Tropical Health Matters

A malaria control curiosity appeared in the news this past week – vaporized lighting. The concept seems simple enough – using the heat of a light bulb to vaporize and disperse insecticides. While we encourage multiple vector control efforts, the feasibility of finding functioning light bulbs among the must vulnerable populations gives pause to the quest for ever more clever mosquito control innovations.

In contrast Jeffrey Sachs and colleagues draw us back to the basics by asking whether we can get insecticide treated nets to everyone and make a real impact on malaria. He stresses the importance of long lasting insecticide-treated nets (LLINs) as both an individual and a community protection intervention. What is unique in Sach’s call for action is asking donors to get serious about providing nets for ALL people in endemic communities, not just children, not just pregnant women, not just those who can afford subsidized socially marketed nets. This gets at the heart of the supply and demand problem. As long as there are inadequate nets to cover the whole population (and working adults also need nets to prevent malaria and increase their economic productivity) then there will always be loss and leakage from the supplies intended to serve the most vulnerable.

The practicalities of getting nets out to all is addressed by Grabowsky et al. (2007) who examine a dual approach of using both campaigns and routine health services as complimentary methods for net distribution. In this way malaria control programs can both ‘catch-up’ and ‘keep-up’ with need.

Finally Charles Griffin of the Brookings Institute calls on donors, large and small, as well as national malaria control programs to take the long term view to preventing malaria. He calls on donors and governments not only to make a long term commitment to sustain efforts but at the same time to strengthen the ability for local industry to produce and sustain supplies for malaria commodities and to enhance the role of the private sector in protecting its workforce.

the foregoing ideas require an unprecedented level of donor-government-private sector collaboration – but without such cooperation we will not achieve nets for all.

The American Enterprise Institute has raised concerns about the quality of drugs that might be purchased for large scale donor efforts. Roger Bate explained that for malaria, “only 7% of malarial drugs on the Global Fund’s list have undergone bioequivalence testing yet malaria kills more than a million people a year.” He goes further to note that, “Some of the drugs are “monotherapies,” single drugs which have been actively discouraged by WHO because they encourage drug resistance. The list contains further drugs which go against good medical practice, the specific advice of the WHO and even, according to insiders, against the technical advice of competent people at the Global Fund.” The head of Kenya’s malaria control program quotes as saying that their ministry “plans to buy untested Indian copies of Coartem.” Mr Bate is therefore concerned that, “Uganda and Nigeria are likely to do the same. And this is probably just the tip of the iceberg.”

As we have reported before, there are definite concerns about cost and availability of malaria drugs expressed by African countries. What can be said about quality? The Global Fund, one of the largest sources of money for malaria drug purchases, addressed the quality issue through its Board, which has issued guidelines for countries. These guidelines distinguish four categories od medicines: A, B, Ci and Cii. Of note, “The Global Fund does not endorse or warrant the fitness of any product on the Compliance List for a particular purpose,” These categories are defined as follows:

A – Products acceptable under the WHO Prequalification Program

B – Products authorized for use by a stringent regulatory authority

Ci – The manufacturer has submitted an application for approval of such product to the WHO Prequalification Program or a stringent regulatory authority

Cii – If the manufacturer of such product has not submitted an application for approval of such product to the WHO Prequalification Program or a stringent regulatory authority, such product is manufactured at a GMP compliant manufacturing site, as certified (after inspection) by the WHO or a stringent regulatory authority

Only one drug in the list is found in category A: Artemether-Lumefantrine by Novartis. Only one is ranked in category B: Artesunate-Mefloquine by Mepha. This list is available in the internet for all countries to review and use for planning. The so-called monotherapy drugs are in large part artemether rectal capsules for use in severe malaria only. Sulphadoxine-pyrimethamine is listed since it is the drug used for Intermittent Preventive Treatment/Therapy in Pregnancy.

For the past three months the international Roll Back Malaria Partners have been providing technical guidance to African countries as they develop their next proposal for the Global Fund, and these partners are using such guidance from WHO and GFATM to ensure that countries order quality medicines. Contrary to fears that Nigeria may be ready to buy cheap, poor quality alternatives, the Nigerian proposal development team is at this very moment basing all its procurement and costing estimates on Artemether-Lumefantrine (Coartem). A positive and synergistic aspect of the planning is that if high coverage of long lasting insecticide treated nets is achieved, demand for ACTs will actually decrease, which addresses in part the cost issue.

Finally, although major RBM partners are trying to address quality issues, there are still many areas of concern – what malaria drugs are being imported and sold through the private sector? – what malaria drugs are governments in endemic countries buying with their own funds? The RBM partnership has made a start to ensure malaria drug quality, but must continue advocacy until all organizations and agencies that purchase malaria drugs adhere to quality standards and more drugs are added to the prequalification list.

The Agencia de Informacao de Mocambique reported that, “spraying campaigns have often failed to attain the desired results because people refuse to allow the Ministry of Health teams to spray their homes. The last spraying campaign, intended to cover 47 of Mozambique’s 128 districts, only met 37 per cent of its target.” The Ministry of Health reported that, “much of the low coverage is due to people simply refusing the health workers access to their homes.” Similarly the President’s Malaria Initiative (PMI) identified that only 50% of targeted homes were covered in a 2006 IRS campaign in Mozambique.

The World Health Organization confirms that part of the decline in the use of IRS to control malaria has been low community acceptance. “Community acceptance of house spraying and cooperation, for exam­ple, by allowing access and removing some household contents prior to spray­ing, are critical for the program to be successful. Repeated spraying of houses commonly generates fatigue and refusal by householders. Reduced acceptability has been an impediment to effective IRS implementation in vari­ous parts of the world.”

WHO identifies other factors that reduce community acceptance including, “Some insecticide formulations are less acceptable because of their smell or because they leave unattractive deposits on walls.” IRS may also make community members feel uncomfortable and suspicious of spray teams, such as when household possessions are moved to enable spraying, as seen in the drawing from a WHO Eastern Mediterranean Office publication.

One was to overcome these problems is enhancing community participation and improving the capacity of the health system: “Acceptance and cooperation by house owners are higher with better health education and more involvement in planning. The cost for personnel is much reduced although the local health service or a community-based organization may have to give the spray workers some financial or other compensation. The health services, however, have to be strengthened in order to provide health education as well as the supervision and evaluation of activities.”  Similarly, PMI suggested that a “well-run … spraying program has been able to keep refusals below 5-10% over the course of 11 rounds of spraying” through involving community leaders and string health education efforts. Therefore, IRS, like any other public health intervention, needs a strong community involvement and health education component to succeed.

Claudia Vondrasek, based in Mali for the Voices Project, offers these perspectives (in French and English) on malaria control in Mali.

Quel rôle le secteur privé devrait jouer ?

Le paludisme constitue un problème prioritaire de santé publique de part sa fréquence, sa gravité chez la population malienne. La politique nationale de lutte contre le paludisme prend désormais en charge les couches vulnérables que sont les femmes enceintes et les enfants de moins de 5 ans. Cependant, force est de reconnaître, que malgré la volonté des autorités, il manque suffisamment de ressources pour faciliter l’accessibilité et la disponibilité du traitement à un moindre coût (en subventionnant par exemple) pour les couches hors cibles. Le secteur privé peut combler ce vide en partie en jouant un rôle important dans la protection et la prise en charge des employés et leurs familles. En plus, le secteur privé pourrait soutenir le ministère de la santé dans l’acheminement des produits antipaludiques et la construction ou la réhabilitation de magasins appropriés pour le stockage de ces produits.

Le paludisme est–il la chasse gardée du ministère de la santé ?

Vu la gravité et l’ampleur de la maladie, les défis pour éradiquer le paludisme au Mali dépassent les seules capacités du ministère de la santé. Il est aujourd’hui nécessaire de stimuler des actions citoyennes des entreprises et sociétés au Mali pour contribuer de façon significative à la protection et prise en charge de leurs employés et familles du paludisme. Les entreprises peuvent ainsi offrir de l’éducation sur le paludisme aux employés ; rendre accessible et disponible les produits antipaludiques (SP, CTAS, MII, TDR…) dans leurs infirmeries ou dans les centres de santé inter – entreprises…

Fort de cette opportunité, Le projet Les Voix du Mali a organisé, le samedi 2 juin, un dîner-gala pour stimuler l’engagement des entreprises privées dans la lutte contre le paludisme. Quatorze sociétés et entreprises se sont engagés à prendre des actions concrètes contre le paludisme dès cet hivernage en faveur de leurs employés et leurs familles.

Ces engagements peuvent s’expliquer par une prise de conscience des chefs d’entreprises de la gravité et l’impact socio-économique du paludisme. Il apparaissait clairement que les chefs d’entreprises ne disposaient pas d’informations fiables sur les conséquences du paludisme. Une action soutenue d’information des chefs d’entreprises permettra d’aboutir à l’adhésion d’un grand nombre d’entre eux non seulement pour concrétiser la volonté du Conseil du Patronat National de créer une coalition des chefs d’entreprise contre le paludisme au Mali mais aussi et surtout de protéger tous les travailleurs du secteur et leur familles contre le paludisme.

Egalement, tous les ministères (que ce soit Agriculture, Mines, Tourisme, Communication, Transport …) et la Société Civile dans sa totalité, doivent absolument s’engager aux côtés du Ministère de la Santé pour lutter contre le paludisme et faire du Mali un pays sans paludisme, une réalité.

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What role should the Private Sector play in Malaria Control? Malaria is a priority public health problem due to its frequency and its burden on the Malian population. National policy now targets the most vulnerable populations: pregnant women and children under 5 years old. However, the Ministry of Health lacks the resources today to facilitate access and availability of subsidized treatment on a national scale to other adults and older children. The private sector can fill this void in part by playing an important role in protecting and taking responsibility for their employees and their families. In addition, the private sector can support the Ministry by helping with supply chain for antimalarial products and by constructing or installing appropriate storage facilities for stocking these products.

Malaria: is it the exclusive domain of the Ministry of Health?

In light of the gravity and magnitude of the disease, the challenge of eradicating malaria in Mali surpasses the capacity of the Ministry of Health alone. Today it is necessary to galvanize Malian companies and businesses to make substantial efforts towards protecting and taking responsibility for their employees and families from malaria. Companies can thus offer education about malaria to their employees, and help make antimalarial products (SP, ACTS, ITNS, RDTS…) accessible and available in the company clinics or health centers.

To encourage this opportunity, the Mali Voices project organized a diner-gala on Saturday June 2, 2007 to engage the private sector in the fight against malaria. Fourteen companies and businesses agreed to take concrete actions against malaria during the upcoming rainy season for the benefit of their employees and their families. These actions are the results of companies’ executives becoming aware of the seriousness of the socioeconomic impact of malaria. It appears clear that the CEOs were not previously aware of the consequences of the disease. Getting a steady flow of information to executives will encourage many of them to participate in malaria control activities, and build support in the National Business Council to create a Private Sector coalition against malaria in Mali.

Every year in Mali, malaria kills more than 100,000 people, mostly children. It is the responsibility for all sectors to contribute to a successful fight against malaria parasites and vectors. Civil society organizations and Ministries of Agriculture, Transportation, Mines, Tourism, Communication, etc. must take on the responsibility of complementing Ministry of Health actions to make Mali malaria free.

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PRIVATE SECTOR NEWS FROM RBM

Meeting in Dakar aims to improve private sector involvement in the global fight against AIDS, tuberculosis and malaria
In cooperation with Global Fund, ILO, WHO, UNAIDS, Partners against AIDS, and the Roll Back Malaria Partnership Secretariat, a West and Central Africa regional workshop was organized in Dakar to exchange experiences and develop country strategies in order to enhance private sector involvement in the response against the three major diseases. It brought together private sector stakeholders, finance institutions, workers, international agencies, professional associations, labour unions, and 18 countries from West and Central Africa.

Réunion à Dakar vise à améliorer l’engagement du secteur privé dans la riposte mondiale contre le sida, la tuberculose et le paludisme
Avec la cooperation du Fonds Mondial, le BIT, l’OMS, l’ONUSIDA, les Partenaires Contre le Sida, et le Partenariat “Faire Reculer le Paludisme” un atelier régional a été organisé à Dakar afin de faciliter l’échange d’expériences et d’aider les pays à développer des stratégies visant à augmenter l’engagement du secteur privé dans la riposte contre les trois maladies les plus importantes. Cet atelier a regroupé les parties prenantes du secteur privé, les institutions financières, les travailleurs, les agences internationales, les syndicats, et 18 pays d’Afrique de l’Ouest centrale et d’Afrique centrale.

Cotton subsidies enjoyed by U.S. farmers has a dampening effect on agricultural family incomes in the Sahelian countries of West Africa according to a news story in the New York Times. An Oxfam supported study found that a typical farm family of 10 in Chad, Mali, Burkina Faso or Benin “that now earns $2,000 a year would have an extra $46 to $114 a year to spend if American subsidies were removed.

While critics were quoted as saying that the amount of gain is low, that cotton prices are naturally volatile, and that countries would gain more by investing in industry, the seemingly slight potential economic improvement would be quite meaningful to rural families.

Daniel Sumner of the University of California Davis, who was involved in the Oxfam study, has previously written that, “The United States is the only WTO member that highly subsidizes cotton and that plays a significant role in the global cotton market.” He Further explains that, “Unlike rice, where poor nonfarm consumers likely gain from lower world prices, the rich-country cotton subsidies likely have little benefit for any of the poor in poor countries. And, unlike sugar, for which some poor countries get valuable preferential access to rich-country markets, there are no poor-country cotton producers that gain from the rich-country cotton subsidies.”

Oxfam has been raising concern about the cotton subsidy issue for over five years. For example in 2002, Oxfam explained that, “American cotton subsidies are destroying livelihoods in Africa and other developing regions. By encouraging over-production and export dumping, these subsidies are driving down world prices. Oxfam also documented that, “Federal subsidies to the 25,000 US cotton farmers were worth more than $4.2 billion dollars in 2004-2005 – more than the gross national product of Burkina Faso.” In addition to subsidies, Oxfam has addressed World Bank policies and programs that seem privatization of the cotton industry at the expense of the rural poor.

So what if the poor in the Sahel cotton producing countries had the extra cash? Would they use it to buy bednets to prevent malaria? Would they access ACT malaria treatments? Such actions might help offset the tremendous economic burden of malaria. Freedom From Hunger Foundation has found a successful link between microcredit and controlling malaria by families whose income improves. Doing away with cotton subsidies in rich countries may have an even wider impact on poor families’ ability to control malaria in Africa.

This past week eight companies were honored by Global Business Coalition (GBC) on HIV/AIDS, TB and Malaria for the Fight against Global Epidemics. The malaria winner was Marathon Oil Corporation who “led the formation of a unique $12.8 million public- private partnership which includes Noble Energy, the Government of Equatorial Guinea, Medical Care Development International and leading health specialists.”  Results of the first three years of The Bioko Island Malaria Control Project included a 95 percent reduction in malaria transmitting mosquitoes caught indoors and a 44 percent reduction in the presence of malaria parasites in children. Also commended at the honors ceremony for work on malaria were Novartis Pharma AG, BHP Billiton and AngloGold Ashanti.  According to the New York Times (NYT), $2 million was also raised that night.

The NYT also reported that just a day before the GBC event, “the Millennium Promise, co-founded in 2005 by the well-known Columbia economist Jeffrey Sachs, and Malaria No More, a spinoff started last December, held their first fund-raising dinner” where “an astonishing $2.7 million” was raised.  The amount of money raised at the events would cover only a few months of operation of a national malaria control program in Africa, but it has symbolic value and may stimulate governments in the industrialized world to keep on track with the billions they have promised for disease control.

Other models of business contribution include: discounts on product price, as for example, Novartis selling Coartem below cost, efforts by businesses working in endemic countries work to protect their staff, families and communities from malaria, and of course the contributions of large business-based foundations like those of Gates and Buffet.  The private sector not only finances to its own malaria and disease control projects, but makes contributions to multilateral efforts like the Global Fund (approximately 3% of funds received so far).  The model described in Equatorial Guinea falls within the realm of “co-investment.” GTZ defines co-investment in the context of the HIV/AIDS response: “the term co-investment refers to the harmonized and coordinated joint investment of public and private resources with the common objective to improve equitable access to and provision of HIV/AIDS services.”

The issue is not just the money business brings to the table. Small grants from the philanthropic sections of major corporations can actually sponsor innovative projects that can later be taken to scale. If these innovations are to have a wider impact, business needs to be actively involved in national malaria partnerships.  This was one of the ideas behind the organization of a National Malaria Conference last week in Durban, South Africa.

Joe Nocera of the NYT warned readers that, “… it is probably best not to get too excited, no matter how inspiring the speeches at New York fund-raisers.  Because someday malaria is no longer going to be the pet cause in American boardrooms. And then what?”  One answer may lie in another disease control model, the Mectizan Donation Program, which has been providing free ivermectin for onchocerciasis control for two decades. A second answer may be for large corporations working in Africa to develop national capacity to produce effective and cheap malaria control products. Businesses will likely continue to play a role in malaria control; coordination and partnership is the answer to ensuring that this role has impact.

The Ghanaian Chronical this week quotes a district medical office’s concerns “about the continuous sale of chloroquine at chemical shops and urged the Ghana Standard Board to intensify its activities to withdraw the chloroquine from the shops since it would negatively affect the new drug policy,” which lists artesunate-amodiaquine as its first line antimalarial drug. This is backed by research that shows Plasmodium falciparum is highly resistant to chloroquine in Ghana. The question arises whether it is feasible to ban chloroquine.

Nigeria has also gone through a change of malaria drug policy dropping chloroquine as the first line drug and substituting artemether-lumefantrine (AL).  When this happened, the press and the public assumed that a ban on chloroquine would soon follow, but this did not happen. To date chloroquine has not been banned, but efforts have been made to increase the supply of the new artemisinin-based combination therapy drug AL through support from donors like the Global Fund. The reality is that it takes time to transition to new malaria drugs, and when supplies of the more expensive ACTs are not yet available throughout the country, it would be irresponsible to ban other products.

A better approach than banning products is combining donor and national support to acquire adequate ACT supplies with education of both the public and health care providers (public and private) on the benefits of the new drugs. If adequate supplies of free ACTs are available, at least for children under five years of age, demand for chloroquine will naturally decline.

On the demand side, WHO has stressed the importance of educating the public on judicious use of antimicrobial drugs to prevent resistance, and also recommended that. “Education programmes must also be tailored to the needs of specific groups – be they village healers, market vendors, street dispensers, health care workers, paramedical assistants, midwives, nurses, dentists, doctors or others involved in primary care.” Hopefully the two-pronged approach of supply and demand will help countries like Ghana confront their chloroquine challenge.

PS: We shared recently findings from Malawi that after withdrawal of chloroquine in 1993, malaria parasites are again showing susceptibility to chloroquine.  The same experience may occur in Ghana and other West Africa countries in another 10 or more years if ACTs become not only the official policy but the only drugs that are actually demanded and prescribed. A work of caution is needed though. Juliano used new techniques to identify previously undetectable genetic evidence of continued chloroquine resistance in Malawi. This reinforces the importance of combination therapy as the only way forward in the future of malaria control.

The G8 has just reaffirmed its pledge to support malaria and other disease control efforts in Africa and many countries are in the process of developing their Global Fund Round 7 grants. Therefore it is an interesting time to consider a 2005 Der Spiegel interview of Kenyan economist James Shikwati that calls on the industrialized world to STOP AID.

According to Shikwati, “Such intentions have been damaging our continent for the past 40 years. If the industrial nations really want to help the Africans, they should finally terminate this awful aid. The countries that have collected the most development aid are also the ones that are in the worst shape. Despite the billions that have poured in to Africa, the continent remains poor.”  Walter E. Williams of George Mason University echoed these views in the Baltimore Examiner on 28 June 2006 when he said, “No amount of Western foreign aid can bring about the political and socio-economic climate necessary for economic growth.”

Shikwati said the problem arises because, “Huge bureaucracies are financed (with the aid money), corruption and complacency are promoted, Africans are taught to be beggars and not to be independent. In addition, development aid weakens the local markets everywhere and dampens the spirit of entrepreneurship that we so desperately need. As absurd as it may sound: Development aid is one of the reasons for Africa’s problems. If the West were to cancel these payments, normal Africans wouldn’t even notice. Only the functionaries would be hard hit, which is why they maintain that the world would stop turning without this development aid.”

On the other side is praise for aid. The Global Fund has praised the announcement by the G8 to commit US$ 60 billion for disease control efforts. This may be a way for GFATM to reach its recently announced goal to become a $US 6-8 billion operation annually. Ironically, these efforts are criticized as inadequate. The BBC News reported Bob Geldorf as saying, “This wasn’t serious; this was a total farce… I won’t have it spun as anything else except a farce.” According to BBC, Geldorf added that instead of re-committing to the promises made two years ago, the G8 leaders had to get serious and deliver. Oxfam was reported to analyze that only “$3bn of the money was new.”

So the question remains – is global development and disease control aid helpful, inadequate or a hindrance? Aid can hinder entrepreneurship as was the case in Nigeria where one donor was working with local textile and pharmaceutical companies to develop net and insecticide bundled packages while other donors started importing LLINs for their programs. Can aid be more effective if there is donor coordination? Can aid succeed if it focuses on technology transfer and trade? Finally, does a performance based approach to aid as practiced by the GFATM really work and make bureaucracies deliver the goods and be accountable? If the answers to these questions are yes, there may be some hope for development aid.

A team of researchers from Burkina Faso and Germany have accused donors of lacking coordination in meeting the malaria drug needs of low income countries in endemic regions. They believe this lack of coordination between donors and international health agencies is leading to the needless deaths of too many African children from malaria, according to Medical News Today.

Kouate et al. go on to point out that donors, in fact are very coordinated when it comes to decisions to promote ACTS. ACTS, in particular the Coartem brand of artemether-lumefantrin, is the drug of choice approved through WHO’s prequalification program. All donors ranging from Global Fund and World Bank to USAID/President’s Malaria Initiative are on board with this decision.

The clearly articulated challenge is actually finance, not questions of efficacy. This is a similar concern raised by pharmacists in Kenya as mentioned in one of our recent blogs, and creates a sense of resentment in endemic countries. The Kenya example also shows that countries put in a lot of work and effort to make the transition from monotherapy antimalarial drugs to the recommended ACT drug policy. In fact it took Kenya 32 months to finalize the decision, but once having been made, new drug policies do not guarantee that the newer, safer and more effective drugs will be available, as seen in Burkina Faso.

Dr. Uwem Inyang who has worked with malaria and global fund programming in Nigeria shares similar concerns. He observed that countries, “adopt their policies without any in-depth consideration of its availability and alternatives through economic analysis.”

The challenges of changing the policy in Kenya reflects the same challenges including, “lack of clarity on sustainable financing of an expensive therapeutic for a common disease, a delay in release of funding, a lack of comparative efficacy data between AL and amodiaquine-based alternatives, a poor dialogue with pharmaceutical companies with a national interest in antimalarial drug supply versus the single sourcing of AL and complex drug ordering, tendering and procurement procedures. Need careful attention to myriad of financial, political and legislative issues that might limit the rapid translation of drug policy change into action,” according to Abdinasir Amin and colleagues in Malaria Journal.

Dr. Inyang stressed that, “We can not go back on this policy change but we can begin to take stock on how to treat malaria and thus reduce the economic burden arising from it.” Hopefully donors like those in the G8 Industrialized Nations will also realize that we live in an era of ACTs and make good on promises to fund malaria control in Burkina Faso, Kenya, Nigeria and other endemic countries.

Kenya is not only facing increased budget demands to treat malaria using the newer effective antimalarial drugs, it also must deal with expanding habitats for the malaria carrying anopheles mosquitoes.

The East African media organization reported, “The money used last year for malaria was the largest amount ever spent in one year in Kenya on a single disease other than HIV/Aids, and analysts say this reflects both the growing commitment of donors and the government to combat the country’s leading killer.” While donor support such as that from the Global Fund to Fight AIDS, TB and Malaria, can make child doses of Coartem available to the country at cost – about one US dollar – the country must cope with market pricing to meet its total malaria drug needs. This may range upwards to $US 8 per treatment for the consumer. If countries do not forecast and fund their total antimalarial drug needs for both children and adults, cheaper medicines from donor funds may be misused for adult clients who have malaria.
The article also implied that countries may feel resentment because they perceive that that WHO and other donors have forced their hand in adopting new drug policies that favor Coartem among other combination therapies.  Apparently the Pharmaceutical Society of Kenya (PSK) protested that the drug was too expensive. The PSK was worried that this decision to promote Coartem could not be sustained when donor funds wound down.  If countries decide to return to cheaper but less effective alternatives, the small headway made in recent years will be lost. Clearly this should be a wakeup call to donors and the pharmaceutical industry to find cheaper AND effective alternatives.

If the $US 58 price tag for antimalarials in one year was not enough of a challenge, Kenya is also faced with expanding mosquito habitats.  According to The Standard “The discovery of malaria-causing mosquito (Anopheles gambiae) in the Central highlands may have been a surprise to many, but not to climate change experts.” People living in these new malaria territories do not have the acquired immunity that those in endemic areas have, and hence the impact will be great.  While Kenya itself cannot control global climate change, being the home of the UN Environmental Agency, it should be a major advocate for encouraging global cooperation on the issue. In the meantime Kenya will have to budget even more scarce funds for malaria drugs, insecticide treated nets and IRS.

Finally, a third challenge is program management. Although one can empathize about the dilemmas facing Kenya, one needs to draw attention to the fact that the Global Fund does have concerns about how Kenya is managing the support it is receiving to provice malaria treatment. According to the Round 2 Malaria Grant Score Card (2005) which states: “The Program has failed to meet targets inseveral important service delivery areas (SDAs) including distributionof insecticide-treatednets (ITNs) (0% of target) and no data is available for number of people receiving treatment for Malaria, pregnant women receiving IPT (Intermittent Preventive treatment) or Case fatality rate.” the progress report of November 2006 shows some progress on IPT, but not nets and treatments received.

A concerted donor-country effort is needed to meet these triple challenges in a timely manner.