Posts or Comments 18 July 2024

Monthly Archive for "May 2011"

Burden &Procurement Supply Management Bill Brieger | 26 May 2011

Population Growth and Malaria Elimination

A major challenge in successful malaria control programming is correctly estimating the numbers of commodities needed and ensuring their timely delivery.  It is not clear the extent to which this forecasting process accounts for population growth.

Therefore, when the International Herald Tribune (IHT) reports on population growth in the region with the heaviest burden of malaria, we take notice … “What is most striking, though, is the unabated demographic swelling of Africa. Africa’s population has almost doubled between 1975 and 2000, growing from 416 to 811 million; it will add another 75 percent to reach 1.4 billion people in 2025, and presumably another 55 percent to reach the staggering figure of 2.2 billion by mid-century.”

pop3africabig.gifOne wonders whether successful efforts to reach 2015 targets of reduced malaria morbidity and mortality might offset the need for more and more LLINs, ACTs and other commodities? In some countries moving close to elimination, this might be true, but the high burden countries – high because of their large populations and challenging logistics – remain a concern. As the IHT observed, “countries such as Nigeria (230 million in 2025, 390 million in 2050); Ethiopia (110 million and 145 million) and Congo (95 million and 148 million) have since long been identified as the demographic giants of sub-Saharan Africa.”
We already know that universal coverage was not achieved by 31 December 2010 as many endemic countries are still sourcing and distributing nets and other commodities in the hopes of reaching the target in 2011. All the while, population does not remain static.

We also know that there has been strong competition for nets and drugs among endemic countries because of the low number of manufacturers of approved products.  A lesson from the field is that rapid diagnostic test supplies are not close to catching up with supplies of artemisinin-based combination therapy (ACT) medicines, and long lasting insecticide treated nets (LLINs) are not as long lasting as once thought.  Will we be able to get enough nets in 2013-14 to replace those distributed in 2010-11?

So in the short run as population increases, need for malaria control commodities will also increase.  And, one wonders can donor support be counted on?

Ironically even as fertility decreases (though is still high), population grows because of the success in disease control programs and reduced mortality. Also as UNFPA explains, the fact that the majority of people in developing countries are young means that the bulk of the population still has many years of reproductive life ahead, hence population in the foreseeable future will increase even if fertility of lower.
Of course, even when people survive malaria episodes they experience personal costs that holds back the national economy.  The question is whether we can get enough malaria commodities on the scene and in people’s hands before population doubles?

Asia &Resistance &Urban Bill Brieger | 23 May 2011

Mumbai – is transmission season increasing?

The Times of India reports that, “Malaria is no longer restricted to just monsoon months as in the past. Spurred on by widespread construction activity and the resulting poor sanitation, the disease has becomes a round-the-year feature in Mumbai, killing less people but afflicting more.”

An increase was noted: “In all, 76,755 contracted the ailment in 2010, 74% more than the 2009’s figure of 44,035,” but with fewer deaths (better case management?), but it is not clear whether these cases were parasitologically diagnosed.

A member of the medical association attributes the increase, especially the off-season rise, to human activity – construction projects. The official stated that, “Construction sites have puddles of water in which mosquitoes breed. Since construction work goes on throughout the year, so does the breeding. This obviously increases the incidence of malaria.”

Worry was also expressed about, “resistance developed by the Anopheles albimanus mosquito that the civic body’s insecticide fumigation has no effect on it.” This has led the city to consider using “bacillus thuringiensis variety israelensis” for control.

Ironically, in pointing out that, “Another reason for the spread of malaria, which is caused by a parasite called plasmodium, during non-monsoon months is that plasmodium can stay in the body for a long period,” the article raises the possibility that the upswing may not be fully due to new transmission.

asia-in-wmr-2008.gifAside from these possible limitations on the validity of the data,  the potential for increased transmission is worrisome, especially in a part of the world that has received less (but increasing) attention from the Roll Back Malaria Partnership. The map from the 2008 World Malaria Report shows the extent of the problem in Asia.

India has a double problem with malaria, hosting both P. vivax and P falciparum.  A recently published article reports that while the national control program has introduced artemisinin-based combination therapy for P. falciparum as a first-line treatment, the older drugs, chloroquine (CQ) and Sulphadoxine-Pyrimethamine (SP) are still available. Unfortunately Shrabanee Mullic and colleagues found that, “In Jalpaiguri District the overall failure rate of CQ was 61% and of SP 14%, which was well above the WHO recommended cut-off threshold level (10%) for change of drug policy.”

Other research in India examined vector control with positive effects. “A study was conducted to evaluate the preventive efficacy of insecticide-treated mosquito nets (ITMNs) and mosquito repellent (MR) in a malaria-endemic foothill area of Assam, India, with forest ecosystem.” The researchers found that, “The total vector population in the three intervention sectors decreased significantly compared with that of the non-intervention one.”

Overall, malaria in India is a complex phenomenon with different forms of the parasite, different ecological settings and different levels of government involved. More attention is needed to address this complex situation is malaria is ever to be eliminated.

Drug Quality &Treatment Bill Brieger | 22 May 2011

AMFm – affordable? even available?

Reporting from Nairobi, Inter Press Service (IPS) documents the experience of James Odhiambo who “goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund’s logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.” James finds what he needs at the sixth shop.

ips_amfmkenya_wordpress.jpgWithout subsidy from the Affordable Medicines Facility malaria (AMFm), these drugs would cost about $5 or two days salary. See the much sought after medicine packet in a photo on the right by Isaiah Esipisu of IPS.

IPS, on further investigation, attributed the scarcity of the subsidized malaria medicines to the low profit margin that pharmacies who agree to sell the medicines are officially allowed. While the actual price of the AMFm drugs should be $0.50 for adult and $0.12 for child doses, IPS learned form a science reporter of the Nation Media Group that, “Two months ago, we requested our reporters from different parts of the country, including rural areas, to check on retailing prices of the subsidised anti-malarial drugs. As a result, we discovered that pharmacists sold them at varying prices ranging from 80 KES (one dollar), to 240 KES (three dollars).”

IPS learned from a private pharmacist that if she sold the commercial variety of Coartem (the approved artemether-lumefantrine combination drug) she could make $2 profit. The AMFm drugs were permitted only about $0.15 profit. For this pharmacist, ” it would not make any economic … considering her costs of transporting it from the distributors, and other inputs.”

Apparently the Ministry of Health believes the problem can be solved through an “awareness campaign (that) will help consumers make an informed choice and enable them to seek outlets that sell the drugs at the right price.” The cost of transport around town seeking the correctly priced drugs may wind up to be more that the price of the drugs themselves.

AMFm is still a new program. The Global Fund explains that, “Following the Global Fund Board’s decisions on successful applications to Phase 1 in November 2009, grant amendments or new grant agreements have been signed with most AMFm Phase 1 countries and implementation has started in several countries. The first co-paid ACTs were delivered to Ghana and Kenya in August 2010.” Seven other pilot projects are in varying stages of implementation.

Nigeria started implementation of AMFm in March 2011. The Director of the National Malaria Control Program in Abuja hoped that the AMFm subsidies would help crowd out fake and substandard malaria drugs from the market by offering medicines at around $0.50 instead of the $6-8 prices per packet in shops.  Ironically conversations with people responsible for a pre-pilot of sorts carried out under a previous GFATM grant in Nigeria identified similar attitudes about profitability by medicine shop keepers. Might Nigeria be heading down the same road as Kenya?

Word is still out on AFFm implementation in Ghana. So far the Ghana Health Service is touting the benefits of AMFm – the low costs, the savings to the national insurance scheme and the edging out of poor quality drugs from the market. Interestingly, none of the news emanating from implementing countries appear to address the need for proper diagnostics to reduce inappropriate use of the malaria medicines.

Fortunately the Global Fund is planning an evaluation of the AMFm experience. This will address availability, affordability, use and market share.  AMFm is a grand experiment. We hope it is well enough designed from the start to test real life forces in the private sector. Arbitrarily suggesting profit margin is not the way to go, but in the end shop keepers and pharmacists will hold the day through their choice to participate and the prices they set.  Whether these decisions will improve coverage with appropriate malaria medicines will eventually be known when this two-year pilot finishes. In the meantime it appears that some important operational lessons can and should be learned and applied NOW.

PS – see article on low malaria transmission risk in Nairobi in Malaria Journal.

ITNs Bill Brieger | 21 May 2011

Misuse of nets in Abat

commob-pics-070sm.jpgDuring a recent community mobilization and supervisory visit to Abat community Onna Local Government Area (LGA) in Akwa Ibom State, Nigeria, colleagues saw nets from last year’s mass distribution being used to protect vegetable gardens.  Bright Orji commented that, “When we spoke with community about the mis-use, they claimed that those were torn nets. We did not believe them, and also told them that torn nets could be amended.”

The team took four pictures of different nets in several places, Orji said that, “Mis-use is on the rise, and we need to counter this urgently.” Before they had nets community members used a small shade built of palm fronds to protect the plants, but apparently the nets are seen as a better deal as they also keep off some animals and insects. Ironically if community members think nets will keep off insects are fooling themselves as sun exposure will destroy the pesticide.

commob-pics-068sm.jpgThe team had heard complaints about nets before – sleeping under a net is too hot; nets are difficult to hang. Because of such complaints, Orji noted, “In our focal communities we are teaching community health workers to hang nets using net hangers provided by the State Ministry of Health (SMOH).”

We wondered whether people are using the nets that adults would have used, or are they taking away from children and pregnant women? Orji explained that, “Most households in our LGAs have more than two. Some nets had been given to pregnant women before the State placed two nets per household. So, men can take new ones from State to use while women continue to use the ones obtained from us or vice visa.”

commob-pics-069sm.jpgOrji added that, “It is very important for a formative research to investigate net use, reasons for non use and mis-use. We will develop a proposal to the SMOH for this.”

Apparently the local health authorities were unaware of this problem until Orji “shared the photos at one of our partners’ meetings.” An SMOH staff member on the mobilization/supervision team told Orji that, “We only do monitoring when an NGO invites us, or go out whenever the National Malaria Control Program visits.”

This net mis-use highlighted some of the gender dynamics in the community. In terms of growing these vegetables, and farming in general, it is women’s responsibility. Orji explained that, “One of the villlage chiefs informed us that women are the ones farming all their lands. In Onna the tradition is that men stay at home to drink while women go to farm.”

Therefore the women most likely put up the nets over the vegetables.  Orji somewhat joking added that, “Perhaps when the man got drunk, the woman decided to punish him by exposing him to mosquitos through the removal of his net.”

commob-pics-067sm.jpgWhat we have learned from this experience is two-fold. Follow-up education and assistance is needed to ensure that nets given out freely are actually used for the intended purpose. Secondly, this effort will be aided by formative research on how people perceive and value the nets. Otherwise all we will achieve is universal coverage of vegetable gardens! We should also find the agriculture extension agents in the area to help the people find better ways to protect their gardens from pests, otherwise nets will remain an attractive option.

ITNs &Universal Coverage Bill Brieger | 16 May 2011

Off-Road in Uganda

Uganda’s 2010 Roll Back Malaria Roadmap seemed reassuring.  Apparently 2.7m nets were already in place by late 2009, and supposedly a supply of another 18m long lasting nets (or at least the funding) was ready for achieving universal coverage by December 2010.

Assessment of Uganda’s Roadmap progress credited the country with achieving procurement of these nets. It seems odd therefore that the 2011 Roadmap indicates that 6.4m nets are in place and 10.4m need to be distributed in 2011. What’s going on?

staying-on-the-road.jpgA new study by Carla Proietti and colleagues provides some answers. Not only do they document continued high transmission in the northern part of Uganda (polymerase chain reaction rate of 72% in children below five year of age), a situation that threatens control efforts by neighbors, but they also identify plausible reasons for the lag.

The researchers politely suggest that, “The failure to reduce the burden of malaria could reflect sub-optimal implementation of malaria control measures.” They also explained that, “Malaria control efforts in Apac (sub-county) were not reliably monitored in the last decade and affected by political unrest in preceding years.”

Stockouts of anti-malarial ACTs was also listed as a problem. It should be recalled a few years ago that, “The Global Fund has decided to suspend its five grants to Uganda because there is evidence of serious mismanagement by the Project Management Unit (PMU) for Global Fund grants in Uganda.” Although the programs have resumed, satisfactory settlement of the problem was not achieved.

In light of this study warns us not to let successes in recent years blind us to reality. “Those who believe that Africa is within shooting distance of malaria elimination may wish to reconsider their position after reading this article (Proietti et al.). One should qualify this Ugandan article in several ways: 1) Local insurgency in the area under consideration, 2) Hiccoughs with the GF over misappropriation of resources, 3) Autocratic gerontocracy at the national level. Unfortunately, these three factors are not peculiar to Uganda.”

As mentioned yesterday, Roadmaps are a good tool to help us plan for malaria control and elimination – but we must stay on the road for them to work.

Procurement Supply Management &Universal Coverage Bill Brieger | 15 May 2011

Redrawing Roadmaps – can we get there from here?

The Roll Back Malaria Partnership guided countries to develop 2010 roadmaps for major malaria commodity and support service availability and gaps. The aim was to aid planning to reach universal coverage by the end of 2010.  Forty-seven countries/locations on the African Continent and surrounding islands completed the analysis and started moving down the road to success.

In the case of 36 countries the road became a little longer than anticipated.  Part of the challenge was international – there are only a few manufacturers of long lasting insecticide-treated nets, for example. Some of the barriers were internal, inadequate estimates of the logistical costs to distribute commodities, even if they were in hand. Now we have 2011 roadmaps in an effort to meet up with the original 2010 goals of 80% coverage with essential malaria commodities.

proportion-of-countries-that-missed-2010-rbm-roadmap-sm.jpgAt least one-quarter of countries that actually targeted a specific intervention in 2010, did not meet the 80% goals.  Of particular concern is the fact that Rapid Diagnostic test use is both off target and not keeping up with ACTs.

Meeting procurement and distribution targets is one step, but getting people to use malaria control interventions is another challenge. As the director of a prominent Nigerian NGO recently said, “… ‘though about 35.6 million nets have been distributed across the country, it is highly under utilized,’ which according to him is responsible for the high death rate associated with malaria.”

Nigeria provides an instructive case. The roadmap for 2010 called for 62.9m LLINs of which 4.4m were already in place and pledges were set for 49.4m. This left a gap of 9.2m.  While the RBM 2010 roadmap analysis shows that Nigeria met its LLIN target, the implication is that the target did not include the gap.  Now the 2011 roadmap for Nigeria now shows that resources are in hand for both the 9.2m gap from the 2010 campaign plus an additional 8.2 m for routine distribution in clinics as a keep-up measure.

The gross figures do not fully reflect the fact that of the 36 states (plus one capital territory), campaign distribution of LLINs continued from 2010 into 2011 in 17 states. So far 9 or the 17 have completed distribution, but by carrying the campaign into 2011 additional delays were met in the remainder due to national elections, delayed local funding for the effort, and distribution logistics. So again while the roadmaps help identify commodity gaps, they do not always identify the challenges at the level of distribution and use.

The roadmap process is an important planning tool. It needs to be supplemented with plans for logistical support and health education to encourage use of the malaria commodities and services that are eventually distributed.  For example, Nigeria estimates that it needs close to $17m for Monitoring and Evaluation and Information. Education and Communication. We can see from the Nigerian roadmaps that this planning needs to be a continuous process – not only is annual resupply of ACTs, RDTs and SP for IPTp needed, but also continuous stocks of nets for routine, keep-up services.

Partnership &Private Sector Bill Brieger | 13 May 2011

Private Sector and Malaria – Many Roles, Many Benefits

progress-and-impact-business-investing-in-malaria-control.jpgThe latest edition in the Roll Back Malaria Progress and Impact Series is “Business investing in malaria control: economic returns and a healthy workforce for Africa. “The report provides an overview of the direct and indirect economic costs of malaria and looks closely at activities by three businesses in Zambia to tackle the malaria problem.

These companies were “able to scale up malaria control quickly and have seen a rapid return on investment. Malaria-related spending at three company clinics in Zambia decreased by more than 75%, and a very conservative estimate showed that the companies gained an annualized rate of return of 28%.” These experiences provided “Strong models … for businesses to take leadership roles in controlling malaria, protecting their workers and their families, strengthening their businesses, and extending programmes into communities.”

In fact there are several different and complimentary business roles for participation in rolling back malaria as seen below …

  • Manufacturers of preventive and treatment commodities
  • Wholesalers and retailers of malaria prevention and treatment commodities
  • Private health service providers: Formal orthodox, Informal, Indigenous
  • Private companies and industries based in endemic areas that aim to prevent and treat malaria among their employees and surrounding communities
  • Private companies and industries that provide donations to or organize malaria programs whether they are based in endemic areas or not
  • Sales of non-malaria products with a proportion/donation to malaria programming, like PRODUCT RED
  • Private companies that donate to malaria programming through their Foundations

The RBM website that features the Progress and Impact Series on Business involvement provides 16 downloadable case studies on the different models outlined above. Several diverse examples follow:

  • The Azalaï Hotels Group in West Africa, an active participant in the United Against Malaria (UAM) campaign, implements programmes to protect its employees with nets and hotel guests against malaria.
  • The ExxonMobil Malaria Initiative protects employees, supports malaria research and enables NGOs to carry out innovative community malaria control efforts
  • The MTN telecommunications group uses its technology and communication platforms to educate communities through radio, television, SMS, billboards and fliers.
  • The Sumitomo Chemical Company not only produces long lasting insecticide-treated nets but has provided technical assistance toward the establishment of the A to Z Textile Mills, based in Arusha and Kisongo, Tanzania, to ensure locally produced net supplies.

Although not featured by RBM, AngloGold Ashanti in Ghana has maintained an indoor residual spraying from for all structures in Obuasi District for five years now. Cases of malaria illness have steadily reduced at the district hospital.  This protects employees, their families and the wider community.

The impact of individual business efforts may affect a community or a region and vary widely from place to place. In order for greater impact to be felt, national malaria control programs need to identify all potential and actual business partners and bring them into national partnership forums so that collectively the private sector impact on malaria will be most strongly felt.