The 2015 Millennium Development Goals milestone of reducing malaria morbidity and mortality is sometimes hard to see from here because of the many carts that got ahead of the horses and clogged the road.Â We discussed earlier this week about the big push for universal coverage with long lasting insecticide-treated nets that got ahead of thoughts and plans for disposing the net packaging as well as old nets in an environmentally sound way.
Only a few efforts are underway to find a solution to old net disposal. In fact the need to replace LLINs much sooner than expected because of less than desired durability in real life field settings was another cart that surprised some horses and may lead to stock-outs in the next few years as financial sources for nets are not as certain as before.
A classic example â€˜carthorsologyâ€™ is the roll out of artemisinin-based combination therapy medicines long before appropriate, easy to use diagnostic procedures were in place. Certainly we needed to save lives, but while most endemic African countries replaced first line drugs to which parasites had developed resistance with ACTs between 2005 and 2008, there was no alternative to clinical diagnosis in place.
Hopes that net use and other preventive measures would bring down the demand for ACTs were thwarted when health workers had to rely on their clinical judgment and continued to prescribe the more expensive ACTs presumptively just as they had done for the cheaper chloroquine and sulphadoxine-pyrimethamine. When RDTs finally became more common, there was an uphill battle to convince health workers that their clinical diagnosis was no longer acceptable.
In actuality, RDT supplies are still not matching need â€“ i.e. enough to test all fevers and suspected cases of malaria. So in hindsight we are rushing to invest more heavily in RDTs and health worker diagnostic training and trying to find ways to safely dispose old nets.
Processes like RoapMap planning sponsored by RBM and WHO are certainly moving us in the right direction that views holistically the totality of the malaria intervention package intervention. One wonders though if any other carts lie unforeseen ahead to block our horses.
One example of needed foresight is the development of appropriate strategies for end game pre-elimination and elimination.Â In particular are appropriate surveillance systems in place?
Donors, especially the Global Fund seem reluctant to support the challenges of pre-elimination in countries like Swaziland, Namibia, Solomon Islands and others who are on the frontline of the elimination effort.Â Fortunately the Clinton Health Initiative is one of those with foresight.Â Hopefully we can keep investing in the forward march without additional unforeseen diversions in the RoadMaps.