Category Archives: Procurement Supply Management

Appreciating Many Years of Malaria Partnerships and Investment

wmd2013logo-sm.jpgWhile today it technically the sixth World Malaria Day, one should actually trace the origins back 13 years to the first Africa Malaria Day (AMD) in 2001, held to encourage progress based on the Africa malaria Summit in Abuja just one year before.  And since the Abuja summit and its resulting declaration were backed by the Roll Back Malaria Partnership, which formed in 1998, one could say the world has 15 years to considering in judging progress in and plans for partner investments in ridding the world of malaria.

In 2001 organizers of Malaria Day events were encouraged to feature a ‘new’ medicine that WHO said could save 100,000 child healths annually in Africa. artimisinin-based combination therapy (ACT) drugs are now the front line treatment in most all endemic countries, and deaths have declined somewhat on the order of 400,000. At that time there was only one major manufacturer of ACTs. Investments by pharmaceutical companies in generic ACTs now means that there are at least nine companies that produce prequalified ACTs. What is needed is more indigenous African pharmaceutical companies approved to invest in ACT production.

logo_animated.gifThe first AMD stressed the risk of malaria to pregnant women and recommended widespread use of Intermittent Preventive Treatment in pregnancy (IPTp).  This recommendation has been adopted in countries with stable falciparum malaria transmission, but has lagged in terms of implementation, and coverage still lags below the 80% target set at the 2000 Abuja Summit.  There are missed opportunities to provide IPTp at antenatal clinics due to stock-outs, provider attitudes, and client beliefs. Weak health information systems mean that even when services are provided, reporting may not accurately reflect true coverage of IPTp.

In the meantime resistance is growing to sulphadoxine-pyrimethamine (SP), the drug used for IPTp in part due to the inability or unwillingness of country drug authorities to curb its inappropriate use for case management.  WHO now recommends more that the original two IPTp doses and suggests that pregnant women get SP at each ANC visit after quickening.  In the meantime research is underway to find substitutes for SP.

The first AMD addressed the role of insecticide treated nets (ITNs) in helping halve the world’s malaria burden by 2010.  Major progress came in 2008 when the whole United Nations community and of course companies invested in net production got behind universal coverage. In addition the advent of the long lasting insecticide-treated net with insecticide infused in the fabric from point of production pointed the way to success.

These three core interventions – ACTs, IPTp and ITNs – have been strengthened with better diagnostics and a variety of other vector control measures, Hopes for a vaccine still remain a dream, though an achievable one.  While we have high expectations for eradication, we can see that some of the health systems challenges that thwarted the first malaria eradication effort are still with us including weak procurement and supply management, inadequate human resources and gaps in health information systems.

The foregoing implies that we need at least two forms of future investment in malaria. First is investment by governments in strengthening the health system that deliver malaria services. The second investment is in continued biomedical research in order to fend off resistance by mosquitoes and parasites and of course social research to address issues of behavior, adoption of innovations and program management practices. Let’s hope that when World Malaria Day 2014 rolls around, we can measure these increases investments.

Stock-outs: how can we achieve malaria treatment goals?

Of twenty-two malaria endemic countries in Africa that receive support from both USAID/PMI and the Global Fund, eleven reported gaps in malaria medicine funding in the 2011 Road Maps countries prepare for Roll Back Malaria.  Likewise, 16 of these countries reported gaps in RDT financing and supplies.

dscn0296sm.jpgThese stock and procurement problems arise from many causes including ability to forecast need,  poor donor coordination and leadership, and lack of adherence to new guidelines that require diagnostic verification of malaria before treatment among others.  We are well past the 2010 RBM target date to achieve 80% treatment coverage, but the most recent DHS and MIS results from the 22 countries for appropriate treatment of children below five years of age show that the country with the highest achievement of ACT coverage in this age group was Malawi with only 36.2%.  The median among these 22 countries was 16.5%.

Therefore, it was not surprising that The Citizen newspaper reported from Dar es Salaam that, “Thousands of Tanzanians have continued to die from malaria annually due to lack of medicines despite massive investment by the government and donors towards improved supply of relevant drugs in health facilities.” Apparently programs like SMS for Life and AMFm have not had their desired effects.

The Citizen lamented that, “Phone calls to the CEO of Medical Stores Department (MSD), which is charged with responsibility of distributing drugs in the country, went unanswered.”  Other malaria implementation partners gave their own views that the problem was due to lack of professionalism among health officials and a lack of commitment to implementing the malaria program.

If we cannot even achieve malaria treatment targets by 2010, what hope do we have of reducing mortality by 2015 – let alone head toward elimination? Technical assistance may be needed, but cannot succeed if there is a lack of will on the part of program implementation partners from the endemic countries.

Malaria and Mobiles – Hacking or Helping

Surprise – the latest in the Rupert Murdoch scandal concerns malaria.  Yesterday Metro Online headlined a story: “Cheryl Cole’s ‘phone hacked while she was suffering from malaria.'”  The claims are still at the level of rumors, and thus investigators are still “looking into claims that her voicemails were hacked while she was hospitalised.”

A year ago when Ms Cole’s bout with malaria hit the news, The News of the World was mentioned as a source. One online posting noted that Ms Cole, “is believed to have lost half a stone during her battle with malaria. A source told the News of the World that the Girls Aloud beauty is now just over 7 stone. The insider told the newspaper that medics have said that it could be six months before Cole is allowed to perform her strenuous dance routines.”

Similarly another website reported last year that, “A source told the News of the World: “We nearly lost her and the battle is far from over. She is so weak and this horrible illness has taken complete hold of her. ‘It got so bad she was literally only hours from death’s door. Thank goodness she was diagnosed in time.'”

cellphone-mango.JPGNow a year later MTV UK published that, “Cheryl’s lawyers are investigating claims by a former News of the World journalist, who stated that the Geordie’s voicemails were listened to “while she underwent treatment for malaria.”

Fortunately most use of mobile phone technology these days helps promote malaria control and elimination. In Nigeria for example, mobile phone SMS has been used to track bednet distribution.  A UNICEF spokesperson who is involved in promoting such innovations explained that …

In Africa, we are finding there are systemic failures in public health and supply in terms of getting reliable information quickly from the field. Ninety percent of the developing world has access to a cell phone, so we’re experimenting with the use of instant messaging to make a difference. We’re finding that we can train people in villages to be data collectors and help us by using cell phones to text information to central authorities; we and governments can then respond faster to specific needs. In some places, it takes months just to get a piece of paper from the field. Mobile phones and SMS technology can help surmount that hurdle.

Recently the Business Standard reported that, “The University of Glasgow has received a grant from the Bill & Melinda Gates Foundation to further help in the diagnosis of malaria. The $100,000 award would go towards developing a device which uses mobile-phone derived technology to detect and separate red blood cells infected with malaria parasites.”

A study by Caroline Asiimwe and colleagues in Uganda has shown SMS improves the timeliness in reporting of specific, time-sensitive information on RDT positivity rates and ACT stockouts at modest cost, while by-passing current bottlenecks in the flow of data. Likewise in Tanzania “A multinational computer, technology and IT consulting company, IBM, in partnership with Novartis and Vodafone, together with Roll Back Malaria and Tanzania’s Ministry of Health and Social Welfare have reaped from the technology dubbed ‘SMS for Life’. The system tracks movement and the supply of anti-malaria drugs in sub-Saharan Africa.”

People have argued that technology itself is ethically neutral – it is how people use it that has ethical ramifications. In the case of malaria hopefully we will see more uses that help save lives instead of illegally spying on and disrupting them.

Population Growth and Malaria Elimination

A major challenge in successful malaria control programming is correctly estimating the numbers of commodities needed and ensuring their timely delivery.  It is not clear the extent to which this forecasting process accounts for population growth.

Therefore, when the International Herald Tribune (IHT) reports on population growth in the region with the heaviest burden of malaria, we take notice … “What is most striking, though, is the unabated demographic swelling of Africa. Africa’s population has almost doubled between 1975 and 2000, growing from 416 to 811 million; it will add another 75 percent to reach 1.4 billion people in 2025, and presumably another 55 percent to reach the staggering figure of 2.2 billion by mid-century.”

pop3africabig.gifOne wonders whether successful efforts to reach 2015 targets of reduced malaria morbidity and mortality might offset the need for more and more LLINs, ACTs and other commodities? In some countries moving close to elimination, this might be true, but the high burden countries – high because of their large populations and challenging logistics – remain a concern. As the IHT observed, “countries such as Nigeria (230 million in 2025, 390 million in 2050); Ethiopia (110 million and 145 million) and Congo (95 million and 148 million) have since long been identified as the demographic giants of sub-Saharan Africa.”
We already know that universal coverage was not achieved by 31 December 2010 as many endemic countries are still sourcing and distributing nets and other commodities in the hopes of reaching the target in 2011. All the while, population does not remain static.

We also know that there has been strong competition for nets and drugs among endemic countries because of the low number of manufacturers of approved products.  A lesson from the field is that rapid diagnostic test supplies are not close to catching up with supplies of artemisinin-based combination therapy (ACT) medicines, and long lasting insecticide treated nets (LLINs) are not as long lasting as once thought.  Will we be able to get enough nets in 2013-14 to replace those distributed in 2010-11?

So in the short run as population increases, need for malaria control commodities will also increase.  And, one wonders can donor support be counted on?

Ironically even as fertility decreases (though is still high), population grows because of the success in disease control programs and reduced mortality. Also as UNFPA explains, the fact that the majority of people in developing countries are young means that the bulk of the population still has many years of reproductive life ahead, hence population in the foreseeable future will increase even if fertility of lower.
Of course, even when people survive malaria episodes they experience personal costs that holds back the national economy.  The question is whether we can get enough malaria commodities on the scene and in people’s hands before population doubles?

Redrawing Roadmaps – can we get there from here?

The Roll Back Malaria Partnership guided countries to develop 2010 roadmaps for major malaria commodity and support service availability and gaps. The aim was to aid planning to reach universal coverage by the end of 2010.  Forty-seven countries/locations on the African Continent and surrounding islands completed the analysis and started moving down the road to success.

In the case of 36 countries the road became a little longer than anticipated.  Part of the challenge was international – there are only a few manufacturers of long lasting insecticide-treated nets, for example. Some of the barriers were internal, inadequate estimates of the logistical costs to distribute commodities, even if they were in hand. Now we have 2011 roadmaps in an effort to meet up with the original 2010 goals of 80% coverage with essential malaria commodities.

proportion-of-countries-that-missed-2010-rbm-roadmap-sm.jpgAt least one-quarter of countries that actually targeted a specific intervention in 2010, did not meet the 80% goals.  Of particular concern is the fact that Rapid Diagnostic test use is both off target and not keeping up with ACTs.

Meeting procurement and distribution targets is one step, but getting people to use malaria control interventions is another challenge. As the director of a prominent Nigerian NGO recently said, “… ‘though about 35.6 million nets have been distributed across the country, it is highly under utilized,’ which according to him is responsible for the high death rate associated with malaria.”

Nigeria provides an instructive case. The roadmap for 2010 called for 62.9m LLINs of which 4.4m were already in place and pledges were set for 49.4m. This left a gap of 9.2m.  While the RBM 2010 roadmap analysis shows that Nigeria met its LLIN target, the implication is that the target did not include the gap.  Now the 2011 roadmap for Nigeria now shows that resources are in hand for both the 9.2m gap from the 2010 campaign plus an additional 8.2 m for routine distribution in clinics as a keep-up measure.

The gross figures do not fully reflect the fact that of the 36 states (plus one capital territory), campaign distribution of LLINs continued from 2010 into 2011 in 17 states. So far 9 or the 17 have completed distribution, but by carrying the campaign into 2011 additional delays were met in the remainder due to national elections, delayed local funding for the effort, and distribution logistics. So again while the roadmaps help identify commodity gaps, they do not always identify the challenges at the level of distribution and use.

The roadmap process is an important planning tool. It needs to be supplemented with plans for logistical support and health education to encourage use of the malaria commodities and services that are eventually distributed.  For example, Nigeria estimates that it needs close to $17m for Monitoring and Evaluation and Information. Education and Communication. We can see from the Nigerian roadmaps that this planning needs to be a continuous process – not only is annual resupply of ACTs, RDTs and SP for IPTp needed, but also continuous stocks of nets for routine, keep-up services.

SP Stock-Outs – What’s the Problem?

dscn8010-sm.JPGIn today’s guest report, Michelle Wallon from Jhpiego’s Zambia office discusses the challenges of maintaining stocks of sulphadoxine-pyrimethamine (SP) for use in Intermittent Preventive Treatment for pregnant women (IPTp) that arose during recent Roll Back Malaria meetings in Livingstone and Lusaka:

The effects of malaria in pregnancy are many and the interventions, simple.  Intermittent Preventive Treatment (IPTp), insecticide-treated bed nets, and timely case management can reduce effects including maternal anemia, low birth weight, and maternal and fetal mortality. Yet, when speaking to clinicians and public health experts across Africa about prevention and control of malaria in pregnancy (MIP), there is a common theme – stock-outs of SP, the drug used for IPTp, commonly inhibit the effectiveness of MIP interventions.

IPTp is relatively straight-forward and SP, is an inexpensive drug.  Furthermore, at the time that the IPTp recommendations were adopted via the Abuja Declaration in 2000, many countries were still procuring SP as the first-line treatment for the general population (For example, Nigeria did not officially switch to ACTs as firstline malaria drugs until 2005).

SP supplies were abundant when it was still recommended as treatment. What then is the problem now?

Although SP stock-outs are formally documented in only a few African countries, including Zambia, Tanzania, and Malawi, the problem can be inferred by most of the recent Demographic and Health Survey and Malaria Indicator Survey reports (e.g. Liberia, Nigeria, Uganda, Senegal) showing low coverage of the recommended two doses of IPTp. MIP experts readily and repeatedly identify a handful of culprits for the SP stock-out phenomenon.

    One set of problems surrounds continued and irrational use of SP for treatment in RDT-negative cases in the general population that siphon off SP supplies from MIP services. These stem from …

    • Provider mistrust of RDTs coupled with policies that ACTs be provided only after positive diagnosis via RDT or microscopy
    • Real or perceived high incidences of malaria
    • Strong correlation in the community between fever and malaria with high expectations for malaria treatment
    • Weak clinical skills in the appropriate diagnosis and management of fever
    • Lack of skilled providers and high client loads

    Inaccurate SP quantification based on population rather than consumption data and/or quantification failing to account for irrational use also create stock problems. Weak logistics systems with bottlenecks between central-level drug stores and receiving facilities result in stock-outs of both SP and ACTs.

    These problems are not new and neither are the solutions.  MIP has a potential advantage in that it falls under both reproductive health and national malaria control programs, and yet the persistence of SP stock-outs indicates that this is often used less as an opportunity for collaboration than as an excuse to pass the buck.

    As the public health community moves towards more integrated programming, we must seize the opportunity to bridge the programmatic gap.

Chronic diseases – as if malaria were not enough

Two news stories today remind us that low and middle income countries (LIMCs) not only continue to suffer from infectious diseases like malaria, but that they are also burdened with chronic health problems arising from ‘western lifestyle’ behaviors like smoking and over-eating.

The New York Times describes efforts of cigarette companies, not only to promote use of tobacco products, but also to intimidate through lawsuits LMICs who try to control tobacco advertising and sales. Specifically …

Companies like Philip Morris International and British American Tobacco are contesting limits on ads in Britain, bigger health warnings in South America and higher cigarette taxes in the Philippines and Mexico. They are also spending billions on lobbying and marketing campaigns in Africa and Asia, and in one case provided undisclosed financing for TV commercials in Australia.

A Lancet article reported in the BBC documents how adult obesity in Brazil, Mexico and South Africa are above the average for Organization for Economic Co-operation and Development (OECD) countries. Recommendations to reverse these trends include “media campaigns promoting healthier lifestyles, taxes and subsidies to improve diets, tighter government regulation of food labeling and restrictions on food advertising.”

We have here an intersection among the public, the private and the personal. Although individuals can make personal choices and public health organizations can provide health education, the private sector can use their disproportionately enormous financial resources to advertise unhealthy behaviors and threaten in court those who oppose their efforts against health. Statements by agencies like the World Health Organization (WHO) may have a relatively smaller effect here.

The balance seems completely different when it comes to malaria. All partners appear to promoting the same healthy agenda – use of Long Lasting Insecticide-treated Nets and prompt treatment with appropriate antimalarial drugs to name a two key behaviors. The role of WHO is stronger in determining what are appropriate malaria commodities including its pre-qualification of medicines and the WHOPES evaluation scheme for reviewing insecticides.

These WHO processes influence the bulk of purchases for major international donors and national malaria control programs. This is not to say that “unqualified”, substandard or counterfeit malaria drugs don’t make it into the markets of developing countries, but the legal framework is more likely to work against such unhealthy schemes.

Hopefully the malaria partnership that promotes healthy behaviors will continue, resulting in reduced mortality among vulnerable groups such as young children.  It would be a shame for these efforts to reduce infant and child mortality were overshadowed by forces that threaten the lifespan in later years from obesity and tobacco induced cancers and coronary problems.

Health Posts – meeting rural needs

People living in rugged rural terrain often go without formal health services. The population may be remote and even migratory, as some herd cattle.

dscn0659a.JPGAngola is working to ensure that at minimum there are Health Posts staffed by trained nurses to provide services beyond the municipal/district headquarters. And since onchocerciasis is common in many of such areas, we are also talking about providing integrated disease control and health care ‘beyond the end of the road,’ as advocated by the African Program for Onchocerciasis Control.

Life for these nurses is not easy as there is usually just one staff member to run the post. Also this situation means that male nurses predominate – one reason why it is presumed that antenatal care may not be easy to provide.

dscn0699-sm.JPGA visit to such a health post recently showed that not only was the nurse enthusiastic, but that he could provide some of the basic components of antenatal care in all but name.

The post had a good supply of sulphadoxine-pyramethamine that is required for intermittent preventive treatment of malaria in pregnant women. There were other medicines and supplements routinely given pregnant women such as ferrous sulfate and de-worming drugs.  The nurse even had a fetal stethoscope.

Strengthening these rural outposts is a priority for malaria control and health equity. These rural populations do not even have access to medicine shops as found in some areas.

Regular supplies of nets, RDTs, ACTs and SP will guarantee that all parts of Africa can work toward reducing malaria deaths by 2015.

GAPS – funding, oversight and participation

AIDSPAN has produced another valuable issue of the Global Fund Observer (GFO) that reports and analyzes the challenges of implementing Global Fund grants. Three of the main articles address serious gaps in various areas of programming.

The first gap is one of funding. As we discussed recently, even with an overall increase in pledges to the GFATM, the amounts are inadequate to achieve goals. The inability to raise funds at all level shows serious weaknesses in commitment and planning. AIDSPAN notes consequences of this such that for example …

In fact, though, this week’s pledges provide only $2.9 billion for Rounds 10, 11 and 12. The current estimate of the cost of Phase 1 of Round 10 is $2.0 billion. So the prospects for adequately funding Rounds 11 and 12, and Phase 2 of Round 10, are currently bleak, unless funds significantly in excess of this week’s pledges end up being raised.

dscn0330-community-health-nurse-officer-in-stma-chps-sm.JPGThe second gap is in oversight of procurement and supply management (PSM). “Deficiencies in the oversight of procurement and supply management (PSM) arrangements may be exposing Global Fund grants to unnecessary and unacceptable risks. This is one of the conclusions of an audit report released by the Fund’s Office of the Inspector General (OIG) in April 2010.”
Some of the main PSM deficiencies as summarized by GFO are –

  • weak forecasting of requirements for drugs and health product
  • weak technical specifications for procurement
  • absence of, or weak, procurement policies and procedures
  • poor inventory management
  • poor storage and transportation facilities at national and sub-national level
  • weak procurement planning resulting in frequent emergency procurements and
  • inadequate management information systems

The third major gap reported in the GFO is lack of civil society participation in County Coordinating Mechanisms (CCMs) for global fund grants. The article highlights the Civil Society Action Team’s recent report. This report documented the fact that while persons affected by the three diseases in theory have representation on CCMs, they often do not take part in the real decision making.

In particular, “civil society representatives often lack the capacity and expertise to fully engage in CCM processes and to properly represent their constituents.” Lack of participation threatens the relevance and acceptability of programs.
These gaps focus on weaknesses basic health systems management processes and competencies. It is not enough to point out these gaps. Serious efforts are needed to strengthen health systems. Unless these three gaps are closed, partner interest in pursuing the noble goals of disease control and elimination will be threatened.

What if available malaria tools actually reached people?

Tachi Yamada of the Gates Foundation told Discover Magazine (October 2010) that, “… childhood deaths … could fall by half by 2025 if we could deliver existing vaccines, malaria treatment, and today’s other lifesaving tools with 90% penetration to those at risk.” During the push towards Universal Coverage, it is good to ask whether we can really reach people with our existing tools.

efficacy-to-effectiveness-sm.jpgThe INDEPTH Effectiveness and Safety Studies (INESS) offers a conceptual model as to what happens when a when efforts are made to ensure that a highly efficacious tool – malaria medicines, LLINs – actually reaches people. This ultimately impacts on the effectiveness of the tool. Thus a drug that is 95% efficacious, may be less than 50% effective if the right people do not take it at the tight time.

First people need access to the tool – in the INESS case ACTs. We must deal with all the procurement and supply chain management issues that determine whether the medicines will reach the sick people in good condition beyond the end of the tarmac road.  Then targeting must be considered – do the right people get the medicines? Next the health workers themselves must comply with treatment guidelines, and finally, if the person with malaria gets his/her drugs, will he/she adhere to the treatment regimen?

Peter Moszynski in the British Medical Journal also expresses concern about the access and compliance issues:

Despite the widespread availability of effective new (malaria) drugs and diagnostic tools … major problems remain. Issues such as misdiagnosis and overprescription of treatments, counterfeit drugs, problems in supply and delivery, and emerging resistance to drugs “all hamper effective treatment.” A lack of awareness among donors and the public of some these basic problems “threaten the success of global malaria control efforts.“

Beatrice Wasunna, et al. addressed the provider compliance issue when they found that, “In-service training and provision of job aids alone may not be adequate to improve the prescribing, dispensing and counseling tasks necessary to change malaria case-management practices and the inclusion of supervision and post-training follow-up should be considered in future clinical practice change initiatives.”

Many resources are flowing through health systems right now, especially with the pressure to achieve Universal Coverage and the enthusiasm generated by the MDG Summit. Can we ensure that the health systems in place can bring the effectiveness of these tools closer to their actual scientifically tested efficacy?