Progress with Roll Back Malaria by output
This section illustrates some of the major achievements made by WHO to Roll Back Malaria during the preparatory phase, organized by each of the six major outputs. In addition to what is defined below, WHO has catalyzed action in other organizations and within countries -- the global movement to Roll Back Malaria has begun.
1. Communication of the RBM concept, strategy, approach and progress, and advocacy to mobilize political commitment and resources
Approach:
WHO's role in the partnership is to provide strategic support to the global movement to roll back malaria. The RBM Cabinet Project is working to break down barriers and change the way things are done within WHO. To ensure that it receives contributions from the across the Organization, Roll Back Malaria is managed as a cross-"cluster" and multi-sectoral project. All levels of WHO are unified in the voice of policy and programme debates and are working to an agreed strategy and mode of operation, with headquarters and regions operating in a coherent manner.
Progress:
The first six months of the preparatory phase were spent developing the underlying concepts and principles of RBM through discussions with WHO headquarters, regional and country staff, personnel from other partners, legislators and officials from malaria-affected countries, researchers and other interested parties. A preliminary strategic workplan and logical framework has been prepared and circulated for comment. In the upcoming six months, this document will be further detailed and a WHO-wide composite workplan on malaria will be developed.
The six elements of a strategy to Roll Back Malaria also received widespread support. These build on the WHO global malaria control strategy, endorsed in Amsterdam in 1992, with its emphasis on (1) early detection of malaria outbreaks; (2) rapid diagnosis and treatment of those who are ill; (3) multiple and cost-effective means of preventing infection; and (4) focused research to develop and test new products. It includes two additional elements: (5) well coordinated action through stronger capacity to health sector and community-level effort; and (6) a dynamic global movement supported by a coalition of partners working toward a common approach. These elements need to be taken forward within an enabling environment of strong in-country institutions and cross-sectoral collaboration.
RBM has also begun a number of studies to examine policy issues including gender, poverty, and economics. Intensive discussions have begun and will continue on the marriage of the movement to roll back malaria to existing cross-sectoral modalities such as Integrated Management of Childhood Illness (IMCI), Safe Motherhood and Essential Drugs and Medicines. The World Bank has been very active in these policy areas: hosting a recent conference on malaria and infrastructure issues; completing desk review on economic impact of malaria in Africa; providing support for further work on cost-effectiveness.
As part of the advocacy message development process, a prototype RBM logo was created and tested during the MIM meeting. In June 1999, a graphic arts agency was contracted to refine this logo. The proposed logo was then was tested further and partners were invited to contribute to this process. Many alternative designs were suggested, but, ultimately, it was agreed to adopt the round logo with the hand rolling the earth as seen on the cover page of this report. The logo can be adjusted within different countries provided that the theme is maintained. It will be evaluated in one year's time, and will evolve if necessary.
For the past six months, RBM has been working with partners to develop an advocacy strategy. A prototype advocacy brochure was prepared in March 1999 in English, French and Portuguese. This prototype was then tested through focus groups, surveys conducted at the MIM meeting in Durban, South Africa, and further consultations with partners. In September 1999, the brochure was revised to reflect the suggestions of partners, and large quantities of the revised brochure were printed and distributed. Other promotional materials such as folders and fact sheets have also been developed.
Milestones:
| 1. A global movement to roll back malaria initiated by the Director-General | May 1998 |
| 2. WHO Cabinet Project to roll back malaria established | July 1998 |
| 3. Cabinet Project Manager appointed | Jan 1999 |
| 4. WHO-wide strategy for rolling back malaria formulated and approved/endorsed throughout WHO | Feb - Jul 1999 |
| 5. First advocacy material for Roll Back Malaria developed and tested | Mar 1999 |
| 6. Visit by Director-General to African countries for Roll Back Malaria | Apr 1999 |
| 7. Global health leadership fellows from all regions appointed to RBM Cabinet Project | Apr 1999 |
| 8. Presentation at ECOSOC | Jul 1999 |
| 9. Major Media Event surrounding bednets | Oct 1999 |
Current Status:
RBM is currently finalizing the first WHO-wide workplan on malaria, encompassing all malaria-related activities to be carried out by all levels of the Organization in 2000-01. This plan includes milestones, resource requirements, and key partners involved per product.
2. National authorities, development partners and other groups supported as they establish country-level partnerships in support of action to RBM
Approach:
The RBM movement is about building and strengthening the capacity of national health services to help communities tackle all illnesses that undermine their well being. The principles that guide the partnership can be summarized as follows:
Progress:
The Roll Back Malaria movement was officially launched jointly by the UNDP, UNICEF, World Bank and WHO in October 1998. The Global Partnership was then consolidated at the 1st Global Partners' Meeting held in December 1998 and further entrenched at the 2nd Global Partners' meeting in Harare in June 1999. Bilateral discussions with a number of partners have been ongoing. The RBM Global Partnership will further develop its own set of structural, governance and operational strategies in the upcoming months. This includes further work to be completed over the next six months to guide and promote the effective use of partnerships with the private sector. In the meantime, informal agreements have been made with the World Bank, UNDP, and UNICEF. the World Bank, USAID and CDC have agreed to second staff to the Cabinet Project. A preliminary division of work has been agreed: the World Bank will take the lead on tax and tariff, infrastructure and financing issues and country programmes in a number of designated countries; UNICEF has taken the lead on the technical support network for insecticide treated nets, joint consultations on IMCI and RBM at the country level and RBM in the Mekong region.
During the last months of 1998 and the first months of 1999, the World Bank, UNICEF, UNDP and WHO conducted rapid assessments in six African countries (Kenya, Uganda, Tanzania, Mozambique, Ethiopia and Malawi) in consultations with national government officials. These missions were to respond to requests for support, to acquire an overview of country-specific and cross-country needs and opportunities and to explore collaborative roles for each agency at field level. These missions emphasized (i) the need to institutionalize operational procedures for working in partnership, (ii) the opportunities to address malaria control through non-health sectors, and (iii) the commonality of the issue of how to "prioritize" a leading health concern within the context of health sector reform and sector-wide approaches. In addition, the assessments also unearthed a great demand for opportunities to collect lessons and share experiences across countries.
Following the launch, a series of regional meetings took place throughout Asia, Africa and Central Europe to build consensus around the nature of Roll Back Malaria, the form it will take at country, regional and global levels, and the ownership of the new initiative by different stakeholders. The first took place in the Mekong region early in March, building on a pre-existing initiative by six countries in the region to work together more effectively with the combined support of WHO and UNCEF working as an alliance. Vietnam, Thailand and China indicated how they could share their successful experiences with Laos, Cambodia and, most importantly, Burma. The approach to be adopted would supplement efforts to reduce the threat of HIV and encourage integrated disease surveillance in the region. Countries agreed to prepare more detailed plans and identify resource needs during September 1999.
In addition, four of these meetings were held in Central, Southern, East, and West Africa. These meetings reviewed the achievements of and lessons learned from the Accelerated Malaria Control Program. The principles, objectives, and features of Roll Back Malaria Africa were reviewed; options for process and methodology for implementation of RBM in Africa were discussed; country-specific statements of intent for introducing and implementing RBM in Africa were developed. Participation was wide including high level country delegations (Director of Medical Services, Director of Planning in the Ministry of Health, Malaria Programme Manager, representative of Ministry of Finance), WHO, World Bank, UNICEF, UNDP, UNESCO, African Development Bank, Organization of African Unity, SADC, USAID, DFID, JICA, OCCGE, Italian Co-operation, Rotary International, French Co-operation, OCEAC, Fundacao Calouste Gulbenkian of Portugal, AMREF, Services Medical Catholique, PSI, private manufacturers and suppliers of bednets and insecticides. The six elements of the RBM strategy (described above) and the concepts and principles which will form the basis of the work of the partnership were debated and agreed. Country delegations to the upcoming consensus building meeting for the Amazon region will include representatives from indigenous people's organizations.
The first took place in the Mekong region early in March, building on a pre-existing initiative by six countries in the region to work together more effectively with the combined support of WHO and UNCEF working as an alliance. Vietnam, Thailand and China indicated how they could share their successful experiences with Laos, Cambodia and, most importantly, Burma. The approach to be adopted would supplement efforts to reduce the threat of HIV and encourage integrated disease surveillance in the region. Countries agreed to prepare more detailed plans and identify resource needs during September 1999.
Country delegates have also worked with representatives of partner organizations to launch their national RBM partnership (see attachment 1 for a summary of country level action). WHO -- through the RBM project and in consultation with other partners -- has recently distributed a Note for Partners, which provides guidance for the implementation of RBM action at the country level within the context of health sector development. This Note for Partners also covers the operation and maintenance of country-level partnerships and the means for ensuring unified WHO technical support to country action. It suggests approaches to supporting community-level action through societal movements to roll back malaria.
In July 1999, a meeting of several key partners in the African Region (WHO, UNICEF, USAID, DFID, World Bank, African Development Bank) identified eleven African countries to "spotlight" the partnership. These countries were selected as they present opportunities to learn how the partnership can best function in a variety of situations (including complex emergencies and cross-border strategies). Special attention will be paid within these countries to reduce the fragmentation of assistance from the multi- and bi-lateral agencies involved. The lessons learned from the new joint working methods within these eleven countries would then be extended to other countries around the world. Technical assistance with initiating country-level action to roll back malaria will not be confined to these eleven "spotlight" countries, but will continue to be provided by HQ and AFRO in response to needs.
Milestones:
| 1. Global Partnership launched by WHO, World Bank, UNICEF, UNDP | Oct 1998 |
| 2. Letters from the Director-General to African Heads of State soliciting recruitment into the Roll Back Malaria initiative | Oct 1998 |
| 3. 1st Global Partners' Meeting in Geneva consolidated the Global Partnership to Roll Back Malaria | Dec 1998 |
| 4. Rapid consultations conducted by WHO, UNICEF, UNDP and World Bank joint teams to assess the situation and identify key issues in six African countries | Nov 98 - Mar 99 |
| 5. Alliance between WHO and UNICEF formed to roll back malaria in the Mekong sub-region including meeting of partners to launch RBM | Mar 1999 |
| 6 . Sub-regional consensus building meetings: | |
| Mekong (Ho-Chi-Minh City) | Mar 1999 |
| West Africa (Abidjan) | Mar 1999 |
| East Africa (Nairobi) | Apr 1999 |
| Southern Africa (Maputo) | Apr 1999 |
| Central Africa (Yaounde) | Apr 1999 |
| South Asia (New Delhi) | May 1999 |
| Central Asia | |
| Amazona (Lima) | Oct 1999 |
| Middle East (Cairo) | Sept 1999 |
| 7. Country Inception Meetings | ongoing |
| 8. Representative of USAID, World Bank and CDC seconded to work with the Cabinet Project | Mar 1999 |
| 9. WHO-wide RBM retreat | May 1999 |
| 10 G7 Summit discussions and commitment | Jun 1999 |
| 11. 2nd Global Partners' Meeting in Harare | Jul 1999 |
| 12 . Meeting of key partners in Africa to identify eleven countries to "spotlight" the partnership | Jul 1999 |
Current Status:
The preparatory activities for rolling back malaria in African countries are steadily gaining momentum. Many heads of state form malaria-affected countries in Africa have expressed, in writing, the commitment of their countries to the global movement to roll back malaria. Following the consensus meetings, a number of countries have developed plans for the inception of RBM in their countries with the support of the regional office of WHO. Key intentions expressed by countries include:
During this period, countries have also continued with the implementation of priority malaria control actions. The WHO has actively supported both the on-going activities and the activities for the inception of Roll Back Malaria, financially and through technical assistance.
Attachment 1 outlines the current status each endemic country, summarizing their RBM activities to date.
3. Technical guidance for action to Roll Back Malaria ensured, through help to develop in-country capacity (for operational research and evidence-based decision making) and provision of consistent, good quality advice as appropriate
Approach:
WHO, via its RBM Cabinet Project, has a specific function as Secretariat to the RBM Global Partnership. In this role, the Cabinet Project takes a lead in strategy development, consensus building and catalyzing action. WHO as a whole has a critical role, as one of the Global Partners, to support country action according to its comparative advantages.
In this context, WHO as an institution is generally expected to establish technical standards and provide technical support. The WHO Roll Back Malaria Cabinet Project has a role in ensuring that this support is more effective and responsive and takes account of the new concepts, approaches and strategies associated with the RBM movement. It can draw on the comparative advantages of other Global partners to help make that happen.
WHO's activities in relation to this output are undertaken by departments in different HQ clusters and by similar departments in regional offices after working together as teams with regular electronic, and intermittent face-to-face meetings. The RBM Cabinet Project offers an overarching framework, strategic inputs and supplementary resources that are designed to enhance the effectiveness of these technical activities.
Effective WHO support to country action, entails:
Progress:
Capacity - The lack of human capacity and adequate training within countries has repeatedly been identified as a major constraint in moving forward efforts to roll back malaria. To this end, WHO's Communicable Diseases cluster (CDS), with the support of the World Bank, has been involved in the development and production of a number of malaria related training materials targeted at most categories of health workers and IEC materials for use in schools and communities. Areas of expertise covered include: diagnosis, case management, vector control, community/school-based, programme management and epidemiology. In addition, a number of training courses have been developed with the support of the World Bank:
| International Course on Malaria and Other Tropical Diseases and Planning their Control | AFR |
| ACTMalaria, Management of Malaria Field Operations | SEAR/WPR |
| International Training Course on Malaria and Planning its Control | EMR |
| Regional Training Course on Comprehensive Vector Control | SEAR |
| International Course on Malaria and Planning its Control | EUR |
The Roll Back Malaria Cabinet Project, country and regional offices are working together to assess and ensure adequate capacity and skills development at country and regional level. The RBM Cabinet project is collaborating with DFID and USAID on a joint evaluation examining the human capacity needs within WHO to support effective country action. This includes defining the new functions and the technical, managerial and administrative skills required (finalized October 1999). In addition the RBM Cabinet Project and has agreed with DFID to undertaken an RBM institutional analysis to ensure the optimum functioning of WHO and the RBM Global Partnership (to begin end 1999).
Guidelines – All WHO departments continue to play a central role in developing and disseminating guidelines based upon best available evidence. The guidelines are reviewed and modified based on findings of operational and other research and adapted as necessary to reflect in country technical, institutional and political realities (please see research section following).
Coordinated Technical Support - Technical support continues to be provided through existing WHO technical support mechanisms in country, regional and HQ. In addition, issue-based technical support areas have been identified. Systems are being developed to provide coordinated technical support from across the partnership in a manner which helps strengthen, national capacity to assess and address difficult programme and policy issues. In some cases coordinated networks of competent personal are being established which cut across institutional and country boundaries. Many of these networks will be based, and draw on personal in the country and region concerned.
Progress has been made in a number of the technical areas identified below. For each of these areas, details on evolution and approach are available.
a. Situation Analysis
Situation analysis instruments – with particular reference to Africa – were developed during 1998 by a multidisciplinary group of experts supported by the work of WHO HQ and regional offices. The instruments focus on analyzing the malaria situation and the health sector's response, particularly at community level. They are flexible enough to build on existing assessments and require the minimum of extensive new data collection and analysis. In 1999, the instruments were pre-tested at national, district, and community levels in four African countries and made available to endemic countries in Africa in March 1999. The methodology was adapted for South Asia in April 1999. The methodology is now being adapted and used by many African countries as part of their national process of RBM strategy development.
b. Mapping of Malaria Burden and Access to Health Care
New techniques for detailed mapping of malaria risk using mathematical models for malaria transmission, climate information and satellite imagery have been developed recently. Combined with geographical data on the location of populations and health services, these new techniques allow the mapping of malaria risk stratification, populations at risk and their access to health services, and facilitate estimation of malaria disease burden. Spatiotemporal models of malaria epidemics have been developed to improve the timely prediction of malaria epidemics using climate data. The RBM project worked with groups in the Communicable Diseases cluster to review the availability of detailed malaria risk maps, encourage collaboration, and make proposals to improve usefulness and accessibility for countries while working with national authorities on their use. A network has been created to collaborate with several Universities, UNICEF (through the "HealthMap" project) – particularly in the Mekong region, and the MARA Malaria Atlas for Africa venture based in South Africa. With RBM support, MARA has printed provisional malaria risk maps for each endemic country in Africa and it is providing these to the ministries of health concerned. Over the next few years, the network will: improve the stratification and mapping of malaria risk in Africa as relevant to control; facilitate the mapping of communities and their access to health care resources; provide spatial database and mapping support to other RBM networks; contribute to improved estimation of the burden of malaria and help strengthen the capacity for operational application of malaria mapping at the national level.
c. Improving Health Systems Response
Action to roll back malaria will be sustained if it is incorporated within actions to develop the health sector. Technical support in this area draws on experiences of the WHO Health Systems department. It calls for a fusion of the concepts of communicable disease control and health system reform, with a focus on outcomes. Targeted operational work is being undertaken on the interface between IMCI and RBM by individual HQ and regional WHO departments, and by UNICEF. Country level financing issues will be assessed by the World Bank and DfID. Special efforts are being undertaken to establish how RBM can work within decentralized health systems, and to explore synergy between approaches to RBM, tackle HIV, reduce TB, and address dengue and leishmaniasis.
d. Malaria Surveillance and Epidemic Response
A technical support network was established in November 1998 with a number of institutions and agencies to be based in WHO CDS. It was formed to develop methodologies and support endemic prone countries in 2 complementary areas: i) forecasting and prevention, and ii) early detection and control of malaria epidemics. The network links surveillance information from countries and regional surveillance systems and establishes the means of routine and rapid analysis of this information in order for it to be useful for forecasting and early detection of epidemics.
e. Complex Emergencies
A technical support network to roll back malaria in complex emergencies has been formally established by the WHO Department of Emergency and Humanitarian Action. This network consists of experts from WHO, UNHCR, UNICEF, CDC, Malaria Consortium, MSF and Merlin. The network was developed to address a number of issues arising in complex emergency situations including: inadequate technical knowledge of malaria among operational agencies, lack of information on drug resistance, delays in access to supplies, multiple organizations proving health care with poor co-ordination, gaps in research and a lack of data on the burden of malaria in these situations.
RBM, through this network, will improve co-ordination between national/local authorities, UN agencies and NGOs and ensure activities involve existing local health systems. The network will monitor malaria burden by implementing integrated disease surveillance systems and will support operational research projects. Currently, the network is targeting sixteen countries, of which twelve are in Africa. A strategy for malaria control in complex emergencies is being developed through hands-on experience in South Sudan. Case studies have been undertaken in eight countries and epidemiological profiles of seven countries have been developed. Operational research priorities have been identified. In addition, a meeting of involved NGOs and donors took place in late September. The workplan of activities in countries in complex emergency situations was further developed at another meeting of the Network.
f. Reducing Transmission and Vector Control
Insecticide Treated Materials - In October 1998, a technical support network on insecticide treated nets (ITNs) was established within CDS with UNICEF taking the lead as manager. Several partners are collaborating and have refined the Terms of Reference.
The WHO RBM Cabinet project is working closely with the African Regional Office to establish baseline data on the susceptibility of the major vectors in the African Region to a number of insecticides. This data will be compiled by investigators from six countries (Burkina Faso, Cameroon, Cote d' Ivoire, Kenya, Malawi and Senegal).
The effect of nets on malaria transmission, morbidity and overall mortality is now well established. However, several questions remain in relation to commercialization and proper use of ITNs, and addressing these areas will facilitate the wide scale use of ITNs in malarious areas, especially in Africa. Remaining operational research needs are being assessed e.g. marketing and distribution issues, proper use and re-treatment of nets, the latter being one of the central issues. A vector group, within the CDS cluster, is currently investigating whether nets can be treated in such a way that the insecticide will be resistant to washings and be effective for much longer (as long as the life of the net itself -- four to five years). Initial trials have been carried out and, on the basis of these, WHO has started to collaborate with textile companies to produce similar long lasting nets. In addition, a new type of permanent net has recently been produced and field trials will soon be launched. Other types of permanent nets are expected to be available in the course of the next two years for very large-scale trials with a supportive operational research component.
Vector Control -The vector control group in CDS hosts the WHO Pesticide Evaluation Scheme (WHOPES), this being the only international programme which promotes and co-ordinates the testing and evaluation of pesticides proposed for public health use. In 1999 it undertook the evaluation of a large number of products and chemical compounds in co-operation with 17 institutions. The evaluation of other compounds for the impregnation of bednets against malaria vectors will be finalized by the end of this year. A WHOPES database has been developed and a trial edition has been released to WHO regional offices and selected institutions for content review, user friendliness and design evaluation. WHOPES organized a meeting on guideline specifications for bacterial larvicides for public health use which was held in Geneva this year and has started preparations for the 2nd meeting of the Global Collaboration for Pesticides for Public Health (GCDPP), which is scheduled to be held in Geneva, from 6-7 April 2000. It has also initiated the production of two documents referring to the recent international decision on the production and use of DDT, as well as a manual on indoor residual spraying, and a review document on insecticides for the impregnation of bednets against malaria vectors. In close collaboration with the WHO regional offices, WHOPES has expanded its services on the quality control of pesticides to Member Countries. Presently there are 3 designated Collaborating Centres for such activities in Argentina, Belgium and Pakistan. It is expected that a Centre will also be designated for quality control of pesticides in the AFRO region, in the near future.
g. Home Management of Malaria
A technical support network on improving quality of care at home was established with the Special Programme on Research and Training in Tropical Diseases (TDR) in January 1999 at a meeting held in Nairobi, Kenya. A plan of action of the network was developed and consensus reached on the structure and management. A core group of twenty members from the larger network has been formed to identify priorities from the action plan for inter-country and country level activities. It was proposed that the secretariat of the network be established in the WHO African Regional Office. A process was put in place to recruit a social scientist to strengthen the RBM Team in AFRO and be responsible for the management of the secretariat of the Network. Consultations are currently ongoing to develop a strategy for strengthening community-based interventions in the Region. The priority activities identified for the next two years are:
1) strengthen the division's capacity through the recruitment of a Social Scientist and Data Manager, 2) develop a database on individuals and institutions involved in community-based interventions, 3) regular meetings of the Core group at 6 month intervals, the first to be held in November 4) advocacy and mobilization at all levels to strengthen sustainable community-based interventions aimed at improving quality of care at home, 5) develop a communication strategy, 6) improved contact of health care personnel and families through capacity building.
h. Advocacy
A "Rapid Response" email network has been established to quickly inform partners of malaria-related news headlines in their region. Over 7,000 media outlets are monitored through this network for all media coverage of malaria, and articles are subsequently forwarded to partners in the region concerned. Nearly 500 prospective partners have been added to this virtual network.
i. Improved Case Management
Drug Resistance - A network on antimalarial resistance and drug policies is set up, based in the WHO Africa Regional office in Harare with the involvement of other WHO departments. The network has been working with 88 sentinel sites in 34 countries and has received reports from 13 countries on sensitivity (this is a marked increase in sentinel sites and collaborating countries from the previous year). The sensitivity results have lead to national meetings in Zimbabwe, Eritrea, Tanzania and Mozambique to discuss findings and their policy implications. It has resulted in decisions to update antimalarial drug policies in Eritrea. Quality assessments of the data have been carried out in the Gambia and Nigeria. The economic implications have also been discussed with the WHO health economics unit in AFRO and is resulting in operational research. The regional network will be supported in four sub-regional divisions commencing with the southern African Network in November 1999.
Milestones:
| 1 Identification of areas in which technical support is needed | Jul - Sept 1998 |
2 Review mechanisms initiated, and preliminary planning of technical support networks undertaken
|
Sept 98 – Jan 99 |
| 3 Revision of areas and mechanisms in the light of strategy development, regional consensus building meetings and country needs | Jan - Aug 1999 |
| Progress in this area was slower than anticipated because of extreme shortage of funding until February 1999, and the need to prioritize country-level inception work. | |
4. Applied research to develop new, or modify existing, interventions to RBM, supported and new products (for diagnosis, treatment and/or prevention) developed
Approach:
Special international research and development mechanisms need to be established and existing ones supported, for the development of new and better tools for malaria control. RBM will serve as a link between the public and private sectors to respond to the urgent need to accelerate antimalarial drug development. In addition, greater investment and collaborative arrangements will also accelerate malaria vaccine development.
Progress:
The Roll Back Malaria initiative focuses on the more effective implementation of existing tools for reducing the malaria burden and strategic investment in both the refinement of these tools, and the development of new interventions and products. Indeed, had it not been for the successful efforts to develop interventions and products over recent years, the RBM initiative would have little new to offer. The co-sponsored Special Programme for Research and Training on Tropical Diseases (TDR) has led these efforts.
Plans for rolling back malaria have, from the start, envisaged a continuing iterative process a) to define priorities in intervention and product development, and research capacity strengthening, b) to work with the world's scientific community - through a range of partnerships and initiatives - to pursue these priorities as effectively as possible c) to draw on the results of ongoing basic and strategic research, and d) to review progress, identify gaps and seek ways to fill them.
The partnership is committed to the building of relevant capacity within malaria-affected countries and regions. It will also support initiatives designed to raise funds for strategic research and product development relevant to the longer-term roll back malaria goal (e.g. to help develop effective transmission-blocking vaccines).
While several individual companies are making contributions in the field of tropical medicine, it is clear that profit-making pharmaceutical companies stand to gain much more financially through the development of medicines that target the most developed countries. To counteract this and to act as an incentive for the development of malaria medicines, the Medicines for Malaria Venture (MMV) was established. It is intended that MMV, as an autonomous not-for-profit enterprise, will serve as the link between the public and private sectors. MMV will operate using public funds to accelerate the development of effective new antimalarial treatments. Key interested parties met in late July 1999 to plan the future of MMV, including governance and strategic issues. WHO will retain a position on the Board of Directors.
TDR and RBM cosponsored, with USAID, an Informal Consultation on "Malaria Diagnostics at the Turn of the Century" in Geneva in October 1999. The meeting was being held in response to the urgent need to determine the appropriate region-specific role for alternative malaria diagnostic methods. Specifically, the objectives of the meeting were to:
Increased drug resistant falciparum as well as the increasing ineffectiveness of chloroquine and sulfadoxine/pyrimethamine are leading to policy discussions. It is held that combining drugs with different modes of action frequently results in increased efficacy. In particular, experience with artesunate and mefloquine on the Thai/Burmese border has resulted in sustained, high treatment success rates and a reduction in malaria transmission. The Special Programme on Tropical Disease Research (TDR) and RBM have therefore undertaken a study on multi-drug combinations. Both short term and longer-term community-based trials are on-going, focusing on 11 studies in 9 countries in Africa, and combining 3 drug combinations: artesunate combined with chloroquine, amodiaquine or Fansidar depending on local resistance patterns. These studies are planned to be completed by end of the year after which all data will be analyzed using meta-analysis. It is planned to extend the studies to South America and Asia in late 1999/early 2000.
In October 1998, a meeting of experts on access to and quality of antimalarials concluded that a study on antimalarial quality is a priority. This study, coordinated by the Health Technologies and Pharmaceuticals cluster will provide the evidence-base required for relevant intervention and advocacy. Country teams comprising drug quality control officers, malaria control managers, and drug supply managers have now been formed in Gabon, Ghana, Kenya, Mali, Mozambique, Sudan, Tanzania and Zimbabwe. A study protocol has been agreed with the Regional Directors of AFRO and EMRO and a briefing meeting for team leaders will be held in Accra, Ghana in October 1999. The study will be underway immediately after the meeting and a report is expected by the end of the year. In addition, the meeting will solidify a network of experts and begin the discussions to develop a strategy and plan of action to guide technical support to countries for improving access to essential drugs, specifically antimalarials.
WHO is collaborating with the German Pharma Health Fund to assess the suitability of a rapid quality screening method to be used by drug regulatory authorities to carry out on-the-spot quality checks reliable enough to justify quarantine of doubtful consignments until more confirmatory laboratory analysis can be carried out.
An upcoming meeting is intended to provide malaria control and public health workers with clear guidelines for current use of diagnostics, to be used as a springboard to launch additional research critical to understanding the proper role of dipstick assays, and to stimulate the deployment of appropriate technologies to speed malaria control.Milestones:
| 1 Medicines for Malaria Venture (MMV) established and supported | Oct 1998 |
| 2 Investigations on the economic implications of malaria | Nov 1998 |
| 3 Discussions initiated with the Special Programme for Research and Training in Tropical Diseases and other interested parties regarding strategic support to research and development of malaria vaccines | Mar 1999 |
| 4 Arrangements initiated for negotiations on public sector financing and low-cost production of malaria diagnostics for Roll Back Malaria | Mar 1999 |
5. Intensifying outcomes of RBM action through social movements for health: development of medium term strategy
Approach:
As mentioned above, one of the key principles of Roll Back Malaria is that country and community priorities drive actions and that the interest of the people, particularly those marginalized, are at the center of the movement. To ensure sustainability, Roll Back Malaria is a social movement part of broader societal action for health and human development.
Progress:
WHO has been collaborating with UNICEF in identifying and documenting effective strategies used to mobilize a dynamic community response to malaria. These documented "success stories" will then be used to catalyze others. RBM is considering social mobilization in a slightly unique way: rather than a bottom-up versus a top-down paradigm, RBM will be facilitating horizontal exchanges between communities with shared characteristics. This strategy has been discussed extensively with colleagues from UNICEF regional offices in Africa and Asia. Regional forums for the communications officers from WHO, UNICEF and other key partners, along with their national counterparts, are being planned. These forums will present the opportunity to share and learn from other's experiences in developing a community communications and social mobilization strategy. It is hoped that, through these forums and open lines of communication, RBM will be able to identify and highlight numerous examples of effective community actions.
WHO is currently developing and testing a field guide entitled Communications for Social Change. This guide will outline practical steps towards mobilizing political will, engaging new partnerships outside of health, catalyzing community participation to create movements for health. The guide will address communicable diseases with a specific emphasis on malaria and tuberculosis.
6. National authorities are enabled to track progress, monitor actions to RBM – and evaluate their impact
Approach:
One of the key roles WHO plays in the partnership is to ensure that all aspects of progress of RBM are monitored and to provide global accountability for RBM. As the Roll Back Malaria movement represents a new way of working in the field of public health, it is vital that the successes and failures are monitored and analyzed both quantitatively and qualitatively. This requires a mechanism for ensuring information ,on all actions and aspects of the movement to roll back malaria, is shared with partners, both at global and country-level.
Progress:
A cross-cluster group on monitoring has been created within WHO. The group has developed a consensus proposal for a monitoring framework that identifies the critical areas for monitoring the impact and outcomes of RBM. These critical areas relate directly to the objectives of RBM and include: (i) the impact on malaria burden, (ii) improvements in malaria prevention and treatment and (iii) related health sector development. For consistency between countries and regions it is hoped that all will use this framework to design their own monitoring system (with 5-10 intervention-oriented indicators varying according to local malaria epidemiology and actual strategy for rolling back malaria).
The framework for the approach and key indicators to be used in monitoring RBM is being discussed with other partners and updated on the basis of their comments. The framework is still provisional and will be modified when concrete country strategies are articulated. Work on technical specifications of the monitoring methodology has begun, and UNDP has agreed to fund a joint TDR/RBM proposal for research on methods for community-based monitoring. A start has also been made with the development and implementation of a tracking system of RBM action at country level.
MMD Multimedia Development of Switzerland, partner of Broadvision, Inc. has been contracted to develop a web-enable information system. The system will allows web content to be targeted dynamically to different users, so that each user will see information that is of direct interest to him/her. At some point in the future, it will also be possible to link the system to external databases for information. In order to ensure that the system meets the requirements of future users and RBM partners, a series of workshops have been held and a virtual user committee, with representatives from endemic countries and major partners, has been created to provide feedback on design issues and user needs. The first version of the system is expected to be operational before the end of 1999.