Tropical Health Matters

Advocacy is really a behavior change strategy aimed an policy makers and policy implementers. As such it turns the tables on the traditional behavior change communication approaches that target the community and consumers. Instead the community and consumers through advocacy try to educate the policy makers. At minimum there are three basic components to advocacy:

1. Promoting enactment of policies, laws, standards, guidelines
2. Ensuring that policies are actually funded
3. Monitoring approved policies to be sure they are fully implemented

Galer-Unti and colleagues outline several advocacy strategy approaches to make sure policies are enacted and their benefits reach the public. These strategies involve individual and as well as community commitment for action.

1. VOTING for officials who are likely to enact and uphold policies that promote public health
2. ELECTIONEERING and campaigning for candidates who promise to support public health
3. LOBBYING elected officials and decision makers to follow through on promises to promote public health
4. MOBILIZING THE GRASSROOTS to petition, meet and influence decision makers
5. USING THE INTERNET to draw attention to public health concerns
6. ADVOCATING THROUGH THE MEDIA either by writing news and opinion pieces, serving as a resource for reporters or even better, by staging events that will attract media attention and thereby, that of policy makers

What does this mean for malaria? These days most countries have received guidance from WHO and the Roll Back Malaria Partners in developing national malaria treatment and prevention guidelines and policies. For example, these policies spell out national support for the use of Artemisinin-based Combination Therapy (ACT) for first line case management. It is therefore often at the second and third levels – budgetary support and implementation support – where much of the advocacy is needed.

An example of the follow through needed to make policies a reality comes from Nigeria’s ITN Massive Promotion and Awareness Campaign (IMPAC). The federal government rallied donor support and some domestic funds to acquire seed stocks of ITNs. Memoranda of Understanding (MOUs) were signed with most state and local government (LG) officials indicating that they would supplement ITN stocks to ensure all in need were reached. Unfortunately after the initial federal stocks were exhausted, no further supplies were provided by states and LGs. The federal government continues to mobilize donor support for ITNs, for example through Global Fund, USAID and DfID, and some corporate philanthropic and foundation efforts contribute additional nets, but supplies have been limited.
Fortunately the National Malaria Control Program (NMCP) had budgeted some funds for advocacy. Visits to selected states yielded some results. For example even though it was not a donor recipient, the Niger State Government after an advocacy visit actually purchased nets and undertook distribution. More work is needed to mobilize the grassroots so that they demand nets from their local health departments, but at least we can see that advocacy can work in an African setting. Hopefully this will inspire NMCPs in other countries to get on the advocacy bandwagon.

Cotton subsidies enjoyed by U.S. farmers has a dampening effect on agricultural family incomes in the Sahelian countries of West Africa according to a news story in the New York Times. An Oxfam supported study found that a typical farm family of 10 in Chad, Mali, Burkina Faso or Benin “that now earns $2,000 a year would have an extra $46 to $114 a year to spend if American subsidies were removed.

While critics were quoted as saying that the amount of gain is low, that cotton prices are naturally volatile, and that countries would gain more by investing in industry, the seemingly slight potential economic improvement would be quite meaningful to rural families.

Daniel Sumner of the University of California Davis, who was involved in the Oxfam study, has previously written that, “The United States is the only WTO member that highly subsidizes cotton and that plays a significant role in the global cotton market.” He Further explains that, “Unlike rice, where poor nonfarm consumers likely gain from lower world prices, the rich-country cotton subsidies likely have little benefit for any of the poor in poor countries. And, unlike sugar, for which some poor countries get valuable preferential access to rich-country markets, there are no poor-country cotton producers that gain from the rich-country cotton subsidies.”

Oxfam has been raising concern about the cotton subsidy issue for over five years. For example in 2002, Oxfam explained that, “American cotton subsidies are destroying livelihoods in Africa and other developing regions. By encouraging over-production and export dumping, these subsidies are driving down world prices. Oxfam also documented that, “Federal subsidies to the 25,000 US cotton farmers were worth more than $4.2 billion dollars in 2004-2005 – more than the gross national product of Burkina Faso.” In addition to subsidies, Oxfam has addressed World Bank policies and programs that seem privatization of the cotton industry at the expense of the rural poor.

So what if the poor in the Sahel cotton producing countries had the extra cash? Would they use it to buy bednets to prevent malaria? Would they access ACT malaria treatments? Such actions might help offset the tremendous economic burden of malaria. Freedom From Hunger Foundation has found a successful link between microcredit and controlling malaria by families whose income improves. Doing away with cotton subsidies in rich countries may have an even wider impact on poor families’ ability to control malaria in Africa.

The Ghanaian Chronical this week quotes a district medical office’s concerns “about the continuous sale of chloroquine at chemical shops and urged the Ghana Standard Board to intensify its activities to withdraw the chloroquine from the shops since it would negatively affect the new drug policy,” which lists artesunate-amodiaquine as its first line antimalarial drug. This is backed by research that shows Plasmodium falciparum is highly resistant to chloroquine in Ghana. The question arises whether it is feasible to ban chloroquine.

Nigeria has also gone through a change of malaria drug policy dropping chloroquine as the first line drug and substituting artemether-lumefantrine (AL).  When this happened, the press and the public assumed that a ban on chloroquine would soon follow, but this did not happen. To date chloroquine has not been banned, but efforts have been made to increase the supply of the new artemisinin-based combination therapy drug AL through support from donors like the Global Fund. The reality is that it takes time to transition to new malaria drugs, and when supplies of the more expensive ACTs are not yet available throughout the country, it would be irresponsible to ban other products.

A better approach than banning products is combining donor and national support to acquire adequate ACT supplies with education of both the public and health care providers (public and private) on the benefits of the new drugs. If adequate supplies of free ACTs are available, at least for children under five years of age, demand for chloroquine will naturally decline.

On the demand side, WHO has stressed the importance of educating the public on judicious use of antimicrobial drugs to prevent resistance, and also recommended that. “Education programmes must also be tailored to the needs of specific groups – be they village healers, market vendors, street dispensers, health care workers, paramedical assistants, midwives, nurses, dentists, doctors or others involved in primary care.” Hopefully the two-pronged approach of supply and demand will help countries like Ghana confront their chloroquine challenge.

PS: We shared recently findings from Malawi that after withdrawal of chloroquine in 1993, malaria parasites are again showing susceptibility to chloroquine.  The same experience may occur in Ghana and other West Africa countries in another 10 or more years if ACTs become not only the official policy but the only drugs that are actually demanded and prescribed. A work of caution is needed though. Juliano used new techniques to identify previously undetectable genetic evidence of continued chloroquine resistance in Malawi. This reinforces the importance of combination therapy as the only way forward in the future of malaria control.

A team of researchers from Burkina Faso and Germany have accused donors of lacking coordination in meeting the malaria drug needs of low income countries in endemic regions. They believe this lack of coordination between donors and international health agencies is leading to the needless deaths of too many African children from malaria, according to Medical News Today.

Kouate et al. go on to point out that donors, in fact are very coordinated when it comes to decisions to promote ACTS. ACTS, in particular the Coartem brand of artemether-lumefantrin, is the drug of choice approved through WHO’s prequalification program. All donors ranging from Global Fund and World Bank to USAID/President’s Malaria Initiative are on board with this decision.

The clearly articulated challenge is actually finance, not questions of efficacy. This is a similar concern raised by pharmacists in Kenya as mentioned in one of our recent blogs, and creates a sense of resentment in endemic countries. The Kenya example also shows that countries put in a lot of work and effort to make the transition from monotherapy antimalarial drugs to the recommended ACT drug policy. In fact it took Kenya 32 months to finalize the decision, but once having been made, new drug policies do not guarantee that the newer, safer and more effective drugs will be available, as seen in Burkina Faso.

Dr. Uwem Inyang who has worked with malaria and global fund programming in Nigeria shares similar concerns. He observed that countries, “adopt their policies without any in-depth consideration of its availability and alternatives through economic analysis.”

The challenges of changing the policy in Kenya reflects the same challenges including, “lack of clarity on sustainable financing of an expensive therapeutic for a common disease, a delay in release of funding, a lack of comparative efficacy data between AL and amodiaquine-based alternatives, a poor dialogue with pharmaceutical companies with a national interest in antimalarial drug supply versus the single sourcing of AL and complex drug ordering, tendering and procurement procedures. Need careful attention to myriad of financial, political and legislative issues that might limit the rapid translation of drug policy change into action,” according to Abdinasir Amin and colleagues in Malaria Journal.

Dr. Inyang stressed that, “We can not go back on this policy change but we can begin to take stock on how to treat malaria and thus reduce the economic burden arising from it.” Hopefully donors like those in the G8 Industrialized Nations will also realize that we live in an era of ACTs and make good on promises to fund malaria control in Burkina Faso, Kenya, Nigeria and other endemic countries.

Gloria Oramasionwu just completed her MPH at the Johns Hopkins Bloomberg School of Public Health and did her Capstone Project by analyzing the 2003 Nigeria Demographic and Health Survey in greater depth concerning correct treatment of childhood malaria. Among 1603 children under five years of age who had a febrile illness in the two weeks prior to the survey (a proxy measure for malaria) 26.9% received the appropriate malaria drug (as of 2003) by the second day of onset.

An important finding, seen in the chart below was that correctness was related to source of care. Those who got care from a public sector health facility were the most likely (41.7%) to have received correct treatment. Unfortunately only 24.5% of children got their treatment from a public facility. In contrast 42.1% got treatment from drug vendors, but only 27.8% of this treatment was correct. This has important implications for planning national malaria treatment programs.

Two key concerns arise – training of providers in the non-public sectors to give correct treatment and the cost and availability of new first line ACT drugs. With training, we have found that among staff of orthodox health facilities, those in the public sector are more likely to be included in in-service training programs compared to their counterparts in private facilities. Additionally few programs exist to train drug vendors even though they provide the bulk of malaria medicines in some countries. These training gaps need to be closed in order to increase the likelihood that children will receive correct and timely malaria treatment.

The ACT issue poses different challenges. ACTs may cost up to 10 times that of the chloroquine or sulfadoxine-pyrimethamine that children were given in 2003. This may influence access to correct treatment unless ACTs are free or highly subsidized. Usually ACTs are free in the public sector because of programs like GFATM, PMI and the World Bank Booster Program. These programs may not cover 100% of need, and so cash strapped local health services may buy inappropriate but cheaper alternatives. Additionally, these donor programs have not so far extended into the private sector. There are exploratory efforts to make ACTs available at subsidized rates for the private sector, and those need to be expanded because it is the private sector that meets to bulk of need, for example, nearly 50% of parents get their antimalarial drugs from drug vendors and medicine shops in rural Nigeria.

In conclusion, a proper national malaria treatment plan or strategy requires coordination and planning among all sectors so that whenever a parent of a child with malaria seeks care he/she will be guaranteed to get correct treatment at whatever type of source or facility that is convenient and acceptable.

How does maternal mortality become a priority health issue? Shiffman provides case examples in the May 2007 issue of the American Journal of Public Health. He examined policy and program changes in 5 countries: Guatemala, Honduras, India, Indonesia, and Nigeria, and provides a valuable framework for identifying the domestic and international influences and barriers on policy change. The example of Nigeria helps us see how malaria in pregnancy funding and programming might help draw attention to reducing maternal mortality.

Nigeria has the highest maternal mortality rate of the 5 countries (704/100,000 live births), and Shiffman reports that Safe Motherhood is still not receiving the attention it needs in Nigeria. One hopes that the problem of maternal mortality will receives greater attention because of increased malaria program efforts. Participation by Nigeria in the Roll Back Malaria Partnership and its management of malaria grants from the Global Fund have put a spotlight on the contribution of malaria control to safer motherhood. The National Guidelines for Prevention and Control of Malaria During Pregnancy (2005) outline clearly the path from malaria to anemia to maternal mortality and estimate that malaria contributes to 11% of the nation’s maternal mortality rate. The guidelines therefore stress IPTp, ITNs for pregnant women and prompt case management when pregnant women experience an episode of malaria. Likewise the National Reproductive Health Strategic Framework lists malaria among the preventable causes of maternal morbidity and mortality.

Donors are supporting MIP prevention and control activities. IPTp and ITNs are a key component of Nigeria’s Global Fund grant. USAID and the World Bank Booster program are also operating in Nigeria, and both include MIP interventions, particularly nets and IPTp. This level of external support and attention demonstrates “Transnational influences” on policy through norm promotion and resource provision, as explained by Shiffman.

There remain domestic policy challenges to Safe Motherhood in Nigeria. While partners are pulling together to fight malaria, the same cannot be said for Safe Motherhood. A recent MIP strategy workshop in Abuja sponsored by USAID’s ACCESS project and involving both the malaria and reproductive health (RH) program units of the Federal and some State Ministries of Health specifically forged stronger working relationships between the two program areas such that greater attention to malaria may in fact benefit Safe Motherhood. Shiffman emphasized the importance of reaching out to state and local decision makers too, since in Nigeria they make major decisions about allocating resources for public health.

If international malaria partners continue to stress the importance of addressing malaria in pregnancy using all three key control measures as part of a comprehensive malaria strategy, as is done in Nigeria, their efforts will hopefully also have the benefit of making Motherhood Safer.

Hannah Koenker has put together the following update on progress made in the four country-based programs of VOICES for a Malaria Free Future. Hopefully this will encourage other countries to strengthen their advocacy efforts.

Ghana
Ghana has mobilized leadership in government and civil society to form the National Voices Team, whose advocacy strategy has been accepted by NMCP and its partners as the national malaria advocacy strategy. As remarked by the Program Manager “Advocacy has received very little attention in our malaria control activities; Voices has come to fill the gap.” A number of malaria Champions have been recruited, including government and traditional chiefs. Two monthly Action Alerts have been published, and are seen by the NMCP as a great tool to keep the leadership awake on malaria control issues and to motivate sustained effort. Last but not least, the District Malaria Advocacy System is starting up. The key issues Ghana continues to grapple with are

1. Slow implementation of the new malaria drug policy – the use of the A+Aq. Lack of confidence in the drug due to earlier problems during introduction
2. Failure of the District Assemblies to program the 1% Common Fund for malaria control activities. (We know that at least from our 2 districts.)

Mali
Mali has organized a series of “War Room” meetings with the NMCP and its partners to discuss ITN distribution, household and community barriers to accessing treatment, and the introduction of ACTs for pregnant women and children under five. They have met with a variety of partners, including PSI, UNICEF, Peace Corps Volunteers, PMI, the National Pharmacy, the Koulikoro Regional Health Office, and the Global Fund. The team has also met with several private sector partners to plan employee net distributions. Most notably they have successfully advocated for the renewal of the presidential exoneration of taxes and tariffs on ITNs and insecticides for net treatment, and have written several newspaper articles about their efforts. For Africa Malaria Day, which in Mali is being celebrated throughout the month of April, VOICES produced four 3-minute skits with the director and actors from the popular Malian soap opera “D’ou la famille”, touching on messages like prompt treatment, the role of fathers in treatment-seeking, myths about malaria and mosquitoes, and the importance of ITNs and ACTs. Several Malian musicians have been recruited as malaria champions, and activities are being planned for the near future.

Challenges have been to carry out activities in the workplan while responding to the PMI team’s request for information and help during their visits. In addition, while the government is promising free ACTs and ITNs to pregnant women and children under five, there are not yet enough drugs and nets in-country to meet demand.

Mozambique:
Mozambique continues to update their Resource Center and has scheduled a calendar of malaria talks. They’ve helped the NMCP create a multi-sectorial committee for malaria activities and are serving as the secretariat, as well as helping to set up a database that will map malaria activities. Their advocacy strategy and workplan are finalized and the M&E plan is being finalized, with input from stakeholders. Voices also facilitated the trip of one Mozambican journalist  to participate in the presentation of the UK All Party Parliamentary Malaria Group report (“Financing Mechanisms for Malaria”) and Yvonne Chaka Chaka’s Princess of Africa Foundation launch. With coalition members Voices will tackle the issue of community health workers (CHW), to improve access to malaria prevention and treatment services, and will contribute to the First Lady’s campaign, “Malaria Free Children”.

Kenya 
Kenaam has conducted a two-day advocacy training for KeNAAM members after which a task force was established to develop the Kenya VOICES advocacy strategy. Additional task forces will take on the role of identifying champions, and gathering information on the malaria situation in Kenya.  They have successfully managed the constituency election process so that more malaria CSOs have a voice on the GFATM CCM, and continue advocating for release of funds to NGO implementers. Kenaam’s new communications officer has developed a Kenya work plan that includes activities such as training, outreach to new partners and voices, and documentation of activities. She has also developed a media database and the team is planning a media training targeted for journalists from regions where malaria is particularly bad. A database of Members of Parliament from malarious areas was also created, and contacts have been made so that malaria can be made part of the Parliamentary Health Committee agenda. Partnerships were developed with the Boy Scouts, several youth groups, and the Ministry of Education to train new youth voices in malaria advocacy, and to work with Pfizer’s school health program to include malaria messages in teaching curriculums. A notable recruit was the Kenyan UN Youth Ambassador, who has the potential to be an advocate at global level. Success and advocacy stories are in development, including the Kilifi “Talking Nets” story, and will be featured on the CORE website, later on the KeNAAM site, and linked to the VOICES Homepage. Kenaam’s draft advocacy strategy includes plans for M&E and sets out Kenya’s main challenges,

• the low priority of malaria within the government
• the need for more resources to be included in the GOK budget
• the need for the flow of resources to be less restrictive (GFATM for example and how CSO still have not received Round 2 funds)
• the need for ACTs to be made available at a reduced cost in the private sector (roll out of the new policy is only happening in public hospitals and clinics, but most people access drugs from shops).

In a working paper for the Center for Global Development, Nancy Birdsall challenges some of the basic assumptions of development aid/assistance.  She identifies 24 African countries that are ‘aid-dependent’, deriving more that 10% of their gross national income from international assistance.  The results of this situation need to be monitored, according to the working paper, so that aid providers ‘do no harm.  Problems of aid potentially include poaching of skilled workers by aid agencies, decreased government accountability when income comes from non-indigenous sources and even macroeconomic effects like pressure on currency appreciation.

What does this have to do with malaria?  Obviously national malaria programs are receiving aid in a variety of forms from large scale efforts like the Global Fund to fight AIDS, TB and Malaria, the President’s Malaria Initiative and the World Bank Booster program.  Following the White House Summit on Malaria, many organizations from traditional development NGOs to sports groups have jumped on the bandwagon to assist in the fight against malaria.  Financial aid for malaria, though still far from what is needed to control the disease, has increased by leaps and bounds.  Besides providing bed nets and malaria medicines, what else is this aid doing?

Ideally assistance from sources like GFATM should be used to supplement or compliment national malaria control program efforts. Unfortunately, one often sees that the only resources going to buy Artemisinin-based Combination Therapy (ACT) drugs or Long-Lasting Insecticide-treated Nets are in fact donor funds.  Visits to district health facility medical stores may show a large supply of nets in stock. Many may have been given out to children under five years of age in conjunction with a recent measles campaign. The remainder might be sent to antenatal clinics to give to pregnant women.  When asked what will happen when the stock of donated nets is finished – i.e. what to do next year when there are a new set of pregnant women and a new set of infants in need of nets, the health staff can’t answer. Districts do not have in their budget funds for serious malaria control, and thus the short term gifts are not backed by a commitment to long term sustainability.

What about ACTs? Most aid is used to buy and give ACTs free to children under five years of age. What happens to older children and adults who have malaria?  Again, district health departments often have not planned in a comprehensive way to provide up-to-date malaria treatment for the population, but just rely on the targeted donations for a specific age group. Embarrassed health workers have been known to give two packets of the child medicines to adult clients in need.  Furthermore, if the grant or program has targeted only 20% or 50% of children under five, when the ACTs on hand finish after a few months, there are none available even to treat the children until the next year’s donor supplies arrive.

In many cases therefore, donor supported malaria programs are not really strengthening and supplementing a local program. They are simply providing a stopgap for a portion of the population for a few short years.  Malaria aid without national and district political commitment in endemic countries and comprehensive forecasting and planning is not going to save lives in the long run.

United Press International reports that Kunming Pharmaceutical Corp. maintains that its monotherapy artemisinin product is safe despite WHO trying to clamp down on sales and distribution of monotherapy malaria drugs in order to prevent resistance.  Although Ferreira et al. (2007) note that African surveys have observed that the overall susceptibility to artemisinin derivatives is relatively high they found potential opportunities for resistance to develop and therefore recommend, “Close monitoring of local parasite susceptibility and of putative genetic modulators of drug responses should carry on in view of protecting the long-term efficacy of ACT.”

There is no point waiting until full blown resistance develops before taking action, hence WHO’s call for eliminating monotherapy artemisinin drugs before it is too late.  In stark terms WHO’s malaria chief, Arata Kochi, says, “If we lose artemisinin, we are dead, basically.”

In addition to the natural development of resistance over time one finds human induced problems. Atemnkeng et al., (2007) warn that, “Counterfeit or substandard artemisinin-derivative drugs are being sold in parts of Africa, presenting a potential route for resistance development in the future.”

Ultimately the will and ability to preserve our pharmaceutical arsenal against malaria rest with national governments who set malaria drug policies and guidelines and whose various food and drug regulatory agencies approve which malaria drugs are sold and dispensed.  Mugittu et al. (2006) commend preventive policies. Even though resistance to artemisinin has not yet been selected in Tanzania, they commend the Ministry of Health for making the decision to adopt artemether+lumefantrine as first-line malaria treatment. Governments in endemic countries like that of Tanzania need to step forward and protect their populations against drug-resistant malaria.

Recently we commented on an article in the Bulletin of WHO concerning fertility and equity.  Now a manuscript by Conley, McCord and Sachs look specifically at the relationship between malaria and excess fertility (see attached map on total fertility rates in 2003 from WHO).  They note that, “Much of Africa has not yet gone through a ‘demographic transition’ to reduced mortality and fertility rates.” They found that, “child mortality (proxied by infant mortality) is by far the most important factor among those explaining aggregate total fertility rates, followed by farm productivity. Female literacy (or schooling) and aggregate income do not seem to matter as much, comparatively.”

 

Maternal malaria is also implicated when they note that, “There is some evidence that malaria may reduce lactation period, which might increase fertility through decreased child spacing. Likewise, malaria in pregnancy is also associated with low birthweight and increased neonatal and infant mortality—which is in line with our models.”

They conclude that, “This is where the theory of the demographic transition started: save the children and families will choose to have fewer children.”  They do explain that the transition time between reduced infant and child mortality and reduced fertility may take a generation or two.  The lesson here is that increased fertility may in fact be an inequity caused by child deaths, especially from malaria, and that family planning alone will not address this imbalance.

Malaria is holding back the demographic transition and economic development in Africa.  An investment in treating and preventing malaria in women and children will have long term benefits.  International donor programs like GFATM, World Bank Booster and PMI can help start the process of reducing mother and child mortality, but the effect on fertility and economic development will require a long term commitment by governments in endemic countries. There is no room for complaints about the cost of ACTs and LLINs!