Tropical Health Matters

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

Angola 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.

A 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.

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.

The 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.

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.

The 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?

During visits to private pharmacies in 11 African cities from late 2007 to early 2010 Bate and colleagues purchased 894 samples of antimalarial medicines. Overall 6.5% of these medicines had evidence of being diverted from the public health system. This was only 4.2% of the older malaria therapies, but 27.8% of the 151 ACTs had come from the public sector.

The ACT diversion problem was most noticeable in Nairobi, Lagos, Kampala, Luanda and Dar es Salaam.  The photo here shows ACTs we found in a small pharmacy shop down the street from a clinic in the suburbs of Luanda in 2008. Informal discussions in Luanda with donors also revealed major problems of theft from the ports. Specifically, the Boston Globe reported that, “According to an audit last year by the US President’s Malaria Initiative, about $640,000 worth of medicines sent to Angola vanished from airports and the government’s medicines warehouse.”

The authors are the first to admit that the study design is not perfect and that their sample size could have been larger, but the key issue is that they have actually documented the ‘leakage’ of these donated medicines from the people who need them. This moves the problem beyond the anecdotal level.

Medicines are not the only area where the diversion makes malaria commodities take a detour. Nets disappear, too.

Last year’s universal LLIN distribution in Kano State, Nigeria experienced some challenges in terms of reaching people and their retaining nets.  The goal was two nets per household, but a report by donors after the distribution found that 28% of households surveyed got only one. Seven percent of nets that reached households were also ‘lost’. So far there have been no mechanisms like the study by Bates and colleagues to trace nets into the private sector or elsewhere.

The main issue we see is that health systems need to be strengthened and public education needs to be improved – in this was diversions will be less likely and the public can serve as a watchdog for any malpractices and take an active role in rolling back malaria in their communities.

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