Posts or Comments 18 July 2024

Monthly Archive for "June 2010"

Funding &Partnership Bill Brieger | 26 Jun 2010

Promises: how gr8 is the G8?

As the G8 Summit convenes in Canada this weekend, there comes a time for reflection and accountability. In fact accountability is the theme for a publication – “The Muskoka Accountability Report takes stock of recent G-8 commitments related to development, assesses the results of G-8 actions and identifies lessons for future reporting.” The report explains that …

In 2005, at the Gleneagles Summit and the United Nations Millennium +5 Summit,G8 countries and the world’s major aid donors made commitments to increase Official Development Assistance (ODA). Based on these specific commitments, the Organization for Economic Co-operation and Development (OECD) estimated that ODA from all OECD-Development Assistance Committee (DAC) bilateral donors would increase by around $50 billion a year by 2010, compared to 2004.

behind-each-dollar.jpgThe Muskoka Report notes that ODA increased from $80 billion to $120 billion, with $24 billion coming from G8 countries. But it also explains that this $10 billion shortfall is actually $18 billion in 2004 dollar value. The report notes the following health accomplishments:

  • G8 contributions account for $12.2 billion or 78 percent of the total contributions to the Global Fund
  • G8 is on track to provide over 100 million insecticide-treated nets
    by 2010
  • For the period 2005 to 2009 G8 funding to the Global Polio Eradication Initiative was $1.68 billion

Although the dollar amounts seem large, the Washington Post reports from Toronto that, “Canada announced on Friday a multibillion-dollar initiative to combat infant mortality and improve maternal health globally, but the aid package was far smaller than expected, undercut by a new drive toward austerity that reduced the contributions of wealthy nations.”

An expected package of $10 billion from the G8 may turn out to be only $7.3 billion. “… the plan highlighted how world economic dynamics have made a sudden lurch toward less government spending.”

Oxfam has called the contribution gap between 2005 promised and 2010 realities a ‘bounced check‘ that undermines the G8’s credibility. Maybe this is an accounting trick, suggests Oxfam:

Oxfam also decried the G8’s attempt in their own accountability report to minimize their breach of faith by using 2009 dollars instead of 2004 dollars for the calculation and deducting for lower growth, thus showing only a $10 billion shortfall.

Oxfam calls on the G8 to show the “political will and leadership that at least equals that we saw at Gleneagles.” This involves not only acknowledging that the gap is nearly double the apparent dollar value, but also taking steps to close it.

Save the Children recommends that the Muskoka Summit recommit to funding, but that these “Governments need to do better at the September U.N. Summit on the Millennium Development Goals .” The President of Save the Children observed that while the G8 and upcoming G20 leaders are worried about economic stability …

… both the leaders and the public should understand that global economic growth can never be balanced if the world doesn’t address the tragic circumstances surrounding birth and early life in much of the developing world. Without decisive action, the social costs of global economic downturns will only hit harder and last longer.

The BBC reports today that, “World leaders are due to focus on the nuclear disputes with Iran and North Korea on the second day of the G8 summit in Canada.” Maybe they will eventually come to the realization that global poverty is also a problem for all. As BBC notes, “Mr Obama has called for the group to pull together to promote economic growth, saying that world economies are ‘inextricably linked’.”

Funding &Performance Bill Brieger | 20 Jun 2010

Transparency and Accountability

measles-immu-cote-divoire-who.jpgAlthough we do not have a malaria vaccine ready for widespread use, it is instructive to learn about how the Global Alliance for Vaccines and Immunizations (GAVI) plans for its financial future. The BBC Reports that GAVI “needs more than $4bn (£3bn) by 2015. This would enable it to continue existing programmes and roll out new vaccines against diarrhoea and pneumonia. But there are fears donors may want to cut back in the current climate.”

A new development is greater scrutiny by donors. BBC adds that, “In March, the UK pledged £150m to Gavi over 10 years. £10m has already been paid out, but there are plans to review all funding of international agencies – of which GAVI is one – as part of a drive to direct money at only the most effective organisations, a spokesperson confirmed.”

Specifically Britain’s Department for International Development (DfID) announced on 3rd June 2010 that, Full transparency and new independent watchdog will give UK taxpayers value for money in aid.” International Development Secretary, Andrew Mitchell, explained that, “We can’t escape the fact that today’s fiscal landscape is radically different from what has gone before. There is a massive deficit, which it is our number one priority to tackle. Against this backdrop our protected aid budget imposes a double duty to ensure that for every pound of taxpayers’ money we spend, we demonstrate 100 pence of value.”

Mitchell described further plans to move aid away from middle income countries. “We will spend the money on our priorities such as maternal health, fighting malaria, and extending choice to women over whether and when they have children.” Other budget cutting measures were identified. The Global Fund was not mentioned by name in the speech.

He also expressed agreement with the new approach of USAID and said, “Women can hold the key to development in the world’s poorest countries – in education, enterprise, micro-finance and healthcare. Investing in women pays dividends throughout the entire community.”

GAVI’s concerns ultimately have to do with the stability of funding. In its action agenda for achieving Millennium Development Goals (MDGs) UNDP pointed out that, “Well-targeted and predictable aid is a critical catalyst for meeting the MDGs and has produced significant results in Burkina Faso, Mozambique, Rwanda, Uganda and Vietnam by making more resources available for service delivery.”

UNDP also indirectly warns about dependence on aid: “Evidence, however, also suggests that countries need to expand their own domestic resource mobilization and to adjust their budgets to ensure maximum return on their investment.”

This period of economic uncertainly has produced one certainty – soul (and pocket) searching is needed by governments – both of donor countries as well as disease endemic countries – if programs are going to be sustained to the point of disease elimination.

Corruption &Performance Bill Brieger | 19 Jun 2010

Freezing in Zambia

zambia-malaria-indicators-2008.jpgZambia was one of the first recipients of Global Fund support and since Round 1, it has received 3 HIV grants, 2 TB grants and 3 Malaria grants. The chart here shows that Zambia has performed fairly well on achieving Roll Back Malaria coverage indicators. In fact, though not yet reaching the 2010 targets of 80%, Zambia has been seen as one of the top performers in its efforts to control malaria as highlighted in a panel presentation at the recent Women Deliver Conference.

Therefore it comes as a surprise to read the press release from the Global Fund stating that, “Global Fund confirms freeze on cash disbursements to Zambia’s ministry of health, grants to be transferred to UNDP.” This decision was made in August 2009, though not announced until June 2010. The press release stated …

The freeze in disbursement came after Zambian authorities last year uncovered fraud within its own Ministry of Health. Further investigations by the Global Fund showed that the Ministry of Health was not able to safely manage grants. The organization has demanded the return of US$8 million in unspent funds from the Ministry of Health. The Global Fund has also demanded that Zambia takes action against individuals found to be involved in the unaccounted expenditures that led to the freezing of grant disbursements.

A news source reported that, “Money is still being paid to civil society organisations (CSOs).” As noted above the government component of the grant will be managed by UNDP for the meantime. Sarah Boseley of the Guardian points out threats to continued funding translates to more deaths from the three diseases. Furthermore, “The Global Fund is Zambia’s main donor to the health sector, and the suspension of aid will likely hinder the nation’s efforts to fight Aids, tuberculosis and malaria.”

It is interesting to reflect on the Global Fund 2007 Progress Report which showed that 83% of CSOs as principle recipients of grants scored ‘A’ or ‘B1’ on their grant performance progress reports compared to 75% of grants managed by UNDP and 72% by government agencies. There has been overall improvement in performance in recent years, but the 2009 results reported this year still place CSOs ahead at 84% performing at ‘A’ or ‘B1’ level compared to 75% for governments and 79% for UNDP. Transferring Zambia’s support from government to UNDP is certainly not a long term solution to its problems.

There seemed to be some confusion about the suspension in Zambia. “Zambia’s Health Minister Kapembwa Simbao denied the suspension of funds and said there had been no indication from the organisation to halt donations,” even though the GFATM Board apparently made the decision official at an April 2010 Board meeting. Zambia’s efforts to fight corruption have been undermined when a former president was charged, though acquitted of corruption charges and the Netherlands suspended aid also because of alleged corruption.

Radio France International explained that, “The freeze became public when Aidspan, a group which works with the Global Fund, posted the decision on its website on Monday. The fund issued a statement two days later.” The GFATM is usually known for its transparency, and so the delay of the announcement about the Zambian funding freeze is almost as perplexing as the problem in Zambia itself.

Since GFATM money comes from taxpayers around the world, public accountability is expected. Shining a light on corruption can preserve disease control funding and save lives.


PS – see relevant article in Global Fund Observer:

Funding &Health Systems &Integration &Malaria in Pregnancy Bill Brieger | 19 Jun 2010

Comprehensive, Integrated and Hopefully Not Neglected

As we get very close to achieving the Roll Back Malaria Partnership’s 80% target for 2010 in prevention and treatment coverage, there is a tendency to worry when people talk of shifting funding priorities. The HIV community is particularly worried that funding for treatment and control may become stagnant or even decrease. As AFP reported from Johannesburg, “Thousands of protesters marched Thursday against what they say is a softening commitment to fighting AIDS in Africa by the United States and other developed countries.”

Government donors are by and far the biggest contributors to global disease control efforts, but foundations and corporations can set trends and attract attention and thus influence priorities. For example, Melinda Gates, speaking at the recent Women Deliver Conference in Washington addressed the issue of maternal and child health:

We are nurturing a vision that is changing the world. Donors will spend more on women and children, and those donations will be tracked. Developing countries will pass rigorous policies for women’s and children’s health, and fully fund their implementation, and health workers will have the tools and training they need.

Rahim Kanani, reporting on Melinda’s talk, concluded that, “With global leaders convening next week in Canada for the G8 and G20 Summits, maternal and child health is now a top international priority.” And quoted Melinda thus: “The whole world will be looking to us for leadership. We need to be ready with a single plan.”
dscn7723sm.JPGThese thoughts are certainly in sync with the current US administrations Global Health Initiative, which seeks an integrated approach to health care. GHI will “help partner countries improve health outcomes through strengthened health systems – with a particular focus on improving the health of women, newborns and children through programs including infectious disease, nutrition, maternal and child health, and safe water.”

Malaria definitely needs to be part of the integrated mix of maternal and child health (MCH) services. Pregnant women are more vulnerable to malaria; even mosquitoes are more attracted to them. Malaria leads to maternal anemia and death as well as intrauterine growth retardation leading to low birth weight babies, who have a poor chance of survival. Research is finding more about possible links between malaria and pre-eclampsia and postpartum hemorrhage.

There ultimately should be no reason to fear a loss of malaria funding given the strong advocacy initiatives built by RBM partners. Even more, efforts of the integrated approach to strengthen health systems will benefit malaria control and elimination, which requires a strong health system.

And in closing we are reminded that the wealthy people behind foundation and corporate giving can be advocates themselves.  As NPR reported, “Microsoft Corp. co-founder Bill Gates and billionaire investor Warren Buffett are launching a campaign to get other American billionaires to give at least half their wealth to charity.” We trust that malaria control within an integrated MCH program will remain part of this charitable urge.

Health Systems &Performance Bill Brieger | 13 Jun 2010

Quality Improvement and Malaria

Sheila Leatherman and colleagues have written this month that …

Despite … acknowledgment of the critical role of quality of care in  strengthening health systems, there are few descriptions of how to insure high-quality health care in developing countries. While modern  approaches to improving quality are increasingly used globally, their appropriateness for resource poor settings has received little attention and their adoption remains sporadic.

These authors have put together a reference list of 22 quality improvement research study publications in developing countries in the following areas:

  • Emergency obstetric care
  • Acute child illness care
  • Primary care
  • Health system (microsystem level)
  • Prescribing practices

Unfortunately, “Many if not most QI interventions are never published.”

Though these studies do not address malaria issues directly, all are areas that affect malaria services.

The WHO health systems strengthening action framework (2007) does mention malaria is several instances.  For example, the report recommends “working more directly with other international partners (e.g. The Global Fund to fight AIDS, TB and Malaria) on their support for health systems strengthening.” The report also recognizes that an integrated approach is needed because, “One cannot advise on health systems financing from the perspective of malaria or child health alone.”

There are some recent articles that do address malaria service quality issues. Concerning malaria case management in Angola, Rowe et al. found problems in maintaining drug stocks, clinical supervision, use of malaria tests, and health worker knowledge.

Specifically addressing testing/parasitological diagnosis in Tanzania, Mosha and colleagues were concerned about over-diagnosis of malaria. They concluded that, “The introduction of RDTs is likely to lead to financial savings. However, improving diagnosis to one disease may lead to over diagnosis of another illness. Quality improvement is complex but introducing RDTs for the diagnosis of malaria is a good start.”

In Cambodia, Yasuoka and co-researchers studied village malaria workers and found that, “VMWs were effective in conducting diagnosis with Rapid Diagnostic Tests (RDTs) and prescribing anti-malarials to those who had positive RDT results, skills that they had acquired through their training programmes. However, most other services, such as active detection, explanations about compliance, and follow-up of patients, were carried out by only a small proportion of VMWs.”

100_0517.jpgJhpiego has a system of performance quality improvement known as Standards Based Management and Recognition (SBM-R). Jhpiego’s malaria in pregnancy (MIP) work is based on WHO’s guidance that MIP services should be integrated into antenatal care (ANC).

In each country where Jhpiego works a set of appropriate performance standards are developed – for example, 16 basic standards for ANC in Nigeria and 18 in Angola. Malaria in pregnancy interventions in both countries have linked improvements in ANC standards, which include MIP services, to increased use of these MIP services. [picture shows recognition ceremony for health workers and facilities achieving 80% of the standards.]

Quality improvement for malaria services is crucial at the next stage for highly endemic countries on their pathway to elimination. This year all are scaling up for impact. Moving forward this scale up must be sustained. Sustained effort can only happen if there is high performance quality among malaria service providers.

Eradication &Funding &Leadership Bill Brieger | 05 Jun 2010

Fifty Years – independence and malaria in Africa

dscn7335-sm.JPGThe New York Times points out that “17 African countries, including Nigeria, gained independence in 1960.” Apparently there are few major commemorations. The Times quotes Ibrahima Thioub, a Senegalese historian, who said, “It’s tough to mobilize people for celebrations, because the flowers of independence have faded. The last 50 years have not at all met the people’s hopes and expectations.”

Have these 50 years brought Africa any closer to independence from malaria? It was during those years in the late 1950s and early 1960s when most countries were gaining independence that the first effort to eradicate malaria failed. We have had twelve years of rolling back malaria now – are the critical factors in place to ensure that eliminating the disease is feasible now?

The New York Times article addresses critical factors – ranging from weakness of institutions like parliaments to gaps in civil society engagement – that would impede  public health and social welfare programs including malaria control. African intellectuals quoted in the article bemoan that “democracy is held hostage by elites,” and the public accepts that “power is a matter of essences, a heritage, something in the blood, that what is normal for a state is unlimited monarchy.”  While both power and malaria may be ‘in the blood’, the former does not appear to be as easily transmissible or shareable, making the latter all the less easy to control.

The Times notes that, “… there is the reliance on heavy inflows of foreign aid, which equaled a quarter to nearly a third of government spending in countries like Burkina Faso, Cameroon and Mali in 2008.” Clearly this includes inputs from the Global Fund, The World Bank Booster Program and the US President’s Malaria Initiative (PMI). What aspects of health programming are not covered by aid is often paid out of pocket by the public, which is already impoverished by diseases like malaria.

Although there have been recent worries about both the level of donor funding moving forward and the willingness of countries to sustain programs should donor funding collapse, there are some positive signs from the donor side.  The US Government is increasing its malaria focus beyond the 15 PMI countries to include at least Burkina Faso, Burundi, Nigeria, Democratic Republic of the Congo and Sudan, and the Global Fund is embarking on a new ‘grant architecture.’

Known as ‘single stream funding’ the new Global Fund grant architecture “will shift the Global Fund towards a more program-based approach, with significantly improved harmonization and alignment, improving its support of holistic health planning and implementation,” to each principle recipients. This should simplify management, provide continuity, and reduce transaction costs – so even if funding does not increase as desired, there still may be savings and efficiencies for the allocated resources.

There are signs that we may get closer to independence from malaria this year as strides are being made to achieve universal coverage of malaria interventions. It may take another 50 years to see whether malaria can truly be eradicated. Hopefully when many endemic African countries will be observing their 100th year of independence, malaria will have become a thing of the past.

Community &Funding Bill Brieger | 02 Jun 2010

Microfinance and Malaria

Linking health and microfinance is the goal of an opinion piece by Leatherman and Dunford in the current Bulletin of the World Health Organization. While they recognize the real and potential stumbling blocks of equitably and honestly serving the 155 million household worldwide that are serviced by more than 3500 microfinance institutions, they also see evidence that microfinance can have a positive health impact.

Where it occurs, the link between health and microfinance occurs through an organized health education component during member meetings and through individual loan counseling. Areas that have seen positive health outcomes include child nutrition, diarrheal disease control, HIV prevention and malaria, among others.

The malaria example cited by Leatherman and Dunford is a Freedom from Hunger Foundation (FFHF) project in Ghana. The project researched the effect of malaria health education on microfinance clients by comparing them with a group of clients receiving education on diarrheal diseases and a group of non-clients. By the end of the project a greater proportion of the malaria group …

  • had appropriate malaria knowledge
  • identified groups most vulnerable to malaria
  • reported that insecticide-treated nets (ITNs) provide the best protection against malaria
  • agreed that pregnant women should use ITNs
  • had improved knowledge of malaria complications during pregnancy
  • owned at least one bed net
  • reported at least one child or woman of reproductive age sleeping under a bed net
  • increased in ITN ownership and use

Those who did not have nets complained of both cost and access.  Learning sessions alone could account for knowledge changes listed above, but not necessarily the behavior change. Although FFHF does not claim so directly, the authors set the stage for one to hope that improved living standards afforded by microfinance enabled some to use their knowledge and obtain nets. Otherwise, there would be less reason to justify coupling health education and microfinance.

An indigenous microfinance group in Orissa, India also has tackled malaria. BISWA (Bharat Integrated Social Welfare Agency), a nongovernmental organization tried three interventions with their microfinance self-help groups (SHG): 1) health education on ITN use, 2) health education with free nets, and 3) health education on ITNs that encouraged use of microfinance money to but nets. Nearly 60% of SHG members offered the opportunity to buy ITNs through micro-credit did purchase at least one net, and the majority of those were bought on credit.

Knowledge and access to credit may not be the only factors at work in changed health behaviors. The FFHF group concludes that, “When MFIs provide culturally sensitive education and support to poor women, they not only improve health but also empower women by enhancing their self-confidence and promoting their status in households and communities.”

This hints at what Bamidele has defined as personal agency belief. Personal agency is the multiplication of locus of control and perceived self-efficacy, and he used it as a measure of entrepreneurial spirit of participants in microfinance enterprises in Nigeria. Members of credit societies had greater personal agency beliefs than non-members. This may be why Deji found that, “Membership of cooperative societies is very significant to favorable adoption behavior of women farmers towards agricultural innovations, hence should be encouraged as a strategy for improving the agricultural productivity and livelihoods of the women farmers.”

abuja-territory-012-sm.jpgThe FFHF project acknowledged that during the span of intervention their project did not affect malaria treatment behaviors. Finance of course makes a big difference in treatment seeking by poor people as pointed out by Chuma and colleagues. The poor in Kenya used borrowing from friends and relatives and getting medicines or care on credit as major coping strategies. Purchase of medicines on credit from drug shops was also identified as a common practice by Rutebemberwa et al. in Uganda.

Microcredit services may make access to malaria medicines more reliable with a combination of knowledge, financial resources and enhanced personal agency belief – this is an idea that deserves further research.