Malaria Matters

Jeffrey Sachs has again called on the world to get serious about malaria. In Scientific American he explains why, “The challenge of controlling the disease in Africa by 2010 is fundamentally organizational, not technical.” While partners seem to be in agreement on the basic strategies and interventions, health systems needs remain, including these mentioned by Sachs:

• harmonization among partners in all sectors
• transparency, efficiency and accountability of implementing country governments
• unprecedented coordination of financing, training, monitoring and logistics
• raised production levels of basic commodities to hundreds of millions of units
• training for tens or hundreds of thousands of community health workers on malaria control

These challenges appear daunting, but Sachs implores partners that, “The consequences of organizational failure, on the other hand, would be almost too painful to behold.”

The Global Fund has been encouraging countries to include health systems strengthening (HSS) components in their proposals for quite some time. This has sometimes been framed as separate grant sections and at others as integrated into disease-specific sections. After six rounds only 1% of funds were distinguished as HSS.

Past Global Fund e-forum discussions have addressed HSS and noted the low priority given to this element, the challenge of weak systems in recipient countries and the inability of health systems to reach communities and households where intervention is most needed.  A current forum contribution, for example, looks at how Nigeria was in the process of laying “foundations of what could have been one of the best public health infrastructures…in Africa” with primary health care in the 1980s and 1990s, but “these infrastructures and gains are almost totally lost.”  Is HSS fighting an uphill battle?

The GFATM directs the Technical review Panel (TRP), “in reviewing a disease component which contains a cross-cutting HSS section, the TRP may recommend for funding either: a. The entire disease component, including the cross-cutting HSS section; b. The disease component excluding the cross-cutting HSS section; or c. Only the cross-cutting HSS section if the interventions in that section materially contribute to overcoming health systems constraints to improved HIV, tuberculosis and malaria outcomes.” The reality is that some countries such as Ghana never benefit from HSS in their malaria grants.

People have often looked to the World Bank to address systems and infrastructural issues. This has not always happened in such a way as to impact on specific health programs. Now the Bank says its “new strategy is about strengthening health systems in developing countries while complementing the efforts of other organizations contributing billions of dollars to combat diseases such as HIV/AIDS and malaria.” In order to avoid the pitfalls of a single disease focus approach, “the Bank is shifting its focus to not only funding vaccines and medicine but doing so in a way that ensures a health system is capable of delivering vaccines, medicine, and general health care to more people.”

According to its second annual report, PMI is also paying attention to health systems as follows” “The PMI is organized around four operational principles based on lessons learned from more than 50 yearsof U.S. Government efforts in fighting malaria, together with experience gained from implementation of PEPFAR, which began in 2003. The PMI approach involves: •Use of a comprehensive, integrated package of proven prevention and treatment interventions; •Strengthening of health systems and integrated maternal and child health services; •Commitment to strengthen national malaria control programs and to build capacity for country ownership of malaria control efforts; and •Close coordination with international and in-country partners.”

Just as partners are in agreement about the major malaria control interventions for scale up to 2010 and beyond, we also hope they agree and coordinate their efforts to strengthen the health systems that not only will deliver these interventions, but also will hopefully sustain them.

Three years after “about $1.6 million of Global Fund money had been misappropriated or could not be accounted for” the authorities in Uganda may be about to take some action to resolve the case, ” according to the Global Fund Observer (GFO). A whistle blower had informed GFO back in 2005 about the missing and misappropriated money prompting the Global Fund not only to suspend Uganda’s (at the time) 5 grants, but also to create an independent Office of Inspector General. The GF allowed the Uganda grants to resume operation later in 2005 after management reorganization had taken place, but to date the prosecution of the guilty and the return of the money has lagged.

The GFO reported that, “Finally, in April, the Norwegian AIDS Ambassador, who represents Norway and several other European countries on the Global Fund board, wrote to the Global Fund’s Inspector General.” They made it clear that donors would not tolerate further delays in the prosecutions and return of funds. An official visit by the GF made this demand in person last month.

While testimony by 150 people about the case identified multiple ways that funds were spent lavishly or were diverted by the Ugandan authorities, the process also found that the Local Fund Agent (LFA), the supposed independent monitoring watchdog of the GF in each country, was asleep on the job. Such incidents undoubtedly have also led the GF to evaluate the LFA process and recommend improvements that combine both financial as well as technical monitoring in the future.

Donor attention may have led to Parliamentary action in Uganda. The Monitor reported that, “The coordinating agency of the Global Fund funding for HIV/Aids in the country has issued strict disbursement rules, banning politicians from taking part in the running of the funds. Speaking at Parliament on Wednesday, Dr Kihumuro Apuuli, who heads the Uganda Aids Commission, told Public Accounts Committee that under the new stringent guidelines, Global Fund (GF) cash will be given directly to ministries through accounting officers. ‘There is no politician who will touch this money,’ Dr Apuuli said. ‘Any form of [GF] funding will require a suitable work plan approved by the commission,’ he said.”

The Monitor offers a deeper reason for these problems when it reported Uganda’s status among the 20 weakest, most vulnerable states in the world. The Fund for Peace ranks Uganda the 15th most vulnerable of 177 countries in 2007 (see map). The Monitor thinks that one of the major reasons is Factor Number 7, “Criminalization and/or Delegitimization of the State.” Three components of this factor mirror the problems experienced with the Global Fund in Uganda:

• Massive and endemic corruption or profiteering by ruling elites
• Resistance of ruling elites to transparency, accountability and political representation
• Widespread loss of popular confidence in state institutions and processes

Ultimately it is a testament to GFATM processes that more of such incidents of thievery have not occurred.  Ironically in other cases of threats to grant suspension the cause is more often NOT spending the money on time and thus, not achieving results. In either case, accountability is needed. The Monitor again opines that donors not only should demand accountability for their own funds, but also for all public monies.  They fear that ‘creative bookkeeping’ may be used in Uganda to make it appear that the stolen cash has been recovered, while in the process further impoverishing public finances.

The International Federation of Red Cross and Red Crescent Societies (IFRC) has just released its 2008 World Disasters Report. The report observes that, “The AIDS epidemic has been with us for more than a quarter of a century but the statistics never fail to shock. Around 25 million people have died and about 30 million are living with HIV today. Many of these men, women and children are among the world’s most vulnerable people and, although it is too simplistic to say that poverty is a main driver of the epidemic, many people living with HIV are among the poorest on earth – particularly women.”

HIV/AIDS is a major global disaster because, “Even though anti-retroviral treatment is now available, it does not reach the majority of those who need it in developing countries. Nor are medicines for the opportunistic infections associated with AIDS readily available in many places. It is not just a question of funding, which has increased at a considerable rate. In most affected countries, as in many parts of the developing world, health services are overstretched, with poor infrastructure, and are losing the trained workers they desperately need to the rich countries of the West. Development gains that were achieved in the past two decades have in many cases been reversed. Poverty reduction, income generation, food security – all remain on the agenda for the humanitarian world, and not just in places where major emergencies have occurred.”

While the report quotes the World Bank as saying, “HIV/AIDS, malaria, and armed conflict have contributed to these falling life expectancies,” it does not acknowledge how the negative interaction between HIV and malaria make both problems worse. Skinner-Adams and colleagues summarize the problem as follows: “Although the consequences of co-infection with HIV and malaria parasites are not fully understood, available evidence suggests that the infections act synergistically and together result in worse outcomes.”

According to WHO’s Global Malaria Program, “Malaria and HIV are two of the most devastating global health problems of our time. Together they cause more than 4 million deaths a year. The resulting co-infection and interaction between the two diseases have major public health implications.”

• HIV-infected people must be considered particularly vulnerable to malaria;
• Antenatal care needs to address both diseases and their interactions;
• Where both diseases occur, more attention must be given to specific diagnosis for febrile patients.

Clearly we do not want to start a debate about which disease is more disastrous, and one might even make the case that HIV has a more disastrous effect on the health system, but we do want to stress that solutions require an integrated approach.  People with HIV definitely need protection against malaria as one part of the effort to ameliorate this disaster.

Jhpiego and the USAID ACCESS program have developed a “Malaria Resource Package” (MRP) that contains a variety of tools designed to assist policymakers, public health professionals and health managers in implementing programs that will reduce the incidence of malaria in pregnancy and provide effective treatment for pregnant women with malaria. The package includes among other elements training resources, program planning guides, BCC/IEC resources and an annotated bibliography.

The MRP is available online at
http://www.jhpiego.org/resources/pubs/malarialrp/index.htm
in English and French. A Portuguese version will be available soon

Jhpiego is hoping that countries that are planning their PMI MOPs and Global Fund Proposals will take advantage of these resources.

Malaria cases are dropping according to a United Nations press release described in the British Medical Journal. “… the figures show that the fund has delivered 59 million bed nets impregnated with insecticide to families at risk of catching malaria, almost double the number that were issued a year ago. Michel Kazatchkine, the fund’s executive director, said there was now clear evidence that mortality rates from the disease among children younger than 5 years of age had fallen sharply in 10 sub-Saharan countries, and, in Zanzibar, malaria had been almost eradicated as a public health problem.”

Likewise, Destination Sante exclaims that, “Rolling back malaria really is possible ! Between 2005 and 2007, the authorities in Rwanda and Ethiopia succeeded in reducing the number of cases of malaria and deaths from the disease on their territory by 60%. This victory is the result of close coordination with international sponsors.”

• Le Rwanda par exemple, a réduit de 64% le nombre des infections et de 66% les décès chez les enfants de moins de 5 ans. (In less than two years, Rwanda, for example, reduced the number of infections by 64% and deaths among the under-5s by 66%.)
• En Ethiopie voisine, les succès sont tout aussi encourageants : 55% de transmissions en moins, et 60% de morts évitées. (In neighbouring Ethiopia, the story is just as encouraging: 55% fewer transmissions and 60% of deaths avoided.)

The Lancet, where this information was published earlier, asks how these successes happened and what lessons can be learned for scaling up elsewhere. Chambers et al., in The Lancet explain that, “The case of Ethiopia is especially informative, because this is the first time such significant achievements have been recorded over such a large geographical area in sub-Saharan Africa.” They identified four key components of success that made scale-up in three years possible:

1. a catalytic moment,
2. demand for universal coverage,
3. pragmatic donor response, and
4. innovative problem-solving

The authors offer this crucial piece of advice: “Donors must also be willing to assume greater risk by encouraging and funding ambitious programmes while showing increased flexibility in their processes and procedures. And both parties must plan early for the maintenance and eventual elimination phases so that donor support does not flag as malaria deaths are reduced.”

Finally it is important to observe that these claims of progress could not be made without a system of monitoring and evaluation.  Are the interventions reaching the people? Are they actually using the nets and medicines? Are health systems employing the correct diagnostic tools to determine whether cases of malaria are really dropping?  The Global Fund, being performance based, provides tools to answer these questions.  We encourage all countries who are not writing their Round 8 Global Fund proposals to take advantage of these tools and write strong monitoring and evaluation components into their grants.

The National Academy of Sciences reports that, “The Ugandan government recently started spraying insecticides in homes and settlements to combat mosquitoes that spread malaria, the country’s leading cause of death.  A new report from a committee of the Uganda National Academy of Sciences (UNAS) says that as the spraying continues, the government needs to monitor mosquitoes for resistance to insecticides, and manage the spraying program in ways that minimize resistance.  UNAS is a participant in the African Science Academy Development Initiative, a joint effort of several African academies and the U.S. National Academies to advance science-based policy advice in Africa.”

The Committee that met to assess malaria vector resistance to insecticides used for indoor residual spraying in Uganda has looked at the strengths and weaknesses of the proposed “best practices” in IRS with an aim to maximize the effectiveness of DDT and other insecticides as well as identify contextual issues that would have a bearing on successful implementation of the “best practices.” In short the committee is not against IRS, but wants to ensure that it is carried out in the most safe and effective way.

The report of the Committee is available online. The report documents national policy and the fact that the Ministry of Health was authorized to begin IRS using DDT in August 2007 with support from the US President’s Malaria Initiative. Committee recommendations include establishment of sentinel surveillance sites, baseline entomological assessment, use a variety of factors ranging from susceptibility to cost and reliability of supply in selecting insecticides, and plan for long-term implementation, among others.

PMI’s updated Uganda profile states that, “To date, more than 4,000 local personnel have been trained on proper spraying technique. Spraying has covered almost every targeted household in Uganda and benefited more than 1.8 million people.” In addition PMI’s Malaria Operational Plan for Uganda documents that PMI established insecticide resistance monitoring to IRS in Kabale with a training course in 2006 on the use of the bottle bioassay for mosquito insecticide resistance testing. Additional training and capacity building was planned for 2007. As a result of these activities, “The NMCP intends to monitor the level of susceptibility of malaria vectors to the insecticides scheduled for use in 2008, 2010, and 2012,” in selected sentinel sites as well as consider rotating insecticides to slow the development of resistance.

It would appear that the scientific, programmatic and donor communities are poised to deliver a safe and effective IRS intervention in Uganda. We would feel a bit more comfortable knowing whether Uganda is achieving some of the early milestones implied above - deployment and support of trained personnel, establishment of sentinel centers and conduct of baseline, for a start.

Malaria does not always capture the interest of the press, but for the last two days stories have appeared in a wide variety of sources about experiments to modify the DNA of mosquitoes to make them less able to transmit malaria. If eradication is to happen, new tools are needed. Consequently, Time Magazine reports that, “Faced with a losing battle against malaria, scientists are increasingly exploring new avenues that might have seemed far-fetched just a few years ago.”

Some have doubts about the potential of ITNs. An Associated Press story in the Baltimore Sun indicated that while “the United Nations recently announced a campaign to provide bed nets to anyone who needs them by 2010. Some scientists think creating mutant mosquitoes resistant to the disease might work better.”

ABC News quotes Jo Lines of the London School of Tropical Medicine and Hygiene who raises some doubts. “It’s a series of arms races that the parasite has consistently won. Whenever mosquitoes have developed genes resistant to the malaria-causing parasite, the parasite has always found a way around it, Lines said. Quantity might also be a problem. You are going to need to produce billions of these mosquitoes if this is ever going to work.”

The AP also talked with scientists who expressed concerns about the environmental consequences of modifying organisms and who worried about ‘fooling mother nature.’

Clearly this is not a technology that can be implemented over night.  There are numerous species of Anopheles mosquitoes that carry malaria. (see map from Kiszewksi et al.) And then too, we have several Plasmodium species to worry about.  Mosquitoes have different feeding preferences (animals, humans), and although not every mosquito is an efficient malaria vector for human malaria, mosquitoes have been known to change their behavior and feeding preferences.

Interestingly, in areas where the mosquitoes still exist, but the parasite has been eliminated, genetic modification may be a way to get a head start to prevent the reintroduction of malaria. This approach might also be an answer to the continual problem of insecticide resistance.

So far we have no one magic bullet of an intervention to eliminate malaria. Should we now also include mutant mosquitoes in the mix?

To date the Roll Back Malaria Partnership has focused its attention of tackling the scourge of malaria in Africa, but the call has been growing for the Roll Back Malaria Partnership to give more attention to malaria in Asia and Latin America. About 40% of the malaria grants awarded to date from the Global Fund have been outside Africa, so attention is being paid to the need in some quarters. The US President’s Malaria Initiative has focused on 15 countries Africa, in part to achieve impact within focused population and financial limits, but USAID is also active in malaria control in the Mekong Region.

Three articles focusing on Indonesia and Papua New Guinea bring into focus the malaria control needs in parts of Asia. Poespoprodjo and colleagues explain that while, “Plasmodium falciparum infection exerts a considerable burden on pregnant women, but less is known about the adverse consequences of Plasmodium vivax infection.”

After studying over 3000 pregnant women with either falciparum, vivax or co-infection, they suggested that, “Malaria increases the risk of preterm delivery and stillbirth through fever and contribution to severe anemia rather than through parasitemia per se,” regardless of type of infection. They also debunked the myth that vivax infections are benign.

Drug resistance is increasing in both forms of malaria parasites, but as Tjitra and colleagues point out the myth of vivax being benign has led to some complacency. They found severe forms of the disease in both forms, and stressed that, P. vivax “is associated with severe and fatal malaria particularly in young children.”

Genton et al., with research support from both the US and Australian aid agencies, found the P. vivax and mixed infections resulted in severe malaria. They concluded that, “Interventions targeted toward P. falciparum only might be insufficient to eliminate the overall malaria burden, and especially severe disease, in areas where P. falciparum and P. vivax coexist.

In a commentary on the two PLoS articles Rogerson and Carter state that, “With calls for increased efforts to control malaria internationally, it will be important to ensure that P. vivax receives appropriate attention. We still lack reliable estimates of its global burden, and are only now starting to appreciate certain aspects of disease presentation of P. vivax malarial infection. The burden and severity of vivax in different settings requires further study.” They expressed hope in vaccine development but also highlighted the need for “more effective curative treatment and and better relapse prevention” because of the unique lifecycle of vivax.

Ultimately, malaria can never be eradicated without attention to its global spread.

The 6-country study on fake and substandard malaria drugs published earlier this year was a definite warning and wake up call for strengthened and continued pharmaco-vigilance in Africa. Among 210 samples, 35% tested failed dissolution testing or measurement active pharmaceutical ingredient content against internationally acceptable standards.

Kenya is not relying on the results of such studies alone. “Officials from the Pharmacy and Poisons Board, a government regulatory body under the Medical Services Ministry, recently confiscated thousands of counterfeit Artemisinin-based malaria drugs in a shop in Nairobi. The company that manufactured the drugs was ordered to recall the entire batch,” according to IRIN News. Kenya has done its own research, and an officer from the Board told IRIN News that, “Our [government] study was much wider, we went to all eight provinces in Kenya, and took samples from all public, mission [religious] and private hospitals.” They found 16% of drugs to be substandard and feel that their study is more representative of the country.

That said, Board officials were aware that any level of substandard malaria drugs can undermine the confidence of the public. Ineffective customs control, lax enforcement of pharmaceutical regulations and light sentences for those caught help perpetuate the problem.

Hopefully with donor programs including GFATM, PMI and the World Bank Booster Program, antimalarial drugs in the public sector are of high quality. As the Global Fund says, “For any pharmaceutical products to be eligible for purchase with the Global Fund resources, its compliance with quality standards must be assured.”  But in countries where a large portion of the population relies on the informal and private sector for health care, donors must rethink their methods for getting safe and effective medicines to the people.

The Council of Anglican Provinces of Africa (CAPA) has a strategic 5-year plan for integrating its work on HIV/AIDS, TB and Malaria. Some aspects for the rationale for an integrated approach include the following:

• Control of all three diseases is affected by the same overall quality of care issues including infrastructural and human resource needs
• Faith based organizations have the ability to reach communities and individuals impoverished and affected by all three diseases through their health services and parish programs
• Pastoral care does not distinguish people by the diseases they have, but sees them as whole persons

Specifically for the Anglican community, CAPA explained that, “The Church is uniquely positioned with the ability to reach out to communities through her organized network and constituencies. CAPA through her structure is able to reach over 40 million regular and faithful members of the Church in Africa through different gatherings that are routinely conducted on daily, weekly, monthly and yearly basis using her vast human resource (skilled and unskilled Priest and Volunteers) and institutions.”

Other groups have recognized the value of integration. The Global Fund sees its Health System Strengthening component as an integrated way of addressing institutional bottlenecks that threaten control of all three diseases, as does WHO. Some grant supported programs, such as in Swaziland, already aim to strengthen the integration of TB and HIV/AIDS services.

Treatment of people and communities in a holistic way is an important goal, and may even achieve greater efficiencies and strengthen health systems to provide a greater range of quality services, not just support vertical programs.