and 1960s was inability of the health systems to incorporate and sustain the effort. Hopefully, 40-50 years later, health systems are stronger, but challenges seen in Global Fund Score Cards for malaria grants commonly point to systems and management issues as threats to malaria grant performance. National and international civil society groups, NGOs, corporate sponsors and philanthropic organizations must maintain an active role in the fight against malaria.

According to the Ghana Chronicle of 24 January 2007, the National Malaria Control Program (NMCP) reports that the number of child deaths due to malaria has been cut in half.  The achievement is credited to the country’s grant from the Global Fund to Fight AIDS, TB and Malaria (GFATM).  Ghana is the recipient of two GFATM grants for its malaria program. The NMCP Director was quoted as saying, “Malaria reported cases dropped from 3.5 million in 2003 to about 3.1 million in 2006”, as a result of these grants. She went further to enumerate that 1.5 million ITNs had been distributed and 4 million tablets administered for malaria treatment. This sounds good in the press, but is this progress real? A visit to the Global Fund website confirms achievements.

A GFATM representative who was present stressed that the Global Fund is a performance based organization.  In short, release of funds is based on achievement of targeted indicators. During the first two years of a GFATM grant, known as Phase 1, key indicators are more along the lines of processes (staff trained, resources in place) and outputs (commodities distributed).  On entering Phase 2 a country is expected to start reporting actual epidemiological progress on disease control. Effective and integrated national monitoring and evaluation systems are crucial for measuring performance that guarantees continued release of grant money.

Ghana’s Round Two Malaria Grant has passed this hurdle and has entered Phase 2.  The ‘score card’ issued for Round 2 Phase 1 performance is quite positive in noting that, “Within the first 16 months of the Program and in spite of procurement delays, 150,000 ITNs have been distributed (reaching the Month 18 target three months ahead of schedule). Additionally, by the fifth quarter of the program, 57,623 women had received IPT (360% of target). The program’s community-based agents (4039 trained, 183% of target) raised awareness and sustained the demand for both of these interventions. In Ghana 70% of malaria attacks are managed at home. A key feature of the program has been to educate home caregivers to respond more quickly and efficiently to malaria cases as they occur within the family. 1454 health workers (309% of target) and 3828 community agents (239% of target) have been trained in home-based malaria care.”

Ghana’s second malaria grant, awarded during Round 4, is also performing well according to the progress report on the GFATM website: “PR (Principle Recipient) has achieved or overachieved most targets. Surveys are ongoing to document results related to three outcome/impact indicators. Expenditure rate is satisfactory and implementation rate is on track with planned activities.” For example, implementers report that 214% of the target for women received Intermittent Preventive Treatment, and 155% of the targeted children under five years of age had slept under an ITN prior to the survey.

Ghana sets a hopeful example for not only getting malaria resources and commodities out to people in need, but also in being able to track and report progress. Fortunately the GFATM offers guidance in Monitoring and Evaluation. The challenge in phase two will be verifying that this infusion of external funds does result in lower morbidity and mortality and that the country can sustain these efforts after the grant expires.