Malaria Matters

How does maternal mortality become a priority health issue? Shiffman provides case examples in the May 2007 issue of the American Journal of Public Health. He examined policy and program changes in 5 countries: Guatemala, Honduras, India, Indonesia, and Nigeria, and provides a valuable framework for identifying the domestic and international influences and barriers on policy change. The example of Nigeria helps us see how malaria in pregnancy funding and programming might help draw attention to reducing maternal mortality.

Nigeria has the highest maternal mortality rate of the 5 countries (704/100,000 live births), and Shiffman reports that Safe Motherhood is still not receiving the attention it needs in Nigeria. One hopes that the problem of maternal mortality will receives greater attention because of increased malaria program efforts. Participation by Nigeria in the Roll Back Malaria Partnership and its management of malaria grants from the Global Fund have put a spotlight on the contribution of malaria control to safer motherhood. The National Guidelines for Prevention and Control of Malaria During Pregnancy (2005) outline clearly the path from malaria to anemia to maternal mortality and estimate that malaria contributes to 11% of the nation’s maternal mortality rate. The guidelines therefore stress IPTp, ITNs for pregnant women and prompt case management when pregnant women experience an episode of malaria. Likewise the National Reproductive Health Strategic Framework lists malaria among the preventable causes of maternal morbidity and mortality.

Donors are supporting MIP prevention and control activities. IPTp and ITNs are a key component of Nigeria’s Global Fund grant. USAID and the World Bank Booster program are also operating in Nigeria, and both include MIP interventions, particularly nets and IPTp. This level of external support and attention demonstrates “Transnational influences” on policy through norm promotion and resource provision, as explained by Shiffman.

There remain domestic policy challenges to Safe Motherhood in Nigeria. While partners are pulling together to fight malaria, the same cannot be said for Safe Motherhood. A recent MIP strategy workshop in Abuja sponsored by USAID’s ACCESS project and involving both the malaria and reproductive health (RH) program units of the Federal and some State Ministries of Health specifically forged stronger working relationships between the two program areas such that greater attention to malaria may in fact benefit Safe Motherhood. Shiffman emphasized the importance of reaching out to state and local decision makers too, since in Nigeria they make major decisions about allocating resources for public health.

If international malaria partners continue to stress the importance of addressing malaria in pregnancy using all three key control measures as part of a comprehensive malaria strategy, as is done in Nigeria, their efforts will hopefully also have the benefit of making Motherhood Safer.

The Global Fund to fight Against AIDS, TB and Malaria (GFATM) has to date awarded only about one-quarter of its resources to malaria grants. A new publication entitled Partners in Impact Results Report from GFATM summarizes key activities and performance up through December 2006. There may be some argument about the relative cost of HIV versus Malaria interventions, but as we see from further analysis of grant performance, malaria grants could benefit from more funding to address health systems issues that challenge good performance.

The first two charts seen here summarize concerns presented in the 2007 Results Report. As of December 2006, 215 grants had reached Phase 2 renewal status. A smaller proportion of malaria grants have achieved the higher status “A” and “B1″ classifications concerning performance than HIV or TB grants. Furthermore, when one compares grant performance against targets set by the grants themselves, once can see that Malaria Interventions (ACT and ITN distribution) are less likely to achieve their targets than HIV (ARV distribution and Counseling & Testing, for example) ot TB (DOTs). Clearly Malaria Grant recipients need additional funds and technical assistance to improve their performance.

This brings up another interesting issue. The Results Report also summarizes performance by type of Principal Recipient. NGOs and Civil Society Organizations receive 30% of funding but according to the third chart below, their grant performance is better than government agencies or the UNDP. Although a direct connection cannot be made from the data in the report, this finding suggests that Malaria Grants might benefit from greaer involvement from the NGO sector. In the meantime, technical assistance for malaria grants is needed not only for developing better proposals in Round 7, but more importantly for ensuring that the existing grants perform better and thus justify continued malaria investments in those countries.

Hannah Koenker has put together the following update on progress made in the four country-based programs of VOICES for a Malaria Free Future. Hopefully this will encourage other countries to strengthen their advocacy efforts.

Ghana
Ghana has mobilized leadership in government and civil society to form the National Voices Team, whose advocacy strategy has been accepted by NMCP and its partners as the national malaria advocacy strategy. As remarked by the Program Manager “Advocacy has received very little attention in our malaria control activities; Voices has come to fill the gap.” A number of malaria Champions have been recruited, including government and traditional chiefs. Two monthly Action Alerts have been published, and are seen by the NMCP as a great tool to keep the leadership awake on malaria control issues and to motivate sustained effort. Last but not least, the District Malaria Advocacy System is starting up. The key issues Ghana continues to grapple with are

1. Slow implementation of the new malaria drug policy - the use of the A+Aq. Lack of confidence in the drug due to earlier problems during introduction
2. Failure of the District Assemblies to program the 1% Common Fund for malaria control activities. (We know that at least from our 2 districts.)

Mali
Mali has organized a series of “War Room” meetings with the NMCP and its partners to discuss ITN distribution, household and community barriers to accessing treatment, and the introduction of ACTs for pregnant women and children under five. They have met with a variety of partners, including PSI, UNICEF, Peace Corps Volunteers, PMI, the National Pharmacy, the Koulikoro Regional Health Office, and the Global Fund. The team has also met with several private sector partners to plan employee net distributions. Most notably they have successfully advocated for the renewal of the presidential exoneration of taxes and tariffs on ITNs and insecticides for net treatment, and have written several newspaper articles about their efforts. For Africa Malaria Day, which in Mali is being celebrated throughout the month of April, VOICES produced four 3-minute skits with the director and actors from the popular Malian soap opera “D’ou la famille”, touching on messages like prompt treatment, the role of fathers in treatment-seeking, myths about malaria and mosquitoes, and the importance of ITNs and ACTs. Several Malian musicians have been recruited as malaria champions, and activities are being planned for the near future.

Challenges have been to carry out activities in the workplan while responding to the PMI team’s request for information and help during their visits. In addition, while the government is promising free ACTs and ITNs to pregnant women and children under five, there are not yet enough drugs and nets in-country to meet demand.

Mozambique:
Mozambique continues to update their Resource Center and has scheduled a calendar of malaria talks. They’ve helped the NMCP create a multi-sectorial committee for malaria activities and are serving as the secretariat, as well as helping to set up a database that will map malaria activities. Their advocacy strategy and workplan are finalized and the M&E plan is being finalized, with input from stakeholders. Voices also facilitated the trip of one Mozambican journalist  to participate in the presentation of the UK All Party Parliamentary Malaria Group report (“Financing Mechanisms for Malaria”) and Yvonne Chaka Chaka’s Princess of Africa Foundation launch. With coalition members Voices will tackle the issue of community health workers (CHW), to improve access to malaria prevention and treatment services, and will contribute to the First Lady’s campaign, “Malaria Free Children”.

Kenya 
Kenaam has conducted a two-day advocacy training for KeNAAM members after which a task force was established to develop the Kenya VOICES advocacy strategy. Additional task forces will take on the role of identifying champions, and gathering information on the malaria situation in Kenya.  They have successfully managed the constituency election process so that more malaria CSOs have a voice on the GFATM CCM, and continue advocating for release of funds to NGO implementers. Kenaam’s new communications officer has developed a Kenya work plan that includes activities such as training, outreach to new partners and voices, and documentation of activities. She has also developed a media database and the team is planning a media training targeted for journalists from regions where malaria is particularly bad. A database of Members of Parliament from malarious areas was also created, and contacts have been made so that malaria can be made part of the Parliamentary Health Committee agenda. Partnerships were developed with the Boy Scouts, several youth groups, and the Ministry of Education to train new youth voices in malaria advocacy, and to work with Pfizer’s school health program to include malaria messages in teaching curriculums. A notable recruit was the Kenyan UN Youth Ambassador, who has the potential to be an advocate at global level. Success and advocacy stories are in development, including the Kilifi “Talking Nets” story, and will be featured on the CORE website, later on the KeNAAM site, and linked to the VOICES Homepage. Kenaam’s draft advocacy strategy includes plans for M&E and sets out Kenya’s main challenges,

• the low priority of malaria within the government
• the need for more resources to be included in the GOK budget
• the need for the flow of resources to be less restrictive (GFATM for example and how CSO still have not received Round 2 funds)
• the need for ACTs to be made available at a reduced cost in the private sector (roll out of the new policy is only happening in public hospitals and clinics, but most people access drugs from shops).

Ooms, Van Damme and Temmerman have recently argued that country support from the Global Fund to Fight against AIDS, TB and Malaria (GFATM) should address health workforce gaps so that the situation “Medicines without Doctors” does not lead to misuse or non-use of live saving drugs. The authors express how that the existence and commitment of the GFATM signifies the possibility of sustaining a commitment to funding a health workforce that poor countries cannot achieve due to varying challenges ranging from budgetary problems to the brain drain. This takes sustainability to a different level and involves all countries, especially the richer industralized ones, in sustaining health for all.

These authors focus more on human resources for HIV/AIDS. What are the special workforce needs for malaria? For example, there is need to have adequate staff who understand how to procure, manage, prescribe and counsel on ACTs.  In-service training (IST) may be part of the picture, but quality training is needed. This brings to mind a story about ‘jamboree training’ described by one colleague where over 300 district health staff were assembled and told everything about the GFATM project in just a couple days in order to meet promised training targets, which in turn one hoped would enable the meeting of ACT distribution targets. Workforce enhancement needs to be multidisciplinary – pharmacy, clinical, records, disease control and health education staff have different but interrelated roles to ensure that malaria interventions are planned, delivered and monitored. Districts not within the current scope of the GFATM project often do not get training on current or new national malaria guidelines, and the human resources in private sector are often left out.

Fortunately, attention to Health Systems Strengthening recommended by Ooms et al., is addressed in guidelines to countries applying for Round 7 of the GFATM. This may not solve the problem.  GFATM is not an unrelenting spigot of funding.  Securing a project does not guarantee that it will run for the proposed five years. As the end of the second year approaches, projects are reviewed, and if they are not performing - i.e. meeting indicators, they are not renewed for Phase II.  Similarly, just because a country wins a grant one year does not guarantee it will be lucky in securing future and continuing grants as Ooms et al. would hope. GFATM is ‘performance based.’

Clearly the global community has responsibility for preventing death and disability arising from malaria and other tropical diseases.  The GFATM offers hope, but is not yet the magic solution.  Of course this does not mean that we should accept the current reality, but instead should try to push the boundaries of the commitment to eliminating malaria by both endemic and donor nations.

A current article by Ye et al. in Malaria Journal stresses that while malaria may be a national problem, there are important local variations in malaria risk in an area of northwestern Burkina Faso. Ecological and economic factors may likely play a role and include seasonal rice farming, cattle rearing, irrigation, and living in a semi-urban area. They conclude that, “malaria control strategies should be designed to fit location-specific contexts.” Just because a community has a different ecological setting or requires a different malaria control strategy does not mean it is not part of the global fight against malaria. One size does not fit all.

This brings to mind discussions over the past year whether intermittent preventive treatment for pregnant women (IPTp) is considered a major strategy by WHO’s Global Malaria Control Program (GMP). As of this date (20 April 2007) right in the center of the GMP web page one finds the following statement: “IRS is now one of three main interventions promoted by WHO to control malaria.” This refers to a 2006 document on Indoor Residual Spraying (IRS), which on page 1 recommends the following three ‘primary’ interventions for the control of malaria:

• diagnosis of malaria cases and treatment with effective medicines;
• distribution of insecticide-treated nets (ITNs) to achieve full coverage of populations at risk of malaria; and
• indoor residual spraying (IRS) as a major means of malaria vector control to reduce and eliminate malaria transmission including, where indicated, the use of DDT.

People have taken this to mean that IPTp is no longer considered to be a primary intervention. Recent discussions with colleagues revealed that there is a school of thought that says since IPTp is a key tool for the African Region, it is not a ‘global’ strategy. They explained that pregnant women are a focus when it comes to ITNs. They note further that there are links to a fact sheet on malaria in pregnancy at the Roll Back Malaria Website that lists IPTp as part of a three-pronged approach to malaria control, as well as a link to WHO’s Regional Office for Africa and its Strategic Framework for Prevention and Control of Malaria During Pregnancy, which also lists IPTp as a major strategy.

While these links to other organizations are helpful, they do not dispel the uncomfortable feeling that pregnant women in Africa do not rate the status of being part of the ‘global’ malaria control effort. One also wonders about their sisters in Papua New Guinea or Brazil where falciparum malaria also is of concern.

If one wants to be particular, one can even question whether the GMP is actually global. What are its strategies for controlling malaria in Norway or New Zealand, for example? Obviously what makes the fight against malaria global is the fact that people and agencies in both endemic and non-endemic countries are joining together to do whatever it takes to control the disease.

Excluding IPTp from the ‘global’ arsenal presents a false distinction and reinforces the perceptions of neglect, which Africa and women’s health have suffered on many fronts for too long. As Ye et al. have found, there is no single global malaria context, and while we have a variety of tools to fight malaria, there is no one magic global bullet to eliminate malaria in every situation. Let’s form a global alliance that recognizes a wide arsenal of malaria tools but adapts them to the local ecology and local needs.

Last year EM Kamau wrote about “the enormous potential that exists between (the HIV and the Malaria) initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting”  in the African Journal of Health Sciences. These synergies are not always found in practice. The HIV/AIDS project of the Nigerian NGO Mothers’ Welfare Group targets orphans and/or children affected by HIV. They provide specialized VCT for children and young adolescents and medical care for opportunistic diseases such as malaria. Even though they are working in Kaduna State, which receives support from the Nigeria’s Global Fund Malaria grant, they have found difficulty in obtaining ACTs and ITNs for the vulnerable and HIV-infected children in their care.

The US President’s HIV/AIDS program, PEPFAR, does talk about the need to provide malaria services for people affected by HIV. “PEPFAR-supported interventions to optimize survival of HIV-exposed and -infected children include provision of basic preventive care, including support for infant and young child nutrition, immunizations and prevention of infections such as malaria, tuberculosis, and pneumonia. The pediatric preventive care package includes life-saving interventions, such as cotrimoxazole prophylaxis to prevent opportunistic infections, including diarrheal disease; screening for tuberculosis and malaria; prevention of malaria using long-lasting insecticide-treated mosquito nets; and support for nutrition and safe water.” Under PEPFAR pallitive care shoud include “Provision of the following drugs and commodities: cotrimoxazole; isoniazid; insecticide-treated bed nets; point-of-use water treatment and safe-water storage vessels; soap; and hand - washing instructions for HIV-exposed and -infected children.” PEPFAR even sets reportable indicators around malaria: “PEPFAR indicators for palative care include: Number of service outlets/programs providing malaria care and/or referral for HIVinfected clients (diagnosed or presumed) as part of general HIV-related palliative care. This number is a subset of the number of service outlets/programs providing general HIV-related palliative care.”

Conversely, the US President’s Malaria Initiative acknowledges the need to target PLWHAs as a vulnerable group in malaria prevention and control. As seen in the PMI country action plan for Uganda, “This will be achieved by reaching 85% coverage of the most vulnerable groups-children under five years of age, pregnant women, and people living with HIV/AIDS-with proven preventive and therapeutic interventions, including artemisinin-based combination therapies (ACTs), insecticide-treated nets (ITNs), intermittent preventive treatment (IPT) of pregnant women, and indoor residual spraying (IRS).”

PEPFAR and PMI program planners are consciously thinking about the synergistic possibilities in addressing malaria in HIV.  Other donor efforts and national disease control programs should collaborate more on these two crucial health problems.

This is the season when Central Coordinating Mechanisms in many countries are busy writing proposals for Round 7 of the Global Fund for AIDS, TB and Malaria. Many of the most endemic countries in Africa experienced failure in their Round 6 Malaria proposals. The Roll Back Malaria Partnership’s Harmonization Working Group has done commendable work to provide comprehensive technical assistance through two recent workshops to assist certain African countries to develop stronger proposals. The fear is that these new and improved proposals may face the same fate as last year’s group if more attention is not paid to the bottlenecks that have prevented achieving performance indicators in previously awarded malaria grants.

Much of technical assistance to date to GF grants has taken the form of proposal drafting assistance. Although CCMS are free to include in their proposals provision of technical assistance, few do. Until recently grants reached the Phase II renewal process with troublesome implementation bottlenecks ranging from poor procurement systems to inadequate monitoring and evaluation. It was estimated that nearly 40 countries were facing these implementation bottlenecks in 2006. Recently the Global Fund has inaugurated an Early Alert and Response System to identify these problems. The question is who will help provide TA for projects that are already in progress? Without addressing the existing bottlenecks, not only will current grants be lost, but new proposals will reviewed with a strike against them.

During the past year the US Government recognized the inhibiting effect these bottlenecks were having for both Phase II renewal and the success of new proposals. At present the US provides over one-quarter of all funds to the Global Fund, and does not want to see that investment lost when timely technical assistance could turn a project around. The challenge has been getting CCMs to request the technical assistance, but where they have, as was the case of the Nigeria Malaria Grant, it has helped. More countries are encouraged to take advantage of existing technical assistance channels as well as to write into their new proposals funds for getting technical assistance as they implement their programs.

In a Washington Post book review, “Buyer Beware: Are we training our kids to be consumers rather than citizens?” Barry Schwart ( Sunday, April 8, 2007; Page BW08) noted that, “Viagra and Botox become readily available here while drugs to combat life-threatening malaria and diarrhea are not in developing countries.”

An opinion piece in The Nation entitled “Pigs in Space” (7 April 2007) observed that a millionaire Hungarian-American software programmer paid $20 million to be escorted to the Kazakh steppes, packed into a Russian Soyuz rocket and blasted towards the international space station. The Nation suggested that, “Simonyi might have spent his money fighting AIDS, or building housing for Hurricane Katrina survivors, or providing clean water to developing nations, or mosquito netting and medicine for malaria patients, or musical instruments for needy, photogenic, musically-gifted inner city school children or…well, depressingly, the list goes on and on.”

The Associated Press reported from the recently concluded climate change conference in Brussels that, “Two distinctly different groups, data-driven scientists and nuanced offend-no-one diplomats, collided and then converged this past week. At stake: a report on the future of the planet and the changes it faces with global warming.” The meeting reported that, “Malaria, diarrhea diseases, dengue fever, tick-borne diseases, heat-related deaths will all rise with global warming.”

In an upcoming issue of Newsweek International Jason Overdorf reports that along with global warming there is an increased movement of malaria bearing mosquitoes into highland regional of Asia, Latin America and Asia. He quotes another study that states, “temperature increases from 0.5 degrees to 3 degrees can double the population of Anopheles mosquitoes, which carry malaria.” Economic conditions that enable people in northern countries to afford window screens and air conditioning may stave off the spread of disease.

A recent AFP report focuses on the village of Sauri near Lake Victoria in Kenya. Sauri is one of the first 12 Millennium Development Villages (MDVs) in Africa and has been making strides using an integrated development approach. The Millennium Development Goals (MDGs) focus broadly on improving income, food supply and education, enhancing women’s empowerment, improving health, reducing disease, protecting the environment and encouraging partnership in addressing all these issues. These goals are now being pursued by many nations, but are specifically being addressed in a total of 80 MDVs.

In Sauri both women and men are producing more on their farms after learning new techniques, are sending more of their children to school, and are able to feed themselves. These results are interrelated since improved farming improved diet and makes children more alert in school. School attendance and school performance ranking in the district have risen. To round out the development efforts a free clinic has opened and free ITNs have been distributed in the village. Villagers attribute better school attendance to reduced malaria burden in their children.

Villagers also raise the question about sustaining these achievements. They ask whether the government will maintain the improvements. Some talk of a slow weaning process of donor support for village improvements as a way to ensure the village can stand on its own. In the meantime more people are moving in as they see the benefits enjoyed by their neighbors.

Questions arise. Can we achieve MDGs one village at a time? Can economic improvements enable villagers themselves to maintain the improvements, e.g. through revolving funds to guarantee continued supplies of malaria drugs and nets? Can all the thousands of villages in Africa become MDVs?

George Parris wrote recently in Medical Hypotheses about the likelihood that a malaria medicine trial of pamaquine/plasmoquine in Leopoldville (Kinshasha) in 1927 basically interfered with the work of an existing retrovirus that may have actually helped primate T-cells attack the liver stage of the malaria parasite, and hypothesized that later use of chloroquine exacerbated the problem. Please read the article for the technical details. Based on this analysis, he discounts the common zoonotic hypotheses of the origins of HIV.

If this hypothesis proves true, it is only fitting that the Global Fund addresses both HIV and Malaria, but should do so in equal measure now that new non-chloroquine antimalarial drugs are being promoted. In addition many studies exsit to show the negative synergies between HIV and Malaria. Laufer and Plowe suggest that the effect of malaria infection on HIV disease progression due to increased viral replication may be important and needs to be fully explored. Desai et al. report that HIV increases the risk of malaria and its adverse effects in pregnant women. In a review of recent research Slutsker and Marston state that HIV-infected persons are at increased risk for clinical malaria; the risk is greatest when immune suppression is advanced. They also note that adults with advanced HIV may be at risk for failure of malaria treatment, especially with sulfa-based therapies, and that malaria is associated with increases in HIV viral load that, while modest, may impact HIV progression or the risk of HIV transmission.

Clearly we cannot undo the past, but it is incumbent on countries where both HIV and Malaria coexist to plan integrated and conprehensive approaches to managing both diseases