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Funding &Monitoring &Mortality Bill Brieger | 13 Jan 2010 02:02 pm

Money well spent – are child deaths reducing?

The 2009 World Malaria Report was launched with ‘cautious optimism.’  The WMR “found that the increase in international funding commitments (US$ 1.7 billion in 2009 compared to US$ 730 million in 2006) had allowed a dramatic scale up of malaria control interventions in several countries, along with measurable reductions in malaria burden.”

These figures represent a jump from only $0.3 billion in 2003. The improvements still fall short of the estimated $5 billion needed annually to reach Millennium Development Goals by 2015.

The WMR says that, “In countries that have achieved high coverage of their populations with bed nets and treatment programmes, recorded cases and deaths due to malaria have fallen by 50%.” The five countries referred to do not fit the overall picture of endemic counties where only 24% of children under 5 years of age had slept under an insecticide treated bednet and only 15% of such children had received artemisinin-based combination therapy to treat malaria.

eritrea-polio-immu2.jpgWith efforts to find more funds it “scale up for impact” by the end of 2010 in all endemic countries, a new large scale evaluation of child survival interventions appearing in the Lancet, awakens us to the need to be ‘cautious’ but maybe not ‘optimistic. The study evaluates UNICEF’s Accelerated Child Survival and Development ACSD program in Benin, Ghana and Mali that took place between the years 2001-05. ACSD package was supposed to include –

  • Routine immunisation and periodic measles catch-up and mop-up
  • Vitamin A supplementation to children twice yearly
  • Distribution and promotion of insecticide-treated nets for children and pregnant women, and re-dipping of bednets every 6 months
  • Intermittent preventive treatment of malaria with sulfadoxine-pyrimethamine for pregnant women
  • Tetanus immunisation during pregnancy to prevent maternal and neonatal tetanus
  • Supplementation with iron and folic acid during pregnancy and with vitamin A post partum
  • Promotion of exclusive breastfeeding up to 6 months, timely complementary feeding
  • Improved and integrated management (at the health facility, community, and family levels) of children with pneumonia† malaria, and diarrhoea
  • Promotion of household consumption of iodised salt

Unfortunately mortality reduction in the ACSD districts did not achieve the 25% target, and in Benin and Mali there was greater reduction in the non-ACSD districts (Ghana did not have comparison data).  There was variability in introducing the package of interventions. Contextual factors such as worsening economic conditions at the community level and broad national level policy and programming technical assistance by donors may have affected outcomes.

A Lancet editorial concluded that, “The results of this evaluation do not match with the extravagant claims UNICEF made about the programme in 2005, but show potential for advantages if sufficient resources are directed to interventions addressing the major causes of death.”

The research team also observed that, “The analysis showed that child survival was not accelerated in Benin and Mali focus districts because coverage for effective treatment interventions for malaria and pneumonia were not accelerated, causes of neonatal deaths and undernutrition were not addressed, and stock shortages of insecticide-treated nets restricted the potential effect of this intervention.”

Instead of going away from their analysis discouraged, the researchers actually did take an optimistic view that such evaluations provide valuable lessons for improving service delivery.  Likewise a comment in The Lancet stressed that such large scale evaluation can, “create generalisable knowledge that can accelerate child survival by bridging the know-do gap.”

So what are the lessons of the ACSD evaluation for scaling up malaria control to reach the MDGs? Decreasing funding for fear of failure is certainly not an option.  Instead the evaluation study tells us to pay attention to how the funds are spent, to address structural and contextual barriers to effective implementation and coverage, and to ensure that there is enough funding for proper monitoring and evaluation to give us continual feedback for improvement.

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