Posts or Comments 18 July 2024

Monthly Archive for "February 2008"

Funding Bill Brieger | 25 Feb 2008

Nigeria – on per capita basis malaria funds look pathetic

Nigeria is estimated to have a population of 140 million and is home to one-quarter of sub-Saharan Africa’s population and of course a huge portion of malaria morbidity and mortality on the continent. Yet, the amount of donor money flowing in for malaria control programs is lower on a per capita basis compared to many others. Nigeria is receiving up to US $74.3 million from the Global Fund over about 5 years, and this total is less than 54 US Cents per capita over the total grant, and even less on an annual basis (11 cents). This compares to over $5 per capita for countries like Kenya, Uganda, Mauritania, Malawi, Namibia and Zambia.

Nigeria is receiving $180 million from the World Bank Booster Program over a five-year period, and not being a PMI country, has gotten in the neighborhood of only $2.5 million annually from USAID (though there are rumors that this amount may increase somewhat in the near future). DfID is embarking on a new Nigeria malaria effort soon to the tune of at least 50 million pounds over 5 years. Excluding the upcoming DfID money and possible USAID expansion, the total annual per capita money coming in for malaria now is about 38 US cents.

nigeria-map-sm.jpgNGOs and other donors have contributed – ExxonMobil Foundation, Nothing But Nets, Médecines Sans Frontiers, to name a few – but the big money has somehow eluded Nigeria. Because of Nigeria’s large population this means that malaria control is eluding the continent.

The Harmonization Working Group of the Roll Back Malaria Partnership is including emphasis on large but underfunded countries in its current workplan. This includes Nigeria and Democratic Republic of the Congo.  Hopefully this will not only bring more attention to Nigeria by all partners but increase the likelihood of Nigeria succeeding in securing a Global Fund grant in the upcoming Round 8.

Procurement Supply Management Bill Brieger | 24 Feb 2008

Malaria Commodities – preventing corruption and leakage

Private sector partnership in malaria control does not mean that drugs, nets and other malaria commodities provided by donors for national control programs should disappear from the public sector and find their way into shops and market stalls. Unfortunately this is what has been reported in Cameroon.

The Post of Buea reported Friday that, “Corruption has been identified as the main jinx hindering the effective distribution of modern malaria drugs, subsidised by the Global Health Fund for Malaria AIDS and Tuberculosis. The Permanent Secretary at the National Malaria Control Programme, Dr. Raphael Okalla, made this revelation during a press conference in Yaounde February 14. He said corrupt doctors in some government hospitals were pilfering the subsidised drugs and giving them out to people to sell at higher prices for them to make gains.”

Pilferage is an issue that is often addressed in guidelines, such as ones on ACT from Zambia wherein there is mention that, “A key issue to be addressed is the prevention of pilferage from the public to the private sector facilities.” UNICEF offers advice that looks back near the start of the supply chain, “To avoid pilferage, port storage, container demurrage etc., it is important that shipments are cleared and removed from point of entry (ports/airports as quickly as possible.” WHO Afro recommends proper storage facilities and forecasting of needs as steps to prevent pilferage.

preventing-pilferage-and-leakage-sm.jpgWhile the problem is often discussed, documentation can be problematic. The Chronical of Lilongwe reported on general pilferage in 2004. “A clinician, who refused to be identified, informed us that the hospital received a lot of drugs but the problem was that most of them disappeared to private clinics which several individuals working at the hospital have opened. ‘For many months now,’ our informant began, ‘the hospital lacks a whole range of antibiotics such as Ciprofaxine, Augmentin or Amoxilin. We may have some of them for one month and then they vanish for another six months. Can you imagine that?'” Those interviewed at the hospital said the problem stems in part from poor documentation and supervision.

In The Daily Champion of 11 December 2007, Nigeria, “Dr. Dora Akunyili, painted a sad picture of how common criminals, petty thieves and child murderers masquerading as pharmacists, patent medicine store operators and government functionaries have been colluding to deprive children and nursing mothers of life-saving high dose Vitamin A capsules, Mectizan and Coartem tablets, Oral Rehydration Salts (ORS), cold chain equipment and other essential supplies.” Again, specifics on the location and extent of these transgressions is minimal.

One of the benefits of performance based funding by the Global Fund may be to institute accountability measures that could reduce leakage and pilferage. The Fund notes that with, “transparently by performance-based funding processes, grants are reaching overall programmatic targets.” The will to monitor, supervise and guarantee accountability needs to be extended to all aspects of malaria programming no matter which donor provides the funds.

Advocacy &Eradication Bill Brieger | 22 Feb 2008

Eradication or Control – has the confusion started?

When Bill and Melinda Gates hosted a gathering of key malaria stakeholders last year, Melinda told the audience that, “Advances in science and medicine, promising research, and the rising concern of people around the world represent an historic opportunity not just to treat malaria or to control it—but to chart a long-term course to eradicate it.” Thus the E Word had been uttered and could not be taken back. Even though it was clear from the speech that eradication would be a long term goal, partners worried that funders and endemic countries may start to believe that eradication could be just around the corner. Disappointment may lead to loss of political will.

Now we see the following headline in The Daily Observer of Banjul: “Gambia: Operation Eradicate Malaria Launched.” The story opens with the statement: “Operation Eradicate Malaria in The Gambia was yesterday launched by Dr Aja Isatou Njie-Saidy, vice-president and secretary of state for Women’s Affairs on behalf of President Alhaji Dr Yahya Jammeh, at the July 22nd Square, Banjul.” According to the article, one of the factors that has encouraged this optimism is the fact that, “The Gambia tops the whole of Africa in attaining the Abuja Target of Insecticides Treated Bed Net Use by children and pregnant women by 54 per of the 60 per cent target.”

daily-observer-erad-malaria-gambia2.jpgThe article (see left) reports an awareness of the need to collaborate with neighboring countries to achieve the goal. Unfortunately The Gambia is surrounded by Senegal who has had mixed success in its own malaria control efforts, as evidenced in the low performance rating on its first Global Fund Malaria Grant. Progress has picked up on the Round 4 Grant to Senegal, but there is still a long way to go. As we mentioned yesterday, regional cooperation is a key to solving the malaria problem.

It seems that even in The Gambia there is some difference in conception about the current malaria effort. The Secretary of State for Health and Social Welfare was also quoted as saying that, “the aim of malaria prevention and control strategy is to control malaria so that it cease to be a major public health problem in The Gambia and to provide a framework for the reduction of the malaria burden by 80 per cent by 2015.” This is certainly a more realistic approach for the present situation, but lacks the sensationalism of promoting eradication.

Malaria program advocates certainly have a lot of education to do with policy makers and those who hear their speeches to ensure realistic expectations without reducing commitment to the fight against malaria. Advocates should also continue to press for the development of new malaria tools so that eventually eradication might become a possibility.

Advocacy &Mosquitoes &Partnership Bill Brieger | 21 Feb 2008

Malaria doesn’t respect boundaries – Zambezi River Expedition

NAM News Network reported that, “On March 27, a dedicated team of individuals will embark on a two-month humanitarian journey that will start in the North Western Zambia through six countries along the (2,500 km) Zambezi River to the Mozambique Delta where the river meets the Indian Ocean, in an effort to raise malaria awareness and to help eradicate the spread of the disease in the SADC region.” The expedition plans to reach “remote populations with access to protective bed nets and malaria treatment drugs.”

The Zambezi has also drawn attention of malaria commodity donors in the recent past. Although the Zambezi has “one of the Seven Wonders of the World, Victoria Falls,” It also has zones “where cases of malaria are reported throughout the year” according to the Zimbabwe Red Cross, who organized distribution of over 3,000 nets in 2005 and 2006. USAID also recently supported a year-long expedition down the Zambezi to bring services and attention to the remote populations affected by malaria.

The 2008 expedition is described by the Roll Back Malaria Partnership: “The 2-month expedition along the Zambezi River will raise awareness among both local communities and international donors of what is needed to fight malaria and help strengthen cross-border collaboration on malaria-related policies. The Zambezi Expedition project, supported by 6 countries from the Southern African Development Community, has received financial backing from the nonprofit and the private sectors and will be steered by the Roll Back Malaria Partnership.” AFP explained that, “The teams would distribute mosquito nets and medicines in the communities they visit, and doctors would conduct diagnostic tests for the parasitical disease that claims the life of an African child every 30 seconds.”

Campaigns and expeditions certainly help, but what is needed most is continued regional planning and cooperation since malaria and mosquitoes do not respect boundaries. It is hoped that the Trans-Zambezi countries can put together a joint proposal to the Global Fund for the upcoming Round 8 funding. All partners should join together to support this important regional activity. This will also require much good will and collaboration among the Central Coordinating Mechanisms of the countries to support a joint proposal.

IPTi &Partnership Bill Brieger | 20 Feb 2008

When elephants fight

dscn3097sm.JPGAs the saying goes, when elephants fight, the grass suffers. The New York Times has reported on just such a fight between elephants – titans in the malaria world, The WHO Global Malaria Program (GMP) and the Bill and Melinda Gates Foundation. According to the article GMP has voiced concern that, “the foundation’s money, while crucial, could have ‘far-reaching, largely unintended consequences,'”  and that Gates funded research might subvert the agenda and role of WHO. The Gates Foundation countered by saying that, “the foundation did not second-guess or ‘hold captive’ scientists or research partnerships that it backed,” and values external review.

A key point of contention is the issue of Intermittent Preventive Treatment for Infants (IPTi). GMP’s current position is that sulfadoxine-pyrimethamine (SP) used in IPT may be dangerous given to children in regular doses and that anyway there is increasing resistance to the drug by malaria parasites.  In contrast, research managed by the IPTi Consortium has produced promising results in many countries. The Times quotes scientists on both sides of the debate.

To make the situation more challenging, UNICEF, another key malaria partner, has invested in IPTi and found its effects to be positive: “Research shows that intermittent preventive treatment for infants (IPTi) may be effective in reducing anaemia and clinical malaria in young children, and may soon be provided as part of their routine immunization visits. UNICEF is a member of the IPTi Consortium, which is currently conducting research into the feasibility of introducing this additional intervention in Africa.” UNICEF is stuck in the unenviable middle of the storm.

In the meantime while the elephants fight, infants and small children are the grass that suffers.  While we do have ACTs and LLINs and IRS, we do not have the yet crucial mix of interventions that can permanently rid children from the threat of malaria. We need dialog and partnership in the malaria community, not fighting at the expense of children.

ps – The baby elephants pictured above are not fighting anyone. While they don’t need IPTi, they do need help. They are residents of the Baby Elephant Orphanage near Nairobi.

Advocacy &Development &Funding Bill Brieger | 16 Feb 2008

Malaria Tour – need to connect the development dots

US President Bush has arrived in Benin Republic on the first leg of his second Africa tour that will highlight achievements in various health and development programs including the President’s Malaria Initiative (PMI). The Washington Times reported that, “In what some are calling a “victory lap,” Mr. Bush’s trip will highlight the effect over the past five years of the $1.2 billion the U.S. has sent to fight malaria and the $15 billion to fight HIV/AIDS, which the president wants to double over the next five years.”

There is hope that this trip will help guarantee continuity in US disease efforts after the current administration. The Washington Times reports further that, “The administration’s malaria program has distributed more than 6 million insecticide-treated bed nets. ‘We’ve literally wiped out malaria on the island of Zanzibar,’ Mr. Pittman the president’s senior director for African affairs) said, referring to the semi-autonomous archipelago off the coast of Tanzania.”

But are specific disease control efforts enough to eliminate malaria as a public health problem? We have argued here that there also needs to be attention to the underlying social and economic factors that make people more susceptible to malaria, and when these are not addressed and when donor programs wind down, malaria returns.

BBC News highlights such concerns. “However, international aid agencies have said US trade policy in Africa may undermine struggling African economies. Benin relies on cotton production, for instance – but cannot compete with US cotton because of the large subsidies paid to US farmers.” Unless we connect all parts of the development picture – disease control, trade, economic development, agriculture, etc. – malaria will remain a threat to world health and security.

Advocacy Bill Brieger | 15 Feb 2008

Malaria Gets UN Envoy

Ray Chambers, the US Secretary-General’s newly appointed Special Envoy for Malaria, addressed the press. The UN press release explained that Mr. Chambers hoped that, “over the next five years, a true private-public partnership led by the “Roll Back Malaria Partnership” could raise some $8 billion to $10 billion.” Mr. Chambers whom the UN characterized as a “full-time and hands-on philanthropist” talked about the need to involve multiple partners and employ multiple tools in tackling the problem of malaria.

Although Chambers co-founded Wesray Capital Corp, one of the most successful leveraged-buyout firms of the 1980s, he has spend nearly two decades doing philanthropic work. Mr Chambers described his new duties thus: “What the secretary-general has charged me with is working out what we can do in the next two years, the next three years, the next five years to get mortality from malaria as close to zero as possible,”

The Malaria Foundation included Ray Chambers among its 2007 Honorees,and outlined his achievements as follows: founding co-chairman of Malaria No More, for jump-starting and launching this new organization in December 2006 to help raise the profile of malaria, support the goals of the President’s Malaria Initiative, and raise $10 donations from the public for the purchase and effective distribution of long-lasting insecticide-treated bednets. An example of Mr. Chambers fundraising skills was evident at the Millennium Promise and Malaria No More Joint Benefit event which raised $2.7 million to fight extreme poverty and disease in Africa last June.

Laura Bush at the 2006 White House Malaria Summit also praised the new envoy. “Ray Chambers, who is the Chairman of Malaria No More. Ray is an example to all of us of someone who because of fortune in his life, a fortunate life, he has reached out around the world to help other people. And thank you so much, Ray, for being so involved in this.” Reuters quoted World Health Organization Director-General Margaret Chan as saying that Chambers “has the passion, experience and commitment the world needs right now to secure the political will and the funds needed to profoundly reduce this threat.”

Mr Chambers was realistic at the UN Press Conference when he explained that, “A long-term cure, or eradication, would come from a vaccine, but that goal was years away. It is very difficult to prepare a full-scale, comprehensive vaccine against the malaria parasite. In the short term, attention has to be paid to science, as in the past, both the mosquito and the parasite have developed resistance to certain insecticides and medications.”

Mr. Chambers appears to be starting of with ‘enthusiasm’ as people are saying, but also with a good dose of realism, whether it be about the near term potentials for eradication or limitations of environmental measures to control malaria. We hope this enthusiasm, realism and commitment will spread to policy makers in all donor and endemic countries faster than malaria can spread.

Drug Quality Bill Brieger | 12 Feb 2008

Fake Malaria Drugs – a criminal investigation

Reuters has reported on a unique collaboration between police and scientists to stem the tide of fake antimalarial drugs, particularly artemisinin based medicines in southeast Asia. Details of the investigative process form the basis of an article in PLoS Medicine.

The problem has been know for ten years. Reuters commented that, “An investigation coordinated by Interpol, with input from international researchers, found as many as half of the malaria tablets sampled in Vietnam, Cambodia, Laos, Myanmar and on the Thai/Myanmar border were counterfeit.” This is a huge concern, in part because some tablets contained no active ingredients, older antimalarials, or inappropriate drugs and would therefore not provide a cure and also because some contained less than the required amount of active ingredients and would therefore contribute toward aretemisinin resistance, threatening the main drug used around the world to save lives.

pink-pharmacy.jpgSophisticated scientific techniques for tracing the culprits even ranged to analysis of pollen found in the blister packs. A variety of holographic logos were also found. Specialists were able to spot many fakes simply by examining the packets, the one doubts that the average consumer would be so skilled.

The WHO prequalification process and bulk ordering through GFATM may help some countries avoid fakes, but this does not guarantee safety in the private sector. It also points out the need for speedier efforts to add more antimalarial drugs to the prequalification list. Finally, capacity building is also needed for Food and Drug Agencies in malaria endemic countries to enable timely detection of fakes before they reach clinics and stores.

Indoor Residual Spraying Bill Brieger | 10 Feb 2008

Revisionist Malaria History – the case of IRS

A new report on the implementation of Indoor Residual Spraying (IRS) by the World Health Organization begins with the following ‘historical’ perspective: “In the 1950s and 1960s the WHO led malaria eradication campaign eliminated the risk of malaria infection for about 700 million people mainly in Europe, Asia and Latin America within a period of about 20 years using IRS as a major tool. In the 1980s, following the global consensus to replace malaria eradication campaign by a long term control program, use of IRS was significantly reduced. In Africa, the intervention was abandoned except in some countries in southern and eastern Africa where IRS remained the corner stone of the malaria control strategy.” The report goes on to expound on the return of IRS and its potential for success throughout Africa.

lrg-87-img_1544a_ethiopia_lowres_sm.jpgThe above statement makes it sound like the world community just woke up one day and decided, “Let’s stop IRS”, with little reference to problems faced by famed Malaria Eradication Program (MEP). Fortunately Randall Packard has also recently published a book on the history of malaria that helps set the record straight on the MEP.

Technically the MEP was launched in 1955 and came to an official close in 1969, but even before it started, its main technical intervention, IRS with DDT, had already shown signs of mosquito resistance. A number of factors including low levels of economic development, poor health system infrastructure and donor fatigue led to the close of MEP. It truly was a daunting task given the limited tools and difficult environment in many countries.

Today there are more tools, but some are more expensive, e.g. ACT compared to chloroquine. There is also a greater choice of insecticides, though again, cost is a consideration. The new WHO report brushes on some of these challenges, especially the low levels of health system capacity in some of the most endemic countries. But as Packard points out these tools alone are not enough unless programs address the basic underlying social and economic factors that continue to ‘protect’ the persistence of this killer disease.

Funding Bill Brieger | 08 Feb 2008

Seeing Red

Corporate responsibility can take many forms. An increasingly popular approach is a promise to donate funds to a charity when a consumer buys a particular product. (Product)Red has taken this concept to scale and crosses corporate boundaries to bring many options to consumers who ultimately want to donate to the HIV work of the Global Fund to Fight AIDS, TB and Malaria (GFATM). According to the New York Times, this philanthropic effort has contributed about 2% of the Global Fund’s revenues. The Global Fund itself notes that, “So far PRODUCT(RED) partners have raised more than $57 million, which is already at work as part of Global Fund (HIV) grants in Ghana, Rwanda and Swaziland.”

mosquito-cdc-sm.jpgWhile one would associate Red with the HIV/AIDS red ribbon, one could also not help recall the red blood that mosquitoes consume in the process of spreading malaria. Hopefully (Product)Red efforts may extend to supporting malaria control, even if it starts by ensuring that people living with HIV/AIDS and vulnerable children get prompt malaria treatment and bednets. But that is another matter.

Concern has been raised about the amount of advertising that has gone into promoting Red products compared with the money that has ultimately been donated. The Times quotes a communications professor who says that, “The ads seem to be more about promoting the companies and how good they are than the issue of AIDS.” Various reports of advertising (fundraising) costs range from $100 million to produce $18 million to $50 million to raise $25 million. Defenders are quick to point out that people would buy these products anyway and that the corporations involved are businesses not philanthropies.

By the way, the American Institute of Philanthropy (AIP) states that it is good when an organization spends 60% or more of the funds it generates on the actual charitable purpose. The AIP also rates as good charitable organizations that spend less that $35 to raise $100. I don’t need to do the math here for people to realize that were (Product)Red a charity, it would have a very low rating from the AIP.

The Global Fund has recently launched its challenge to the corporate world, and some large businesses have already become ‘corporate champions.’ The first donor, Chevron, made a $30 million commitment over three years. A few more contributions of this size would more than equal what (Product)Red has contributed, generate positive publicity for the companies and reduce the added advertising costs and consumer culture that in itself may have negative consequences on the environment and disease control efforts. Consumers in fact seem quite satisfied with charities that given them the opportunity for more direct involvement, such as purchasing insecticide treated bednets.

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