Tropical Health Matters

The Future Health Systems (FHS) Research Programme Consortium aims to find ways to translate political and financial commitments to meet the health needs of the poor. The consortium addresses fundamental questions about the design of future health systems, and work closely with actors who are leading the transformation of health systems in their new realities. This consortium addresses fundamental questions about the design of future health systems, and works closely with people who are leading the transformation of health systems in their own countries. FHS research themes are:

• Protecting the poor against the impact of health-related shocks
• Developing innovations in health provision
• Understanding health policy processes and the role of research

Eight partners in eight different countries are exploring various ways to make health systems work for the poor. The team based at the University of Ibadan, Nigeria, has been exploring the role of Patent Medicine Vendors (PMVs) in providing quality, appropriate malaria treatment in the poor communities where they are based. A recent workshop analyzed and wrote a working paper based on the first-year scoping study.

Several key aspects of PMV behavior and knowledge were identified. “This study has documented the problems that people have in getting access to appropriate treatment for malaria. They have little knowledge of the changing patterns of drug resistance and the consequent changes in the drugs that are effective. They must rely either on traditional practices or on the advice of the people who provide the drugs. Since patent medicine vendors provide anti-malarial treatment in a substantial proportion of cases, their knowledge and practice strongly influence people’s wellbeing. This study made two major findings about this knowledge and practice. First, patent medicine vendors have little knowledge about new guidelines for drug use and they still recommend that people use drugs whose efficacy is doubtful. Second, there is a lot of concern about the quality of the drugs they supply. Action is needed to address these problems.”

Watch here as well as the FHS website for further updates on this important research that documents the challenges of a major informal provider, the patent medicine vendor, who has been ignored in formulating malaria access policy. In fact the 2003 Nigeria Demographic and Health Survey found that only about 25% of parents sought malaria treatment for their children in the formal sector. The few efforts to train and upgrade PMVs has been documented by BASICS, but more needs to be done if malaria drugs are going to reach all.

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As a note of interest, the previous entry here on Kenya’s looming drug shortage was filed from one of only two cyber cafes in the town of Igbo-Ora in southwest Nigeria pictured here. The town has 60,000 residents, but electricity is erratic to rare. It took several visits to find that the cafe’s generator was working strongly enough to access this site and make a posting. That is life on the edge of the digital divide. This current posting is being made at the airport lounge in Lagos on wireless connection – shows how the average person in Africa has little access to the internet to gather malaria information and engage in malaria advocacy.

Pfizer has announced the funding of malaria support projects in Kenya, Ghana and Senegal. Pfizer is committing “$15 million over 5 years to support efforts that engage and educate treatment providers and patients to improve the utilization and effectiveness of malaria treatment and patient adherence.” The three-country initiative was awarded based on competitive bid in each location.

An ironic fact is that currently Pfizer does not have a specific malaria product on the market, and therefore its philanthropic work to promote adherence in ACT case management is likely to benefit the correct use of another company’s product, an arthemether-lumefantrine combination. Apparently Pfizer is in Phase III trials on a Zithromax/Chloroquine combination therapy for malaria, but it is not clear how this will be used in the context of widespread chloroquine resistance.

• In Kenya the project will promote symptom recognition and treatment-seeking behaviors at the household level, with an emphasis on pregnant women and children under five, using antenatal clinics in western and coastal provinces as an entry point to these target groups.
• In Senegal the project train community health workers and nurses serving in Tambacounda Region, document the benefits of malaria treatment messaging in the health system and include a complementary patient messaging program.
• The Ghanaian program will build capacity in the informal sector with Licensed Chemical Sellers (LCSs) who are found in over 7,000 retail outlets in almost every community throughout the country.

At the same time Pfizer’s philanthropy is being touted, its research practices in northern Nigeria have come beck to haunt it after over 10 years with suits by federal and state governments. According to the BBC, in Nigeria Pfizer “tested the experimental antibiotic Trovan in Kano during an outbreak of meningitis which had affected thousands in 1996. Some 200 children were tested. Pfizer say 11 of them died of meningitis, but Kano officials say about 50 died whilst others developed mental and physical deformities.” The cases are far from being decided, though.

A lesson here is that corporations are coming under more and more scrutiny in this globalized world. Philanthropy and corporate social responsibility need to be balanced equally with corporate scientific and technical responsibility. Both should result in the saving of lives and improving the quality of those lives saved.

The Ministry of Health in Uganda estimates that private, not-for-profit health (PNPH) facilities account for 30% of all facilities in Uganda, and importantly around 85% of these are located in rural communities. USAID’s ACCESS project has demonstrated that FBO health facilities, an important component of the PNPH sector, can play a major role in increasing the delivery and uptake of malaria in pregnancy (MIP) control interventions in the Kasese District of Uganda. The project was a joint effort of ACCESS partners, particularly Interchurch Medical Assistance (IMA) and JHPIEGO.

The project worked with the Uganda Catholic, Muslim and Protestant Medical Bureaus in five health facilities and upgraded the malaria technical skills of all antenatal care (ANC) staff using JHPIEGO training materials. In addition “community owned resource persons” (village volunteers) and religious leaders were trained to help mobilize women to attend ANC. ANC is a key platform for delivering malaria in pregnancy control interventions.

Over the nine-month intervention 27% of women attending ANC were given Insecticide Treated Nets (ITNs), which were supplied by the project. The facilities normally stocked sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy (IPT). By the end of the project the the proportion of ANC attendees receiving their first dose of IPT rose from 43% to 94%, while those receiving IPT2 increased from 27% to 71%. The Uganda Demographic and Health Survey for 2006 found only 50% of pregnant women nationally had received IPT1, and 17%, IPT2.

Often donor in-service training programs focus exclusively on public sector health workers and neglect those in the private and NGO sectors. In many malaria-endemic countries religious mission health services deliver a large portion of care, and as seen in this Ugandan example, can play a major role in delivering malaria in pregnancy control services if their capacity is improved. Fortunately, these FBO facilities did stock SP from which they could plan and deliver IPT. At the time they did not benefit from supplies of ITNs, although the country was receiving ITNs through Global Fund Grants. It is therefore important for National Malaria Control Programs to integrate FBOs and PNPH facilities into both training and commodity supply programs to ensure full protection of pregnant women from malaria. Since this project was done in collaboration with the Ministry of Health (MOH) in Uganda there is hope that collaboration will continue between the faith mission medical boards and the MOH to expand these MIP services to other FBO facilities.

Claudia Vondrasek, based in Mali for the Voices Project, offers these perspectives (in French and English) on malaria control in Mali.

Quel rôle le secteur privé devrait jouer ?

Le paludisme constitue un problème prioritaire de santé publique de part sa fréquence, sa gravité chez la population malienne. La politique nationale de lutte contre le paludisme prend désormais en charge les couches vulnérables que sont les femmes enceintes et les enfants de moins de 5 ans. Cependant, force est de reconnaître, que malgré la volonté des autorités, il manque suffisamment de ressources pour faciliter l’accessibilité et la disponibilité du traitement à un moindre coût (en subventionnant par exemple) pour les couches hors cibles. Le secteur privé peut combler ce vide en partie en jouant un rôle important dans la protection et la prise en charge des employés et leurs familles. En plus, le secteur privé pourrait soutenir le ministère de la santé dans l’acheminement des produits antipaludiques et la construction ou la réhabilitation de magasins appropriés pour le stockage de ces produits.

Le paludisme est–il la chasse gardée du ministère de la santé ?

Vu la gravité et l’ampleur de la maladie, les défis pour éradiquer le paludisme au Mali dépassent les seules capacités du ministère de la santé. Il est aujourd’hui nécessaire de stimuler des actions citoyennes des entreprises et sociétés au Mali pour contribuer de façon significative à la protection et prise en charge de leurs employés et familles du paludisme. Les entreprises peuvent ainsi offrir de l’éducation sur le paludisme aux employés ; rendre accessible et disponible les produits antipaludiques (SP, CTAS, MII, TDR…) dans leurs infirmeries ou dans les centres de santé inter – entreprises…

Fort de cette opportunité, Le projet Les Voix du Mali a organisé, le samedi 2 juin, un dîner-gala pour stimuler l’engagement des entreprises privées dans la lutte contre le paludisme. Quatorze sociétés et entreprises se sont engagés à prendre des actions concrètes contre le paludisme dès cet hivernage en faveur de leurs employés et leurs familles.

Ces engagements peuvent s’expliquer par une prise de conscience des chefs d’entreprises de la gravité et l’impact socio-économique du paludisme. Il apparaissait clairement que les chefs d’entreprises ne disposaient pas d’informations fiables sur les conséquences du paludisme. Une action soutenue d’information des chefs d’entreprises permettra d’aboutir à l’adhésion d’un grand nombre d’entre eux non seulement pour concrétiser la volonté du Conseil du Patronat National de créer une coalition des chefs d’entreprise contre le paludisme au Mali mais aussi et surtout de protéger tous les travailleurs du secteur et leur familles contre le paludisme.

Egalement, tous les ministères (que ce soit Agriculture, Mines, Tourisme, Communication, Transport …) et la Société Civile dans sa totalité, doivent absolument s’engager aux côtés du Ministère de la Santé pour lutter contre le paludisme et faire du Mali un pays sans paludisme, une réalité.

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What role should the Private Sector play in Malaria Control? Malaria is a priority public health problem due to its frequency and its burden on the Malian population. National policy now targets the most vulnerable populations: pregnant women and children under 5 years old. However, the Ministry of Health lacks the resources today to facilitate access and availability of subsidized treatment on a national scale to other adults and older children. The private sector can fill this void in part by playing an important role in protecting and taking responsibility for their employees and their families. In addition, the private sector can support the Ministry by helping with supply chain for antimalarial products and by constructing or installing appropriate storage facilities for stocking these products.

Malaria: is it the exclusive domain of the Ministry of Health?

In light of the gravity and magnitude of the disease, the challenge of eradicating malaria in Mali surpasses the capacity of the Ministry of Health alone. Today it is necessary to galvanize Malian companies and businesses to make substantial efforts towards protecting and taking responsibility for their employees and families from malaria. Companies can thus offer education about malaria to their employees, and help make antimalarial products (SP, ACTS, ITNS, RDTS…) accessible and available in the company clinics or health centers.

To encourage this opportunity, the Mali Voices project organized a diner-gala on Saturday June 2, 2007 to engage the private sector in the fight against malaria. Fourteen companies and businesses agreed to take concrete actions against malaria during the upcoming rainy season for the benefit of their employees and their families. These actions are the results of companies’ executives becoming aware of the seriousness of the socioeconomic impact of malaria. It appears clear that the CEOs were not previously aware of the consequences of the disease. Getting a steady flow of information to executives will encourage many of them to participate in malaria control activities, and build support in the National Business Council to create a Private Sector coalition against malaria in Mali.

Every year in Mali, malaria kills more than 100,000 people, mostly children. It is the responsibility for all sectors to contribute to a successful fight against malaria parasites and vectors. Civil society organizations and Ministries of Agriculture, Transportation, Mines, Tourism, Communication, etc. must take on the responsibility of complementing Ministry of Health actions to make Mali malaria free.

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PRIVATE SECTOR NEWS FROM RBM

Meeting in Dakar aims to improve private sector involvement in the global fight against AIDS, tuberculosis and malaria
In cooperation with Global Fund, ILO, WHO, UNAIDS, Partners against AIDS, and the Roll Back Malaria Partnership Secretariat, a West and Central Africa regional workshop was organized in Dakar to exchange experiences and develop country strategies in order to enhance private sector involvement in the response against the three major diseases. It brought together private sector stakeholders, finance institutions, workers, international agencies, professional associations, labour unions, and 18 countries from West and Central Africa.

Réunion à Dakar vise à améliorer l’engagement du secteur privé dans la riposte mondiale contre le sida, la tuberculose et le paludisme
Avec la cooperation du Fonds Mondial, le BIT, l’OMS, l’ONUSIDA, les Partenaires Contre le Sida, et le Partenariat “Faire Reculer le Paludisme” un atelier régional a été organisé à Dakar afin de faciliter l’échange d’expériences et d’aider les pays à développer des stratégies visant à augmenter l’engagement du secteur privé dans la riposte contre les trois maladies les plus importantes. Cet atelier a regroupé les parties prenantes du secteur privé, les institutions financières, les travailleurs, les agences internationales, les syndicats, et 18 pays d’Afrique de l’Ouest centrale et d’Afrique centrale.

This past week eight companies were honored by Global Business Coalition (GBC) on HIV/AIDS, TB and Malaria for the Fight against Global Epidemics. The malaria winner was Marathon Oil Corporation who “led the formation of a unique $12.8 million public- private partnership which includes Noble Energy, the Government of Equatorial Guinea, Medical Care Development International and leading health specialists.”  Results of the first three years of The Bioko Island Malaria Control Project included a 95 percent reduction in malaria transmitting mosquitoes caught indoors and a 44 percent reduction in the presence of malaria parasites in children. Also commended at the honors ceremony for work on malaria were Novartis Pharma AG, BHP Billiton and AngloGold Ashanti.  According to the New York Times (NYT), $2 million was also raised that night.

The NYT also reported that just a day before the GBC event, “the Millennium Promise, co-founded in 2005 by the well-known Columbia economist Jeffrey Sachs, and Malaria No More, a spinoff started last December, held their first fund-raising dinner” where “an astonishing $2.7 million” was raised.  The amount of money raised at the events would cover only a few months of operation of a national malaria control program in Africa, but it has symbolic value and may stimulate governments in the industrialized world to keep on track with the billions they have promised for disease control.

Other models of business contribution include: discounts on product price, as for example, Novartis selling Coartem below cost, efforts by businesses working in endemic countries work to protect their staff, families and communities from malaria, and of course the contributions of large business-based foundations like those of Gates and Buffet.  The private sector not only finances to its own malaria and disease control projects, but makes contributions to multilateral efforts like the Global Fund (approximately 3% of funds received so far).  The model described in Equatorial Guinea falls within the realm of “co-investment.” GTZ defines co-investment in the context of the HIV/AIDS response: “the term co-investment refers to the harmonized and coordinated joint investment of public and private resources with the common objective to improve equitable access to and provision of HIV/AIDS services.”

The issue is not just the money business brings to the table. Small grants from the philanthropic sections of major corporations can actually sponsor innovative projects that can later be taken to scale. If these innovations are to have a wider impact, business needs to be actively involved in national malaria partnerships.  This was one of the ideas behind the organization of a National Malaria Conference last week in Durban, South Africa.

Joe Nocera of the NYT warned readers that, “… it is probably best not to get too excited, no matter how inspiring the speeches at New York fund-raisers.  Because someday malaria is no longer going to be the pet cause in American boardrooms. And then what?”  One answer may lie in another disease control model, the Mectizan Donation Program, which has been providing free ivermectin for onchocerciasis control for two decades. A second answer may be for large corporations working in Africa to develop national capacity to produce effective and cheap malaria control products. Businesses will likely continue to play a role in malaria control; coordination and partnership is the answer to ensuring that this role has impact.