Malaria Matters

The Washington Post reported today that a key official in the US President’s Administration has been blocking the publication of the Surgeon General’s 2006 “Call to Action on Global Health,” a draft of which is available on the link provided. Specifically the Post noted that, “A surgeon general’s report in 2006 that called on Americans to help tackle global health problems has been kept from the public by a Bush political appointee without any background or expertise in medicine or public health, chiefly because the report did not promote the administration’s policy accomplishments, according to current and former public health officials.”

Reading through the report one does not find specific mention of the President’s Malaria Initiative (PMI) but does cite the President’s Emergency Plan for AIDS Relief. The report does highlight various global efforts such as the Global Fund to Fight AIDS, TB and Malaria, of which the U.S. is a major supporter/donor, the Roll Back Malaria Partnership, and the United Nations Millennium Development Goals. Concerning the MDGs, the draft report states, “Beyond reducing the disease burden, a successful fight against malaria will have far-reaching impact on child morbidity and mortality, maternal health, and poverty, which in turn could increase global stability.”

The draft report emphasizes that, “Malaria treatment, control and prevention should be an integral function of an effective health system, supported by strong community involvement. Sustained success in malaria reduction calls for development of the health sector; improved case management, the use of intermittent presumptive treatment programs for pregnant women, insecticide-treated bed nets, and spraying of households with insecticide.” This recognition of a comprehensive approach to malaria control programming by the United States certainly needs to be shared widely with other donors and endemic country policy makers.

The draft report also touches on an issue that has been politically sensitive to the Administration, global warming. The report explains the link between malaria and global warming as follows: “The distribution of insects and other organisms that serve as hosts to the microorganisms that cause infectious diseases is likely to be affected. This could lead to changes in disease patterns. For example, malaria might appear in areas where it is currently unknown because of the spread of the mosquito that carries the disease.” In another politically sensitive move the report acknowledges malaria research and technical efforts by the French, the Japanese and the Multilateral Initiative for Malaria.

Although the current Bush Administration may have brought attention to malaria to a new level through PMI, the U.S. has been a leader and a champion of malaria control and prevention for decades through the US Centers for Disease Control and Prevention, the National Institutes of Health, and USAID, to name a few. Some sense of balance is needed. One certainly does not want to see a document that is only a self-congratulatory piece, but one would also expect to see adequate recognition of all contributors and stakeholders who promote global health. The report does deserve to have wide circulation to stimulate greater discussion of and commitment to solving global health challenges by US Citizens and their elected representatives.

Yesterday Reuters reported a story of fake drugs produced in China that was subsequently carried by the Independent. Although three types of drugs were mentioned, it was the fake Viagra that captured the headline. Not surprisingly fake bird flu and malaria medicines did not attract as much attention in a story geared to the western press. This falls on the heels of other discoveries of fake or adulterated products from China ranging from pet food to toothpaste, again products of greater interest in the western world.

Still, more people are likely to die or be harmed by fake malaria drugs than fake Viagra. Other fake drugs from China have over the past years killed children in Nigeria and Panama. There is real concern because China is one of the world’s major suppliers of malaria drugs, especially the newer artemisinin-based drugs developed from a Chinese herb that are being adopted as first line treatment in endemic countries.

Three steps by the World Health Organization may help. WHO recommends artemisinin-based combination therapy (ACT) as first line treatment. These combinations include artemisinin and another drug for which there is no parasite resistance. The second step is coming out clearly and stating that monotherapy artemisinin drugs should be withdrawn from use to prevent the spread drug resistance and increase the useful life of the new artemisinin-based medicines. Finally, WHO has a program for pre-qualification of drugs that focuses on quality issues. The main ACT recommended on that list is artemisinin-lumefantrin (AL), which is produced by one company and has tight quality controls. AL is the drug favored by major donor and NGO programs.

Where dangers may arise is within the commercial pharmaceutical sector where monotherapy artemisinin drugs (see picture) are still available and where ACTs that have not received pre-qualification status are sold. Each malaria endemic country has some form of a food and drug authority that should license and regulate drugs. If these agencies are empowered to do their job, the public will also be protected from fake or inappropriate malaria drugs on sale in shops and private clinics.

The Ministry of Health in Uganda estimates that private, not-for-profit health (PNPH) facilities account for 30% of all facilities in Uganda, and importantly around 85% of these are located in rural communities. USAID’s ACCESS project has demonstrated that FBO health facilities, an important component of the PNPH sector, can play a major role in increasing the delivery and uptake of malaria in pregnancy (MIP) control interventions in the Kasese District of Uganda. The project was a joint effort of ACCESS partners, particularly Interchurch Medical Assistance (IMA) and JHPIEGO.

The project worked with the Uganda Catholic, Muslim and Protestant Medical Bureaus in five health facilities and upgraded the malaria technical skills of all antenatal care (ANC) staff using JHPIEGO training materials. In addition “community owned resource persons” (village volunteers) and religious leaders were trained to help mobilize women to attend ANC. ANC is a key platform for delivering malaria in pregnancy control interventions.

Over the nine-month intervention 27% of women attending ANC were given Insecticide Treated Nets (ITNs), which were supplied by the project. The facilities normally stocked sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy (IPT). By the end of the project the the proportion of ANC attendees receiving their first dose of IPT rose from 43% to 94%, while those receiving IPT2 increased from 27% to 71%. The Uganda Demographic and Health Survey for 2006 found only 50% of pregnant women nationally had received IPT1, and 17%, IPT2.

Often donor in-service training programs focus exclusively on public sector health workers and neglect those in the private and NGO sectors. In many malaria-endemic countries religious mission health services deliver a large portion of care, and as seen in this Ugandan example, can play a major role in delivering malaria in pregnancy control services if their capacity is improved. Fortunately, these FBO facilities did stock SP from which they could plan and deliver IPT. At the time they did not benefit from supplies of ITNs, although the country was receiving ITNs through Global Fund Grants. It is therefore important for National Malaria Control Programs to integrate FBOs and PNPH facilities into both training and commodity supply programs to ensure full protection of pregnant women from malaria. Since this project was done in collaboration with the Ministry of Health (MOH) in Uganda there is hope that collaboration will continue between the faith mission medical boards and the MOH to expand these MIP services to other FBO facilities.

Intermittent preventive treatment (or therapy) in pregnancy (IPTp) with the drug sulfadoxine-pryimethamine (SP) is a key strategy for controlling morbidity and mortality associated with malaria in both pregnant women and newborns. IPTp when given at least twice, one month apart after quickening, reduces maternal anemia, placental malaria, and low birth weight. IPTp with SP has many characteristics of a good public health intervention in that is is relatively low cost, is easy to deliver, and is generally acceptable and available. The longer half-life of SP gives it comparative advantage over alternatives.

Recently questions have arisen about the value of SP as IPT when there are increasing reports of drug resistance when tested and used in children under five years of age. Of note is a lack of study of resistance in pregnant women themselves, which always poses an ethics problem for researchers. WHO African Region issued a statement in 2005 on the efficacy of SP even under conditions of drug resistance in children under 5 and recommended continued use of SP even where resistance levels in children were up to 50%.

To support this position ter Kuile et al. concluded in the June 20th 2007 issue of JAMA that, “In areas in which 1 of 4 treatments with sulfadoxine-pyrimethamine fail in children by day 14, the 2-dose IPT with sulfadoxine-pyrimethamine regimen continues to provide substantial benefit to HIV-negative semi-immune pregnant women. However, more frequent dosing is required in HIV-positive women not using cotrimoxazole prophylaxis for opportunistic infections.” O’Meara et al. further contend that IPTp is unlikely to significantly impact the spread of SP resistant parasites.

While alternative drugs are being considered, none so far are as cheap as SP. These also require more than one dose and thus make directly observed treatment within the context of antenatal care quite difficult. More research is needed to find appropriate substitutes. Basically it is important for countries to continue using SP for IPTp for the meantime, and of course ensure that all pregnant women obtain and sleep under ITNs.

When nations, states, provinces and districts are not allocating enough funds for malaria treatment and prevention, will people speak out? When allocated malaria funds are being used for other purposes, will people speak out? When bed nets are being given only to those who voted for a particular political party, will people speak out?  These are some of the questions that come to mind when reading the new World Bank Report on Governance.

According to the BBC, report measures the quality of government in 212 countries from 1996 to 2006 found Africa had shown the greatest improvement. Six measures that comprise governance include:

• Voice and Accountability
• Political Stability and Absence of Violence
• Government Effectiveness
• Regulatory Quality
• Rule of Law
• Control of Corruption

Voice and Accountability is a major concern in our efforts at the Voices Project. This measure is defined as follows: “The extent to which a country’s citizens are able to participate in selecting their government, as well as freedom of expression, freedom of association, and a free media.”

The report links Voice and Accountability with Control of Corruption. “Countries with voice and accountability challenges … tend to have much more corruption. This is consistent with the idea that when citizens can demand more accountability through the ballot box, or where there is freedom of expression, of the media, and of information, governments become cleaner and less corrupt.” Corruption, as we know, leads to poor prognosis in terms of delivering health services, including malaria control programs, in an efficient and equitable manner.

The Voices Project is focusing on four malaria endemic countries, Ghana, Kenya, Mali and Mozambique, in addition to the major donor agencies and countries.  The World Bank report traces progress for each country on governance issues between 1996 and 2006.  A co-author of the World Bank Report states that, “The good news is that some countries, including some of the poorest ones in Africa, are deciding to move forward, and are showing to the world that it is possible to make substantial inroads in improving governance.” We can see in the chart that the rankings of the four Voices Project countries on Voices and Accountability mean that there will be challenges to advocacy efforts, but there are hopeful signs that the advocacy climate is improving in Ghana and Kenya.  Malaria advocacy will serve as a test case for improving Voice and Accountability in these countries, and the benefit will hopefully go beyond lives saved from malaria to lives lived freely in a more open and free society.

On Thursday a demonstration protesting hunger in Nigeria was broken up because of littering, a trivial excuse for trying to block attention to a crucial development and health issue.  Action Aid, organizers of the Abuja march said, “Despite the country’s massive oil wealth, one in three of Nigeria’s 140 million people goes to bed hungry.” Hunger and the related issue of malnutrition is especially important to control infectious diseases like malaria.
There has been controversy about the exact relationship between malnutrition and malaria, but greater death rates from all causes is associated with malnutrition. A recent PLoS review summarized the issue as follows: “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.” The review clarified that Chronic PEM was associated with malaria.

The association between malaria and the nutritional problem of anemia is not in doubt, and not long ago we shared findings about diet and Artemisinin-Lumenfantrine (AL), the most commonly recommended ACT. Studies found the need for adequate fat consumption to enhance AL absorption, a major challenge for hungry children who have poor diets with low energy intake.

Regardless of associations, the two issues, ending hunger and ending malaria, come together in the Millennium Development Goals. Both should receive the undivided attention of child health advocates and government policy makers

Uganda was the darling of hte international public health community some 15-20 years ago when it tackled the HIV/AIDS epidemic head on with local initiative, both by government and civil society. Today in the era of huge disease control grants Uganda is not doing so well. In August 2005 problems within the Project Management Unit within the Ministry of Health that oversaw all Global Fund grants implementation led to a suspension of all grants. This was a major set back for the Round 2 Malaria Grant, which had started in March 2004. The suspension led to serious drug shortages for the three disease programs.

Although a recently published progress report at the Global Fund shows that grants where government agencies are the principal recipient perform more poorly than those managed by NGOs, the Uganda experience was an extreme event. It appears that the country may not have fully recovered from the problems.

A headline in the Monitor newspaper of 11th July 2007 read, “Shs3.7 Billion Malaria, ARV Drugs Rot in National Medical Stores” (about $US 2.3 million). According to the article, a team of MPs “were shocked to find eight containers of 2-feet, full of expired drugs yet Ugandans are perishing in hospitals without treatment.” These included both ARVs and antimalarial drugs. It was reported that most of these drugs did not ‘belong’ to the National Medical Stores (NMS) but to donor programs. This may point to a deeper problem: the NMS should be part of the management process for these donor programs, not just a passive depository for supplies.

The General Manager of the NMS complained that, “Many of the programmes procure short-lived drugs and leave them for a long time at NMS, which in many cases expire.” The reality is that the current first line antimalarial drugs, artemisinin-based combination therapies (ACTs), have a short shelf life. As seen in the attached picture of a packet of antesunate-amodiaquine, ACTs typically expire two years from manufacture. This means that national malaria programs must forecast, procure and manage ACTs in such a way as to guarantee prompt use of supplies.

This news speaks poorly for the malaria grants in Uganda. The Global Fund publishes report cards and score cards on all grants, and one can easily find these on each country’s page at the Global Fund Website. The most recent progress report for Uganda’s Round 2 malaria grant is November 2006. That progress report noted that, “Performance has been poor because of the loss of momentum due to the suspension of GF grants in Uganda for a period 2.5 months, as well as the disbandment of the Project Management Unit (PMU)” and that implementation was behind schedule.

Concerning procurement, the report stated that, “On lifting the suspension, an aide memoir was signed at which certain actions were agreed upon to be achieved by the PR and CCM. This included the recruitment of a Third Party procurement agent and the revision of work plans and procurement plans to take account of the delays due to the suspension. To date, a procurement agent has not been appointed.”

More specifically, the New Vision newspaper of 11 March 2007 reported that, “The Global Fund has permanently terminated two grants to Uganda for malaria and tuberculosis because of what it called “unsatisfactory performance.” As a result, Uganda has missed about $16 million,” of which $14.7 million was for malaria. The Round 4 malaria grant, which started in December 2005, after the problems of suspension had been resolved, remains. There is hope, as the most recent progress report for this grant, issued in January 2007, indicates that WHO is helping address procurement problems. The report states that, “This grant is achieving its targets, with the first tranche of ACTs having been purchased by WHO. Despite the setback of GF grants in Uganda due to the suspension, this grant, which is largely procurement-dependent, is moving ahead with the support of WHO.”

While we cannot change the shelf life of ACTs, we can improve procurement and supply management of malaria drugs. Although the Global Fund has canceled few grants, it is not unwilling to take action. Ideally RBM partners should step up and provide technical assistance to help grant performance long before the grant cancellation question arises.

The August issue of Tropical Medicine and International Health demonstrates the fact that malaria control interventions do not implement themselves. Providing commodities is only part of the picture. Ouma et al. representing a team from KEMRI, JHPIEGO, CDC and the University of Amsterdam have shown that coverage of Intermittent Preventive Treatment in Pregnancy is enhanced when health workers received training on focused antenatal care (FANC) and the national malaria guidelines.

“The 3-day training used a competency-based learning approach, emphasizing theory with one full day spent in a clinical setting for practical experience. The training materials included a training/orientation package of two-page laminated service provider job aids on malaria in pregnancy and FANC/MIP and community brochures.”

Ironically in Kenya there had been an IPTp policy since 1998, but without adequate staff capacity building the policy was not achieving results. The situation is similar in other countries.

An assessment for malaria in pregnancy in Akwa Ibom State in southeast Nigeria documented that two years after the national Malaria in Pregnancy Guidelines had been published (2005), front line antenatal clinic staff were not familiar with the term IPT. JHPIEGO has worked with the Federal Ministry of Health to develop the guidelines and an orientation package on FANC and MIP and is now planning to roll out MIP training for the health workers in Akwa Ibom State with support from the ExxonMobil Foundation. Hopefully this will produce similar results as the efforts in Kenya.

In conclusion, national malaria control programs and projects cannot succeed on commodities alone. Health workers need basic orientation and skills to roll back malaria

Advocacy is really a behavior change strategy aimed an policy makers and policy implementers. As such it turns the tables on the traditional behavior change communication approaches that target the community and consumers. Instead the community and consumers through advocacy try to educate the policy makers. At minimum there are three basic components to advocacy:

1. Promoting enactment of policies, laws, standards, guidelines
2. Ensuring that policies are actually funded
3. Monitoring approved policies to be sure they are fully implemented

Galer-Unti and colleagues outline several advocacy strategy approaches to make sure policies are enacted and their benefits reach the public. These strategies involve individual and as well as community commitment for action.

1. VOTING for officials who are likely to enact and uphold policies that promote public health
2. ELECTIONEERING and campaigning for candidates who promise to support public health
3. LOBBYING elected officials and decision makers to follow through on promises to promote public health
4. MOBILIZING THE GRASSROOTS to petition, meet and influence decision makers
5. USING THE INTERNET to draw attention to public health concerns
6. ADVOCATING THROUGH THE MEDIA either by writing news and opinion pieces, serving as a resource for reporters or even better, by staging events that will attract media attention and thereby, that of policy makers

What does this mean for malaria? These days most countries have received guidance from WHO and the Roll Back Malaria Partners in developing national malaria treatment and prevention guidelines and policies. For example, these policies spell out national support for the use of Artemisinin-based Combination Therapy (ACT) for first line case management. It is therefore often at the second and third levels - budgetary support and implementation support - where much of the advocacy is needed.

An example of the follow through needed to make policies a reality comes from Nigeria’s ITN Massive Promotion and Awareness Campaign (IMPAC). The federal government rallied donor support and some domestic funds to acquire seed stocks of ITNs. Memoranda of Understanding (MOUs) were signed with most state and local government (LG) officials indicating that they would supplement ITN stocks to ensure all in need were reached. Unfortunately after the initial federal stocks were exhausted, no further supplies were provided by states and LGs. The federal government continues to mobilize donor support for ITNs, for example through Global Fund, USAID and DfID, and some corporate philanthropic and foundation efforts contribute additional nets, but supplies have been limited.
Fortunately the National Malaria Control Program (NMCP) had budgeted some funds for advocacy. Visits to selected states yielded some results. For example even though it was not a donor recipient, the Niger State Government after an advocacy visit actually purchased nets and undertook distribution. More work is needed to mobilize the grassroots so that they demand nets from their local health departments, but at least we can see that advocacy can work in an African setting. Hopefully this will inspire NMCPs in other countries to get on the advocacy bandwagon.

One of our newest African malaria advocates, the Voices Mali Coordinator, Djiba Kane Diallo, appeared in a press conference on French TV channel TV5.  Djiba was in Paris at a press conference about the lack of progress toward achieving the Millennium Development Goals for health.  The conference was organized by Médecins du Monde and the story was broadcast globally on TV5.  She was interviewed and spoke specifically about logistical problems in managing malaria commodities in Africa.  Supply chain management is one of the systems that need to be strengthened to improve malaria control across Africa.

Watch the clip (in French!) at http://www.tv5.org/TV5Site/info/jt_ja.php?edition=20070705&par=6

Les pays européens doivent investir d´urgence dans les services de santé des pays pauvres 

(aired on 5 July 2007)

For non-Francophones, here is the translation of the newsclip:

In a meeting in Paris on July 5, 2007, European NGOs demand that European governments invest more in health services in developing countries in order to meet MDG goals.

It’s the first evaluation of the Millenium Development Goals. At the midway point, a report edited by 15 NGOs gives a poor grade to Europe, and to France in particular. Current financing for goals like reducing child mortality means that they will be met only in 2220. Twenty million Euros were promised for health, but only half of what was promised has been spent.

[Patrick Bertrand, NGO network leader] “Data from 2004-2005 shows that France gives 4% of its foreign aid for the health sector. The average among OECD countries is 11%.” 

On the ground, they are impatient for the missing funds. For the NGO Voix du Mali, which works to control malaria, it’s an emergency. Medicines are there, but there are few funds to distribute them.

[Djiba Kane Diallo, Voix du Mali] “If there is more financing, that enables countries to not only to distribute the medicines out to the community level, but also to stock them in appropriate conditions.”

In the report they highlight not only the need for more money, but also the need to change practices and policies in the health sector. Promote research, train health personnel, and put more responsibility on African governments.

[Michele Brugiere, Medicins du Monde] “African governments need to commit more of their budgets to health - they should be comitting 15-20%. Right now it’s two, three, four percent.”

MDG health goals can still be reached, but donors’ political will must now change into economic reality.