Sierra Leone – malaria emergency

The United Nations’ humanitarian news agency, IRIN, headlines an “Appeal for aid as malaria ’emergency’ looms.” Apparently there has been an upsurge in malaria deaths among children.

IRIN says that WHO and Unicef “are ‘urgently’ appealing for 1.3 million bednets, as well as anti-malaria drugs, at a cost of US$16.9 million. The situation is now considered as constituting a potential emergency,” said their statement. This press release has been reprinted in dozens of sources ranging from news agencies to relief organizations since it appeared a few days ago. How did the situation get this bad?

poor-record-keeping-at-local-health-posts2.jpgSierra Leone is the recipient of two Global Fund malaria grants from Rounds 4 and 7. The Round 4 (R4) grant began on 1st May 2005 and was to run for 5 years.  Strangely, the grant has not been approved for Phase 2 funding although Phase 1 funding supposedly ended in April 2007. The most recent progress report for the R4 grant on the Sierra Leone webpage is dated August 2008, and shows only 78% of the Phase 1 money (or 46% of the intended grant total) was disbursed by that point.

By the end of the second year the R4 there seemingly was acceptable progress toward goals of distributing ITNs and providing IPT to pregnant women.  But malaria treatment was severely lagging.  Overall the grant had been scoring a B2 – “inadequate but potential demonstrated.”

The Round 7 (R7) malaria grant, which began on 1st May 2008, is closing in on its Phase 1 endline. It is also rated B2 and has received 76% of its Phase 1 budget (or 30% of the total planned grant). During the reporting period that ended in May 2009 it appeared that treatment targets for children were being met and malaria drug stockouts were being prevented at facilities, but home/community based treatment goals were falling short.  ITN and IPT distribution looked good, but the review of the grant stated …

PR plans to procure ACTs in the first two installments and accelerate activities that were delayed in Year One. The PR has improved significantly performance on the period as well as general management of the grant … We are cautious with our B2 rating due to the weaknesses in procurement/planning which have been identified. This should be resolved in the next progress report …

It may be possible that the R4 grant had been rolled into the R7 grant. In either case, it appears that malaria treatment was the weak link, and yet IRIN reported that, “Only 26 percent of children sleep under treated bednets.” This contrasts with 56% reported on the RBM webpage for Sierra Leone based on 2007 data reported from the National Malaria Control Program.

IRIN mentioned that the WHO-Unicef communique states that, “the approach to malaria in Sierra Leone is still more curative than preventive.”  This is ironic given the better reported performance for ITNs and IPTp on both the RBM and GFATM websites and the poor performance for malaria treatment also highlighted on both.

Back to the source – WHO and Unicef representatives in the country were reacting to the following: “An analysis of recent data from the Ministry of Health and Sanitation indicates that over the past four months, there has been a significant increase in the number of children under five dying as a result of malaria.” We are not sure whether these were confirmed through laboratory tests nor whether they represent a normal seasonal rise in the disease.
Like other countries Sierra Leone has been guided by RBM to develop a road map toward achieving universal coverage by December 2010. The road map outlines the following gaps:

  • 1.6 million ITNs needed out of a projected requirement of 3.0 million
  • 7.7 million ACT doses needed out of 8.5 million
  • 1.6 million IPTp doses needed out of 1.7 million

At the same time Sierra Leone reports having US $2.5 million for ACT purchases from PLAN, Global Fund and Unicef to reach 2010 malaria treatment targets, and $11.1 million from all sources to address all interventions by 2010.

Based on the GFATM progress report findings, one wonders whether the ‘emergency‘ is really a procurement problem more than a funding problem.  This makes the emergency no less real to people suffering from malaria, but shows that technical assistance to strengthen health systems needs to receive equal attention to funding for commodities.

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PS – The role of the private sector is not mentioned in the communique even though the Concord Times of Freetown reported in June 2009 that, “The Pharmacy Board of Sierra Leone-PBSL in a bid to make Anti Malaria Drugs more accessible to the vast majority of citizenry, has deregulated the sales of Atesunate (the combination therapy for Malaria treatment) which used to be a prescription drug and could now be sold over the counter and in patent drug stores all over the country.” It also does not acknowledge the role of the corporate and NGO sectors: “Standard Chartered in partnership with the Anglican Diocese -Bo will distribute over 16,000 Insecticide-Treated Nets to different target groups in Pujehun, Bo and Freetown” (October 2009).

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