Posts or Comments 18 July 2024

Monthly Archive for "September 2007"

IPTp &Malaria in Pregnancy &Reproductive Health Bill Brieger | 17 Sep 2007

Malaria and Reproductive Health

Population Action International made an important point that the Global Fund to Fight AIDS, TB and Malaria could save even more lives it it addressed reproductive health issues. In particular PAI explains that, “After just a few short years, the Global Fund has saved over 1.8 million lives worldwide. Just think what can be accomplished—how many more lives saved—if the Global Fund partnered with the life-saving work of sexual and reproductive health providers.”

In the area of Malaria control, GFATM funds to contribute toward improving reproductive health through a variety of malaria in pregnancy (MIP) interventions including 1) Intermittent Preventive Treatment (IPTp) with sulfadoxine-pyrimethamine (SP), 2) long lasting insecticide-treated bednets (LLINs) and prompt and appropriate case management with artemisinin-based combination therapy (ACTs)

Of course the potential for including MIP in GF proposals and the actual emphasis on MIP in reality are sometimes different. Since SP is so cheap, its procurement is often overlooked. A recent visit to rural Kenyan clinics found plenty of ACT stocks, but stockouts of SP. ACTs are procured with GAFTM funds through international contracts, while SP is often purchased locally when funds are available in national health budgets.  LLINs are often distributed widely to children under five years of age through well publicized campaigns, while it is difficult to get a bednet as part of regular antenatal care in come countries.  Often GFATM projects are implemented through the vertical disease units in health agencies, leaving little opportunity for reproductive health, or even integrated management of childhood illness units to become involved.
So in short, while we might point out that reproductive health issues can already be part of GFATM activities in principle, we agree with Population Action International that active involvement of reproductive health services, particularly in our area of malaria control, is urgently needed.

Corruption &Funding Bill Brieger | 16 Sep 2007

Filching Funds Facilitates Falciparum

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.

Mental Health &Morbidity Bill Brieger | 16 Sep 2007

Malaria and Mental Health

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

dscn1032a.JPGThe 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.

ITNs &Mortality Bill Brieger | 13 Sep 2007

Malaria Interventions Contribute to Child Mortality Reduction

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.

_44114068_child_mortality_416_3.gifAs 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.

Advocacy &Civil Society Bill Brieger | 10 Sep 2007

Can the Internet Become an Advocacy Tool?

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.

internet-use-africa.jpgThe 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.

Funding &Partnership &Private Sector Bill Brieger | 07 Sep 2007

Malaria Philanthropy, Corporate Responsibility

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.

pmv-in-kano-sm.jpgAt 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.

Drug Quality &Procurement Supply Management &Treatment Bill Brieger | 06 Sep 2007

Malaria Drug Challenges in Kenya

duo_cotecxin.jpgDespite 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.