Tropical Health Matters

The Sunday Times has reported that, “The world’s largest Aids fund has been the victim of a multi-million-pound fraud involving its programme to help chronically ill children in Africa.” Full details have not been released but, “Whitehall sources said that the concerns related to a Global Fund contract given by the United Nations Development Programme (UNDP) to a firm in Denmark. The firm is said to have received help from a British aid consultancy, which has led to suspicions of kickbacks.”

Allegations of Global Fund ‘misdirection’ or ‘loss’ have occurred at the country level. For example, a series of articles in Kenyan newspapers addressed problems of supposed financial impropriety. Accusations of fraud were raised by one government agency against another (The Nation, 26 June 2003). Another article described concerns over lack of timely releasing of and reporting on funds (The East African Standard, 17 March 2006). The issue of lack of transparency and accountability were mentioned when there were drug shortages (The East African Standard, 24 July 2006).

In neighboring Uganda the New Vision reported on 31 December 2006 in a year-end report that, “Mismanagement of the Global Fund dominated the media throughout the year.” Former Cabinet Ministers were implicated in fraud and demands for refunds were made.

In no way should these allegations be taken lightly, but one explanation for the inability in come countries to account may be systemic. Traditionally in most health ministries and agencies program reporting and financial reporting are separate processes serving separate masters. The Global Fund, in contrast, requires that program and financial reporting be linked in order to guarantee that performance based funding (PBF) can occur. As a guiding principle the Global Fund aims to “Focus on performance by linking resources to the achievement of clear, measurable and sustainable results.” Countries often learned about PBF through trial and error since the Global Fund does not provide technical assistance, either management or programmatic, to countries. Not surprisingly during the start-up period, and even into the fourth or fifth year of Global Fund experience, some countries were still trying to link the programmatic and financial channels in reporting by their principal and sub-recipients.

A lack of link between financial and programmatic aspects of projects could as easily imply poor accounting practices as it could embezzlement. Holding of judgment until evidence was in was necessary at the country level, and consequently few grants have been suspended or canceled to date.

Back to what The Sunday Times reported – what appears to have happened is on a grander scale and completely inexcusable. Obviously the Global Fund needs to focus not just on country performance, but also on all the international systems that support procurement and assistance for those countries. There are big fish to catch.

The Lancet has been running a series on Global Mental Health. In the opening article of the series, “No health without mental health,” Martin Prince and colleagues examine the “interconnectedness” between mental health and malaria, among other conditions. Some of the possible connections between malaria and mental health may include –

• association of P falciparum with self-limiting psychiatric disorders
• psychiatric effects of some malaria treatments
• complication or delay of malaria diagnosis in presence of psychiatric disorders
• association between parasitaemia and anxiety, depression, and total psychological symptoms
• deficits in memory, language and attention
• short term effects of malaria on cognitive function and long term effects on cognitive development
• somatization leading to incorrect self-diagnosis of malaria

The foregoing require further research. Areas that have yet to be researched include the role of mental health on malaria medication adherence and adoption of preventive practices, as well as the general possibility that mental disorders might increase the susceptibility to malaria.

Of particular interest in terms of malaria prevention and care of newborns would be research on the effects of postpartum depression (PPD) on malaria. Research by Minkovitz and colleagues in the US has shown that postpartum depression, which can last 2-4 months, has a serious effect on mothers’ parenting skills. A PPD prevalence of 18.6% of mothers at the primary care level in Nigeria was similar to the nearly 18% reported in the US study.

the Lancet makes the point that Mental Health is a neglected issue. Malaria, too, despite new funding being made available, is still neglected based on the 48 million disability adjusted life years attributed to the disease annually. The interconnectedness between malaria and mental health is another reason to stop the neglect of both.

UNICEF has just announced the results of surveys that show a major reduction in child mortality between 1990 and 2006. While it appears that immunization programs have contributed the most to this progress, the role of increased malaria intervention is important. According to UNICEF malaria currently accounts for 8% of child deaths worldwide, and to date insecticide treated nets have made the main contribution to mortality reduction. For example at present over 50% of households own at least one ITN in Malawi.Treatment is also becoming an important component, and since the start of the Global Fund to Fight AIDS, TB and Malaria and other partnership efforts is recognized. For example, to date the GFATM has helped to…

• finance 109 million bed nets to protect families from transmission of malaria, thus becoming the largest financier of insecticide-treated bed nets in the world
• deliver 264 million artemisinin-based combination drug treatments for resistant malaria

Dr. Robert Black of the Johns Hopkins Bloomberg School of Public Health stressed the importance of recognizing regional differences in tackling the challenge of reducing child mortality in the Washington Post. For example pneumonia remains a major force in South Asia, while Malaria is more of a threat to children in sub-Saharan Africa.

As seen in the attached chart from UNICEF at BBC News, child morbidity rates worldwide dropped from 55/1000 live births to 27 between 1990 ans 2006. It is in sub-Saharan Africa where the challenge of child mortality is the highest and where over half of child deaths occur. Malawi, for example, saw a fall in under-five mortality of 29 per cent between 2000 and 2004, and there were reductions of more than 20 per cent in Ethiopia, Mozambique, Namibia, Niger, Rwanda and Tanzania. So, while there were reductions in countries surveyed sub-Saharan Africa the problem remains unacceptably high.

We have addressed the issues of financing, partnership and political commitment before, but these are what it takes to solve the malaria problem. These somewhat hopeful results from UNICEF provide a further opportunity to encourage all partners take all actions needed to remove malaria from the list of major child killers in Africa.

Recently we discussed the value of the website for the Global Fund to Fight AIDS, TB and Malaria as an advocacy tool to get financial, policy and programmatic support for malaria programs. During a recent visit to Kenya I learned that for many NGOs and front line health service staff the internet is a dream at best. Members of civil society organizations complained that it is only those in a well financed NGOs based in the capital who can browse and receive email communication about the latest developments and thus be in a good position to act on new grants and information. This was reiterated by a key development partner who warned that we in the international development community and the national health and development agencies tend to forget that few people can or do access information about malaria funding and technical information through the internet.

The website, Internet World Statistics, helps make this problem graphically clear. Overall only 3.6% of people in African use the internet compared to 20.2% worldwide. In continental Sub-Saharan Africa, South Africa takes the lead at 10.3% while DRC and Ethiopia are lowest at 0.2%. Some of the isalnd nations where mosquitoes and malaria are more easily controlled have internet usage approaching world averages.

One assumes that with the wealth of free information on the internet, though obviously some of questionable quality that the internet would be a most valuable resource for health program planners. In Nigeria we learned that the digital divide seen between Africa and the rest of the world in the attached chart also extends within countries. In southwest Nigeria we found that staff of NGOs were 50% more likely than those of government health agencies to have access to a computer and to browse the internet.

There are a large number of free malaria e-mailings that go out frequently to subscribers. Most helpful is the weekly summary of malaria news and scientific articles from the Roll Back Malaria partnership. Even in Africa AMANET sends out an e-mail newsletter. Africa Fighting Malaria is another group that puts out regular news summaries. But these are of little value if one does not have reliable internet access.

Part of development assistance in the war against malaria therefore, needs to include internet access to government and NGO staff in Sub-Saharan Africa as a major component of its armament. This will enable African malaria workers to be on top of the latest developments and access the information and funds they need to succeed against this killer disease.

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.

Despite a call for pharmacovigilence by the Kenya Pharmacy Board, fake duo-cotexin and cotexin were found in Kenya recently. The producers of duo-cotexin [40mg of dihydroartemisinin (DHA) and 320mg of piperaquine (PPQ)] have promised to introduce counterfeit-proof packaging with features such as a hologram, but in the meantime in Kenya, let the buyer beware. As a Daily Nation editorial opines, at present, “The average person is hardly in a position to differentiate between the counterfeit and the genuine drug. This would mean that there are people who are unnecessarily losing their lives.”

The Daily Nation pinpoints the problem within the Pharmacy Board. “Although the Pharmacy and Poisons Board has drug inspectors who are tasked to not only combat counterfeit drugs but also to ensure that drugs in the market are duly registered, it would appear that they are ill-equipped to police the drug market,” even though the Board claims that, “We ensure that all drugs, locally manufactured, imported and/or exported and registered to ensure their safety quality and efficacy” (sic).

With the presence of major donor programs such as the Global Fund and the President’s Malaria Initiative, Kenya may feel that much of its malaria drug need is being met with provisions of the only WHO prequalified arteseminin-based combination therapy antimalarial, Coartem, but that does not account for the private sector where the fake duo-cotexin appeared. Donor support is needed, not only to import more Coartem, but also to improve the capacity of the National Pharmacy Board and National Quality Control Laboratory to ensure that all Kenyans have access to safe and effective malaria medicines, whether they use the public or private sectors. This same need holds true for other countries in the region.

Front line clinics in Kenya, such as the one pictured here, carry four different dosage packs of Coartem to cover all age groups. In addition, coartem is given for free to all patients, and people over five years of age are generally tested before this artesunate-based combination therapy (ACT) drug is prescribed. This comprehensive approach means that there is no discrimination in providing care.

In other countries free ACTs that have been provided through donor support are intended only for children less than five years of age. ACTs for the remainder of the population have not been bought by health authorities based on concerns for cost. Sometimes then, the free ACTs from donor programs have been used inappropriately for older patients. Kenya appears to be avoiding this problem.

The lesson is even larger than that of the need for drug forecasting and adequate procurement. The Kenyan Ministry of Health recognizes that ACT has a preventive effect as reported by Sutherland and colleagues whose “results suggest that co-artemether has specific activity against immature sequestered gametocytes, and has the capacity to minimize transmission of drug-resistant parasites,” though this can be modest in some settings. If only a portion of the population is treated, this benefit of reducing transmission is missed.

Another benefit is economic. The Kenyan Ministry of Health also recognizes that if a parent is sick with malaria and misses work, the whole family will be affected. Just as WHO is calling for free nets for all, there also needs to be free ACTs for all who are infected with malaria. To do this we need continued donor and country support as well as a wider range of WHO pre-qualified ACTs to create competition and bring ACT prices down.

Last week WHO’s Global Malaria Program (GMP) launched its new guidance for Insecticide Treated Nets. Two key features of the guidance is the stress on providing free nets and the need to achieve total population coverage in endemic areas. The position paper begins by stating that the three primary interventions to be scaled up for effective malaria control include:

• diagnosis of malaria cases and treatment with effective medicines;
• distribution of insecticide-treated nets (ITNs), more specifically long-lasting insecticidal nets (LLINs), to achieve full coverage of populations at risk of malaria; and
• indoor residual spraying (IRS) to reduce and eliminate malaria transmission.

Nowhere in the document, let alone in this highly visible opening paragraph, is there mention of Intermittent Preventive Treatment/Therapy for pregnant women (IPTp). Thus, once again the GMP misses an important opportunity to stress a crucial and well proven intervention to protect the lives of pregnant women, their unborn babies and newborn infants from morbidity and mortality from the most dangerous form of malaria, P. falciparum.

A recent review by ter Kuile et al., has shown once again, that even in areas where there is up to 50% resistance to sulfadoxine-pyrimethamine (SP) in small children, IPTp with SP is still efficacious in controlling maternal malaria and reducing both maternal anemia and low birthweight in newborns.

We are not sure why the GMP itself has high levels of resistance to acknowledging the lifesaving effects of IPTp, and regret the poor example being set by a leader in world health. Fortunately other major development partners who actually have money to spend are still willing to help countries that suffer from malaria by supporting IPTp.

Thursday the 16^th of August 2007 marked a dual launching of two related malaria documents in Nairobi. WHO released its new guidance on insecticide-treated bed nets, and the Ministry of Health (MOH) in Kenya shared its impact report on malaria control interventions. Both stressed the importance of mass distribution of free Long Lasting Insecticidal Nets to achieve coverage of vulnerable populations. WHO explained that Kenyan evidence on net distribution modalities and improvements in malaria morbidity and mortality reinforced the need eventually to cover the entire population in endemic areas to achieve maximum health and economic benefits.

The Washington Post reported that the WHO guidance may put to rest the argument between proponents of free nets and those who believe that, “people who spend their own money on them are more likely to value them and use them properly.” Both documents indicated that equity in reaching the poorest portion of the population was best achieved by providing free nets, but that highly subsidized nets through clinic voucher programs and social marketing may play some role in improving access to LLINs in the poorer segment of society.

Data from the Kenya document seen in the attached picture show that over the past three years the gap between the higher and lower income quintiles of the population has been narrowing. This is an indication of how malaria control can contribute the goal of reducing health inequalities enshrined in Kenya’s National Health Sector Strategic Plan for 2005-10.

WHO also commended Kenya for implementing its national malaria strategy through a broad based international partnerships including DfID, UNICEF, USAID, GFATM, WHO and the Wellcome Trust among others. As the Times reported, donor funding helped make it possible for Kenya to give free nets.

The Kenyan MOH reported that the donor partnership has made one-quarter of a million US dollars available for malaria control since 2002. This amount should be viewed in the light of estimated budgetary needs of US $105 million for the current year alone. The fight against malaria in Kenya requires not only continued donor support, but also greater Kenyan government contributions and wise management of donor support to achieve the greatest health and equity impacts.

Recent discussions with people in countries that have received Global Fund to Fight AIDS, TB and Malaria (GFATM) grants has shown that most people, either in government agencies or in civil society are aware of the great wealth of information about the global fund generally or about their own country’s programs specifically that can be accessed on the GFATM website.

For example, if people are critical of the composition and performance of their country’s Central Coordinating Mechanism, they could download a copy of the CCM guidelines. When they complain about lack of civil society participation as grant recipients, they could download GFATM Board decisions that call for inclusion of NGOs as principal recipients. With such information in hand they can advocate with government, donors and the CCM itself to bring about improvements. Ironically, sometimes improvements may have already been made and described on the GFATM website, but people have not accessed the site to learn about the latest developments.

Another common complaint concerns disbursement of funds. NGOs in particular may wonder why they have not received recent installments of grant money. They are likely to blame the GFATM first, although a basic principle of the Fund in timely and efficient distribution of funds. A look at a particular country’s page on the GFATM website can provide access to the most recent progress reports on each grant wherein one can see the amount of funds pledged, the amount disbursed by the Global Fund and the amount expended by the principal recipient (PR). If a PR is running behind on expending funds received, the Global Fund will not send more. Therefore advocacy again may be needed to ensure accountability on the part of the PR, CCM and even the Local Funds Agency who is supposed to audit expenditure and implementation progress.

Clearly this situation reflects the digital divide. It is not enough for international organizations like the GFATM in professing openness to simply provide open access information on its website. People who need this information often do not have easy access to the internet, or if they do have access, they may have no idea that such a wealth of information exists. The GFATM does not have offices in countries and is therefore in a poor position to communicate about itself to those who need information. Partners like Roll Back Malaria, UNAIDS, and USAID among others, are providing technical assistance to countries for their Global Fund activities. Maybe these international partners can also help educate and link the potential and actual Global Fund partners in country via more accessible print and electronic media to the valuable advocacy resources available online.