Part II: The Global Strategy
2. Control: Overcoming Malaria
A. Scale-up for Impact: Achieving Universal Coverage
As illustrated by the limited levels of coverage described in Part I: Malaria Today, it will be a major challenge to achieve universal coverage with even one intervention for all populations at risk. When countries can scale-up a package of preventive and curative interventions together, the resulting benefits will have a dramatic impact on the global malaria burden.Rowe AK and Steketee RW. Predictions of the impact of malaria control efforts on all-cause child mortality in sub-Saharan Africa. American Journal of Tropical Medicine and Hygiene, 2007, 77 (Supplement 6).
Click for source This concept, known as scale-up for impact (SUFI), is one of the biggest opportunities to have a major impact on global mortality and morbidity.
Figure II.4 illustrates the difference in impact of gradual increases in coverage (red lines) and the dramatic impact that results from rapid scale-up (blue lines)
Figure II.4: Intervention coverage scale-up and burden reduction
Source: Based on Steketee R, Lennon A, "Scaling Up for Impact Through Comprehensive Program Improvement", Malaria Control Partnership (MACEPA), June 2007
Rapidly scaling up to universal coverage for populations at risk is critical to achieve the targets of 50% mortality and morbidity reduction by 2010 and a 75% reduction in morbidity and near zero mortality by 2015. The principle of scale-up has been promoted since 2005 by the RBM Partnership. This commitment has been reaffirmed by the UN Secretary-General’s call on World Malaria Day in April 2008 to “put a stop to malaria deaths by ensuring universal coverage by the end of 2010” through the use of vector control and case management tools and strengthening of community-level efforts.UN Secretary-General Ban Ki-moon, video message, World Malaria Day April 2008. The Secretary-General reiterated the UN vision
for universal interventions coverage in order to end malaria deaths.
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After expanded coverage of malaria interventions, principally LLINs (distributed through a combination of approaches, reaching over 60% coverage of populations at risk in both countries)Coverage levels have continued to increase in these countries since the completion of the study.
and ACTs in Ethiopia and Rwanda, results are promising: malaria cases in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children under 5 years; in Ethiopia, cases decreased by 60% and deaths by 51% in the same age groupImpact of long-lasting insecticidal-treated nets (LLINs) and artemisinin-based combination therapies (ACTs) measured using surveillance data, in four African countries. Geneva, World Health Organization Global Malaria Program, 2008. These results are preliminary and further evidence is needed over time to confirm sustainability of successes due to control efforts. This study is based on results in a limited number of health facilities and therefore not necessarily nationally representative.
in the health facilities selected for the study.
Figure II.5: Impact of increased LLIN and ACT distribution in Ethiopia and Rwanda
a) Numbers calculated assuming three year lifespan of LLINs delivered and one year lifespan for ITNs delivered
b) In-patient malaria cases in children <5 years old, January-October 2003-2007, 7 in-patient facilities, Ethiopia
c) In-patient malaria cases in children <5 years old, January-November 2005-2007, 19 in-patient facilities, Rwanda
Source: Intervention data based on World Malaria Report 2008. Geneva, World Health Organization, 2008; Impact data based on Impact of long-lasting insecticidal-treated nets (LLINs) and artemisinin-based combination therapies (ACTs) measured using surveillance data, in four African countries. Geneva, World Health Organization, Global Malaria Program, 2008
Several other studies demonstrate similar results, including those in Eritrea, Madagascar and Zanzibar. In the latter, high coverage with ACTs and insecticide-treated nets resulted in drastic mortality and morbidity reduction.Bhattarai A et al. Impact of Artemisinin-Based Combination Therapy and Insecticide-Treated Nets on Malaria Burden in Zanzibar, PloS
Medicine, 2007, 4:e309.
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Strengthening health systems lays the groundwork to reach universal coverage. While improving health systems is critical to reaching the universal coverage targets, these efforts will have the biggest impact when they are focused on concrete actions related to malaria control. Therefore, we focus on core elements of health systems needed to enable the scale-up of malaria interventions and not a comprehensive review of all health system strengthening activities.
The sections below describe what is needed from key stakeholders and the components of the health systems to scale-up universal coverage and the support these changes may require from the international community. Many of these activities, while begun during scale-up, will need to be continued once scale-up is complete to sustain control.
Key Stakeholders of the Health System
To strengthen health systems, countries will need strong support from political leaders and coordinated efforts from those who work within the health system at the national, district and local levels. Support required from the international community will be essential.
Strong leadership and governance from political leaders. Success at the country level requires strong, sustained political and budgetary commitment to malaria control. High-level officials (head of state, prime minister, ministries of finance and health) need to support the malaria control programs and their health systems to provide the necessary resources (human and financial), help resolve bottlenecks in countries (remove taxes and tariffs, provide free treatment etc.), accelerate procedures (administrative or regulatory procedures) and affirm governmental leadership in planning and coordinating all partners active in the country to reach rapidly the universal coverage targets. Zambia and Ethiopia, which achieved substantial progress in malaria control, are prime examples of strong political support behind malaria control programs. For instance, the Zambian government has supported the establishment and implementation of the 6-year strategy and has taken the lead on coordinating all partners. The Ethiopian government has demonstrated its commitment by establishing joint steering committees at the national and regional levels to strengthen accountability by removing taxes and tariffs on malaria preventive tools and by promoting demand through communication efforts.
Support required. Advocacy efforts targeted to political leaders to raise malaria on the national agenda of endemic countries are required. Strong emphasis should be placed on the need to create an enabling environment for malaria control by removing bottlenecks to scale-up at the national level. See Part IV - Chapter 1: Advocacy for more detail.
Adequate and well-trained health workforce. Human resource capacity is one of the major concerns in most malaria endemic countries. Scale-up corresponds to a substantial increase in the delivery of malaria interventions and will require bold efforts to match human resources with planned activities. The national malaria control program needs to be structured adequately to match needs, and efforts will be conducted to increase the recruitment, motivation and retention strategies of key personnel (e.g. program managers, logistic or monitoring experts, accountants, entomologists, health workers). Emphasis will be put on developing skills through intensive capacity building and training programs at all levels (national, regional and local). See Part IV - Chapter 4: In-Country Planning.
Support required. Countries need technical assistance to develop comprehensive human resource plans. Increased support for capacity building is needed to increase management skills (program or financial management), technical knowledge (e.g. entomology, monitoring and evaluation, procurement and supply chain management) and knowledge of the delivery of interventions (for community-based health workers and other health care providers).
Components of Health Systems that Enable Scale-up
The key components of the health systems to enable scale-up are presented below. More detail is provided on each of these topics and on the role the RBM Partnership will play in coordinating partner activities around them in Part IV: The Role of the RBM Partnership.
Policy and regulations in line with international guidance. National regulatory bodies register products, ensure quality assurance and enforce mechanisms for quality control of interventions. National policy processes establish treatment and prevention guidelines. National authorities ensure that adopted policies are adopted and implemented throughout the country. Ideally all these national decisions are aligned with international recommendations. The adoption of international regulatory decisions could reduce critical time-delays during the scale-up stage.
Support required. New international recommendations need to be developed (e.g. on RDTs) and current international recommendations (such as WHOPES and prequalification of ACTs) need advocacy in countries to avoid delays in the scale-up stage. Policies that reduce the risk associated with resistance should be strongly encouraged. See Part IV - Chapter 4: Policy and Regulatory for more detail.
Detailed and accurate planning. A clear understanding of local needs will form the basis of accurate planning for each district.For instance the main vector control method chosen depends highly on epidemiological conditions and on logistical in-country capabilities. This is best created through a multi-partner, consensus-based effort, involving the public sector, the private sector, civil society, the main donors, technical and implementation support partners, the research community and neighboring countries. To achieve the ambitious 2010 targets for universal coverage, countries will need detailed, district-by-district planning based on district needs assessments. These should be translated into month-by-month plans of who will do what and where. This will lead to a clear understanding of the major bottlenecks, resource needs and delivery capacities of the country.
Support required. Countries need technical assistance support in developing their health plans and proposal (especially for applications to major donors such as the Global Fund or World Bank). They need to be supported in capacity strengthening to run such processes. The development and dissemination of best-practices of successful scale-up programs will be essential to inform planning. See Part IV - Chapter 5: In-country Planning for more detail.
Timely access to resources. Available resources should be matched to planned activities. Once resource gaps are identified, strong plans should help to build the case for additional funding, and resource mobilization activities should be conducted to fill these gaps. For scale-up, reprogramming of existing grants and accelerating country resources disbursement is a key opportunity: countries and fund recipients need to take advantage of the flexibility offered by major donors,Funding and procurement challenges facing rapid scale-up of LLINs to reach the 2010 targets. World Bank, Presentation at RBM 14th Board Meeting, May 2008.
Click for source such as the Global Fund (frontloading of product purchases, acceleration of phase 2 negotiations and disbursements etc.) or the World Bank (acceleration of commitments for Booster Phase 2, leverage of amendments to previous projects etc.). Mechanisms such as direct payment of grants to procurement agents or manufacturers can be considered to accelerate financing processes.
Support required. An international resource mobilization strategy must be in place to raise funds for all in-country activities and international support required to reach universal coverage. To meet rapidly the scale-up targets, disbursement mechanisms of international donors need to be accelerated. Capacity strengthening at the country level to respond to Technical Review Panels and to resolve disbursement bottlenecks is essential to ensure the availability of resources. Equally important is the political will and accountability within country governments and ministries of finance to ensure the release of funds to malaria control programs. Countries need assistance in completing high-quality procurement and supply management and M&E plans. Besides, innovative financing and procurement mechanisms could be established for ACTs and LLINs. See Part IV - Chapter 6: Financing for more detail.
Effective distribution systems. Expanding distribution to reach universal coverage with interventions requires managing large amounts of products for which adequate forecasting, quality control, procurement and supply chain management systems need to be in place. Strengthening the public health system procurement and supply chain is essential. Quick resolution of implementation bottlenecks and capacity building in procurement and supply chain management are critical to ensure that the short term goals can be achieved while countries manage the long term expansion of these distribution systems.
Support required. Countries need technical assistance to resolve implementation bottlenecks impeding scale-up, especially linked to procurement and supply chain management (PSM) issues. For instance, they need to be supported in using available PSM capabilities of the public sector, the private sector or NGOs and in strengthening mechanisms to improve logistics. To strengthen forecasting capabilities, comprehensive needs assessments are being carried out in sub-Saharan African countries. In the longer term, a process will be established to help identify the best approaches to forecasting for all interventions. Countries may also need to be supported for their tendering systems, contracting out, building and financing supply chains. Updated procurement guidelines will also be prepared. See Part IV - Chapter 7: Procurement and Supply Chain Management for more detail.
Strong communication and behavior change methodologies. Service delivery is not only about delivering products; it is also about ensuring they are used properly. Communication and Behavior Change Methodologies are essential to ensure the appropriate use of interventions. These programs need to be designed with the active participation of both service providers and intervention-users and will aim for improving health-seeking and care-providing behaviors. At the individual level, they will develop strong messages to improve recognition of malaria symptoms and risk groups as well as correct use of interventions (use of LLINs, acceptance of IRS, correct diagnosis to demonstrate parasites before treatment, full compliance with ACTs etc.). They will be designed to create opportunities for people to discuss malaria issues, especially at the community level. Whatever communication channel is chosen, messages need to be tailored to address specific regional and community needs and to involve local leaders (political, religious and traditional) to increase identification and participation of the population.
Support required. To increase utilization rates of interventions, countries need help developing and disseminating consensus-based guidelines and best practices for approaches to Information, Education and Communication / Behavior Change Communication (IEC / BCC) methodologies during the scale-up stage. See Part IV - Chapter 8: Communication and Behavior Change Methodologies for more detail.
Monitoring and Evaluating (M&E). M&E information systems measure the coverage, utilization and health impacts of interventions, with a view to making informed adjustments in future planning. Every country should have a costed malaria M&E plan addressing national and local need. Increasing staff dedicated to M&E and building capacity are essential to track the indicators that are essential for the scale-up stage, especially levels of coverage and utilization of the interventions (including equity in access), which can be measured through regular surveys (e.g. the Multiple Indicator Cluster Survey, the Demographic and Health Surveys and the Malaria Indicator Survey) and through strengthened routine health information systems. For example, additional information will be needed to monitor new approaches such as the AMFm and the prices of ACTs. Once information is collected and analyzed, countries will share it with all major stakeholders to enable global tracking of progress.
Support required. Countries in the scale-up stage need assistance in developing their national M&E plans. They need support as they increase M&E dedicated staff and roll out frequent population-based surveys. Support is also needed to integrate efforts with wider health sector M&E to enable efficiency. International tracking of progress in malaria control needs to be organized and coordinated internationally. See Part IV - Chapter 9: Monitoring and Evaluation for more detail.
Effective Delivery Strategies Required to Reach Universal Coverage
Most countries are still at low levels of coverage. To reach targets of universal coverage, a substantial amount of interventions need to be funded and delivered globally:
- Globally, an estimated 730 million LLINs are needed to protect populations at risk for whom nets are appropriate. Approximately 50 to 100 million nets already distributed (mostly in sub-Saharan Africa) will remain effective for the next two years. Approximately 315 to 340 million new LLINs are needed annually in 2009 and 2010. For Africa alone, 250 – 300 new LLINs are needed to reach universal coverage by 2010.
- Globally, ~172 million households need to be covered with IRS every year.
- ~25 million pregnant women annually are expected to require IPTp. This estimate is only for high transmission areas in sub-Saharan African countries where IPTp is currently recommended .
- The global annual need for diagnostics (by microscopy or RDTs) based on fever cases is ~1.5 billion.
- Target treatment coverage, assuming diagnosis with microscopy or RDTs, is estimated at ~247 million treatments: 228 million treatments of ACTs and 19 million treatments of chloroquine and primaquine for treatment of P. vivax. Without diagnosis, the number of treatments needed would be much higher due to over treatment of fever cases as malaria.
Figure II.6: Global scale-up in interventions from 2006 to 2010
a) Estimate based on number of nets that should be in use. Because of 3-year lifespan, fewer new nets are needed each year than the number in use
b) Today, actual use is likely not matching confirmed malaria cases
Source: Need based on GMAP costing model; actual based on analysis of World Malaria Report 2008. Geneva, World Health Organization, 2008 and Roll Back Malaria Commodities database
Global production capacities need to be increased substantially to be able to reach global scale-up targets. The production issue needs to be addressed for all interventions and could be even more acute for ACTs due to withdrawal of artemisinin producers from the market in 2007-2008 after the substantial decrease of artemisinin prices. Alternative artemisinin produced through bio-technology from yeast culture will not become available before 2010. Global support and effort is needed to address the issue of adequate supplies.
To achieve universal coverage, countries must go beyond the procurement and financing of interventions to ensure that the products can reach every person at risk. Countries can scale-up interventions to reach the largest populations at risk based on best practices demonstrated by other countries.
Gender and socio-economic status should not determine access to interventions. Against the background of universal coverage for all populations at risk, dedicated strategies will need to be put in place to make sure that the most vulnerable and isolated populations are covered by the interventions, especially those in the poorest economic quintiles, populations living in remote areas and women.
For several interventions, using the skills of the private sector proves to be efficient in scaling up interventions. Commercial networks can be used for the delivery of some products (e.g. LLINs or treatments) provided that adequate information and training are provided, enabling access into even remote areas where health facilities might not be accessible. Private companies or consortia could also be contracted out for conducting programs such as IRS. Private sector competencies to foster demand generation or provide capacity building within countries can enable successful malaria control.
Vector control scale-up. Both long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) can dramatically reduce malaria morbidity and mortality. They both provide community protection at high levels of utilization (>80%).
- LLIN scale-up. In the early years of mosquito net distribution, nets were primarily promoted through social marketing largely through the private sector and subsidized distribution approaches as a personal protection tool for vulnerable groups.Teklehaimanot A et al. Malaria Control needs mass distribution of insecticidal bednets. The Lancet, vol. 369, issue 9580, pp.
Click for source Since 2003, a global consensus has been building towards the scaled up distribution of LLINs at no cost to the end-users. WHO endorses this approach and recommends that all targeted populations are 100% covered with LLINs to exploit the community protective effect of insecticide-treated nets (ITNs) that is observed at high coverage levels. For this purpose, distribution to all populations at risk (not only vulnerable groups) with free LLINs is generally considered to be the most rapid and cost effective way to reach universal coverage, and is the approach used successfully in Ethiopia (see Box II.2) and other countries.
Several factors contributed to the success of the Ethiopian LLIN distribution campaign, including the use of a third-party procurement agent, donor flexibility in use of funds which allowed rapid disbursement, and the utilization of multiple delivery methods including enhanced outreach, health facilities and the strong network of 30,000 health extension workers to reach the population.
Using the competencies of the private sector and outsourcing the mass campaigns could also be an effective way to reach the coverage targets, while helping national authorities to focus on their core activities, such as strengthening of routine health services or monitoring and evaluation.
Distribution systems for LLINs should not be viewed as competitive or fighting for “market share”, but as complementary approaches to achieving a single goal: a comprehensive LLIN distribution strategy,Lengeler C et al. Program diversity is key to the success of insecticide-treated bednets. The Lancet, 2007.
Click for source including both campaign and routine distribution mechanisms supported by both the public and private sectors, to create a “net culture” in which the use of LLINs becomes a societal norm.Scaling-up Insecticide-treated netting programs in Africa, RBM-WIN and Insecticide-treated mosquito nets: a WHO position statement. Geneva, World Health Organization, 2006.
Click for source Mass campaigns, often integrated with other health interventions such as immunization and vitamin A supplementation are good for initiating high coverage levels rapidly, and routine systems — e.g. distribution during antenatal or infant immunization services — are very efficient for maintaining coverage between campaigns and ensuring that vulnerable populations (such as pregnant women and children under 5) are reached.
Box II.2: Success of LLIN mass distribution in EthiopiaMinistry of Health of Ethiopia, personal communication, 2008; Chambers, Gupta, Ghebreyesus. Responding to the challenge to end malaria deaths in Africa. The Lancet, 2008; Factsheet Malaria in Ethiopia. New York, UNICEF, 2007.
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Between 2005 and 2007, one of the most ambitious LLIN delivery programs ever attempted was implemented in Ethiopia, where nearly 20 million nets were distributed across the country (two nets for each of the 10 million households targeted).
After its worst malaria epidemic in 2003, Ethiopia made a bold proposal to international donors in 2005: to deliver 20 million LLINs in 3 years. Ethiopia made a strong case for the budget required (US$ 160 million, 3 times the previous national malaria budget). Donors responded positively, with over US$ 200 million coming from the Global Fund, World Bank, DFID, the Carter Center and others. Ethiopia took advantage of flexibility built into both the Global Fund and World Bank processes to frontload funding. Rather than disbursing its grants over 5 years, the country drew down on the pledged funds to finance its ambitious distribution program in 1–2 years.
Ethiopia used UNICEF as a third-party procurement agent to increase procurement speed and reduce transaction costs. Funds flowed directly from the Global Fund to UNICEF, avoiding the need to disburse funds from the Global Fund to the government and then on to a procurement agent. At the same time, significant investments were made by the government and partners to build in-country procurement capacity for the post scale-up stage.
A combination of distribution channels were used to achieve a high level of coverage, especially the Enhanced Outreach Program and the network of 30,000 Health Extension Workers in communities (see Box II.6 later in this chapter), as well as distribution from health facilities. UNICEF has also been supporting the development and implementation of a community based social communication program (toolkits, training of health workers and community volunteers) to ensure high utilization rates of the nets delivered. Ethiopia is developing communication programs to improve usage and developing strategies to provide continued access to additional LLINs to maintain 100% coverage, as presented in Figure II.7 below:
Figure II.7: Targeted distribution channels in Ethiopia
Analysis conducted by the WHO-GMP show that the combined delivery of LLINs and ACTs in Ethiopia was very successful: the weighted average percentage decline for children under 5 in in-patient facilities visited in Ethiopia was 60% for cases and 51% for deaths between 2005 and 2007Impact of long-lasting insecticidal-treated nets (LLINs) and artemisinin-based combination therapies (ACTs) measured using surveillance data, in four African countries. Geneva, World Health Organization Global Malaria Program, 2008.
Click for source with coverage of LLINs of approximately 60% at the time of the study. While great successes have been achieved, opportunities still exist to improve utilization. Additionally, monitoring over time will determine the sustainability of the initial gains.
- IRS scale-up. IRS has proved to be an efficient vector control measure for reducing malaria burden, as was the case with the Lubombo Spatial Development Initiative (LSDI) between Swaziland, Mozambique and South Africa, and in countries targeted by the President’s Malaria Initiative (10 African countries in 2007-2008 and 15 targeted in 2008 and beyond). In the LSDI initiative, intensive IRS campaigns markedly reduced P. falciparum malaria prevalence and between 1999 and 2005, the number of confirmed malaria cases was reduced by 95% in Swaziland and by 96% and 78% in two adjacent provinces of South Africa.Sharp et al. Seven years of regional malaria control collaboration – Mozambique, South Africa and Swaziland. American Journal of
Tropical Medicine and Hygiene, 76(1), pp. 42–47, 2007.
Click for source IRS is also widely used in Southeast Asia and contributed largely to overall burden reduction during the malaria Eradication campaign from 1950-1970 in countries such as IndiaIncidence reduction from 75 million cases to 100,000. Sharma VP. The Malaria Eradication Experience of the Indian Sub-Continent. Presented at the WHO Informal Consultation on Malaria Control and Elimination, 2008.
or Sri Lanka.Child mortality was reduced by 50% between 1946 and 1956. Newman P. Malaria Eradication and Population Growth, with Special Reference to Ceylon and British Guiana. Bureau of Public Health Economics, University of Michigan, School of Public Health, Research Series No. 10, 1965.
Click for source IRS can be scaled up provided that the logistical structures are in place (equipment, well-trained staff), local epidemiology and transmission patterns are well known, and capacity for regular supervision and quality monitoring exists. Even countries which previously did not have this capacity, such as Mozambique pre-LSDI, can implement programs with the appropriate support and commitment. Generally, IRS programs were clearly separated from other programs in the national control strategy and this autonomy was a success factor. National malaria control programs such as in Botswana, Namibia or South Africa have their own teams of spraying operators composed of government-employed public health workers. In other examples, spraying campaigns were outsourced to private sector consortiums or companies. Success of IRS scale-up campaigns is very much linked to the ability to deploy well-trained spraying teams, to manage the logistics of the insecticides (safe storage, handling etc.) and to be able to monitor and map sprayed structures.
- Scale-up of other vector control interventions. Other more targeted vector control interventions, such as larviciding or environmental management, can be used where they are proved to be efficient and cost-effective. One of the key elements of success for these interventions is the participation of local communities, as was the case in IndiaLindsay et al. Environmental Management for Malaria Control in the East Asia and Pacific (EAP) Region. HNP discussion paper, Washington, D.C., World Bank, 2004.
Click for source or in a regional program in Mexico and Central AmericaRegional Program of Action and Demonstration of Sustainable Alternatives to DDT for Malaria Vector Control in Mexico and Central America (DDT-GEF).
Click for source where local communities worked to reduce breeding sites.
Diagnostics scale-up. In parallel to increasing access to treatments, parasitological diagnosis (with microscopy or, where not possible, with Rapid Diagnostic Tests) should be made available to populations at risk when appropriateGuidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.
Click for source (see Box II.3). The use of parasitological diagnosis is still limited overall and needs to be expanded to inform treatment choice and make more rational use of anti-malarial treatments. Microscopy and RDTs are both part of laboratory systems. They need their own supervision and quality control. Their use will necessitate strong algorithms to interpret the results and allow appropriate decisions to be made on both malarial and non-malarial febrile illness, and appropriate supply and logistics to support these decisions.
- Microscopy scale-up: increasing the use of quality-assured microscopy requires strengthening capabilities in health facilities. This includes providing microscopes along with strong training programs on microscopy, quality monitoring systems and increasing attendance at equipped facilities. In Indonesia, the use of microscopy has recently expanded to a wide network of local health facilities.
- Rapid Diagnostic Test (RDT) scale-up: RDTs can be used in public health facilities that do not have access to microscopy services. They are also well suited for community case management and for private sector distribution. As with microscopy, assurance of quality is essential and concerns have been raised over the quality of many RDTs. An initiative to assess quality assurance of RDTs is being carried out by WHO - Western Pacific Regional Office, WHO - the Special Programme for Research and Training in Tropical Diseases (TDR) and Foundation for Innovative New Diagnostics (FIND) and should inform policies in the near-term future. Proper storage and transport are critical for RDTs and need to be closely monitored since the tests can be damaged by high temperatures and freezing. Therefore, countries that want to scale-up RDTs need to have in place cold chains for transport and storage (i.e. avoiding any exposure to temperatures outside manufacturer’s recommendations), quality control testing procedures, and clear treatment algorithms to clarify actions following the results of the test.
Box II.3: Parasite-based Diagnostics for Malaria
Parasite-based diagnosis, based on light microscopy or RDTs, is recommended by WHO for management of all malaria cases, with the exception of children under five in high transmission settings (where evidence of benefit over cost is unclear) and certain specific situations such as epidemics proven to be malaria in low-resource situations. Providing the febrile patient with a correct diagnosis will reduce delays in the correct management of non-malarial febrile illness, and may improve adherence to anti-malarial therapy, thus reducing morbidity and allowing better targeting of resources.
However, the introduction and maintenance of diagnosis through the use of microscopy and RDTs requires considerable investment in training, supervision, logistics and education of health workers and the community. This must be included in program budgets, together with provision for non-malarial febrile illness, as most fevers will not be due to malaria. While this is essential, access to effective anti-malarial medicines must not be delayed, and in some cases may need to be deployed on the basis of clinical diagnosis while capacity for parasite-based diagnosis is rapidly scaled up in such areas.
Anti-malarial treatment scale-up. Universal coverage with anti-malarial treatments (such as ACTs) is a daunting challenge because three-quarters of all anti-malarial treatments are currently obtained outside the public health system,AMFm Technical Design. RBM Resources Working Group, 2007.
Click for source many of the most affected populations live in remote areas with limited access to public facilities, and many cannot afford ACTs at current prices, especially in the private sector. A combination of several strategies can be used to expand treatment coverage:
- Make better use of existing professional resources. Improving the availability and quality of interventions delivered in existing health facilities is the first step to increase effective coverage. This includes improving forecasting and logistical management at all levels, including the local level, to avoid stock outs or expiration of drugs and other supplies, offering training programs for care providers, and using program management to improve the quality of interventions delivered.Scaling Up Home Based Management of Malaria. Geneva, World Health Organization, 2004.
Click for source To avoid overburdening the current health systems, new tasks could be integrated within existing responsibilities, but outsourcing certain activities could also be considered, such as in Bangladesh where the delivery of several interventions was successfully outsourced to NGOs. Every health facility should have adequate drug storage facilities with proper record-keeping procedures.
- Expand the reach of the health system into the community. This can be done by providing access to treatment through community providers, supplying medicines and diagnostics to community workers, and implementing community education and communication programs to ensure proper use of drugs. In Ethiopia, malaria control interventions are integrated with the Health Extension Program, which is staffed by more than 30,000 trained, salaried, community-based Health Extension Workers (HEW) and is coordinated by the Ministry of Health. See Box II.6: Health Services Extension Program and Health Extension Workers in Ethiopia. Ghana has put in place a Community-based Health Planning and Services (CHPS) program based on ~3,000 Community Health Officers who are assisted by community volunteers in delivering a broad package of health services, including the provision of insecticide-treated nets, IPTp and case management for uncomplicated malaria.Community Based Health Planning and Services (CHPS), The operational policy. Ghana Health Services, 2005.
This program has been implemented in 104 of the 110 districts in the country.Nyonator et al. The Ghana Community based health planning and services initiative for scaling up service delivery innovation, Health policy and planning, 2005.
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Increase geographical access through the private sector. Ensuring convenient, affordable high-quality anti-malarial treatments in the private sector, and providing information on how to use them are essential steps. Strategies include training and monitoring private sector drug sellers (market sellers and shop-keepers) in parasite-based diagnosis (such as RDTs) and appropriate treatment. Efficient examples of private sector involvement include franchising or accrediting private pharmacies to provide high quality management, contracting out malaria management to private practitioners, and delivering subsidized, affordable ACTs through retail networks are examples that could increase access. Ideally, the public sector will provide overall stewardship to private providers, including training for diagnosis, drug handling, dispensing, advice giving and referral of severe cases, and monitoring of the management of both malarial and non-malarial febrile illness. Careful planning is necessary to ensure that standard management policies are followed, and that providers have appropriate incentives to maintain good targeting of, and adherence to, therapy.
- Increase financial access and pool health risks: Increasing the financial access is important so that all people at risk of malaria can receive appropriate prevention and treatment regardless of their socioeconomic status. There are several ways to increase financial access. One is to reduce the cost of treatments upstream before they enter countries, as is the case with the innovative financing mechanisms currently being considered (such as the Affordable Medicines Facility - malaria which has been endorsed by the RBM Board). Another is to ensure free delivery of treatment and other health services associated with treatment such as consultation and diagnostic tests. Experience in countries such as Mali shows that making health services free for children under five can have substantially higher impact than delivery of free malaria treatment alone.Médecins sans Frontières, personal communication, 2008.
However, this will require sustained financing to cover the costs of providing treatment. See Part IV – Chapter 6: Financing, especially Box IV.2: Affordable Medicines Facility – malaria. The challenge for many malaria endemic countries is to protect individuals from high out-of pocket payments for malaria and other diseases. In addition to decreasing the costs of interventions and services, countries can institute mechanisms to pool health risks and provide financial protection to the population. Four main health insurance mechanisms are used to pool health risks, promote prepayment, raise revenues, and purchase services. These are state-funded systems through ministries of health or national health services, social health insurance, voluntary or private health insurance or community-based health insurance.Health Financing Revisited, A Practioner's Guide. Washington, D.C., World Bank, 2006.
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- Design, implement and evaluate interventions to reach the poorest and underserved populations: Countries need to identify strategies to expand uptake by those who are not currently accessing any malaria treatment. In general the poorer groups are less likely to have treatment and have lower quality treatment than those who are better off. There is insufficient evidence on how best to reach the poorest and underserved groups. The evidence that does exist shows that a variety of approaches can work, depending on how well they are designed and implemented.Reaching the Poor with Health, Nutrition and Population services, What works, what doesn’t and why? World Bank, 2005.
Click for source However, there is very little evidence specifically on how best to reach the poorest with malaria treatment as most studies have not looked at who is benefiting from treatment.Second interim report on progress against outstanding AMFm implementation challenges. RBM AMFm Taskforce, August 2008.
Click for source This should be assessed in future studies to see which strategies are most cost effective.
Malaria in Pregnancy (MIP) interventions scale-upA strategic framework for malaria prevention and control during pregnancy in the African region. WHO-AFRO, 2004.
Click for source including IPTp. Since at least 70% of pregnant women in Africa seek antenatal care at least once during pregnancy, antenatal care services provide a platform for the delivery of interventions for the prevention and control of malaria during pregnancy (IPTp, LLINs, effective case management and other interventions for ensuring healthy pregnancy outcomes and maternal and child survival such as iron supplementation against anemia). Malaria in Pregnancy programs work best with strong cooperation between national malaria control programs and reproductive health programs. Distribution channels through antenatal care (ANC) clinics are already in place in many countries; today, several challenges impede scale-up of MIP interventions among which are the availability of MIP interventions in ANC clinics as well as the regular and timely attendance clinics throughout pregnancy.
- Minimize missed opportunities. Despite high ANC utilization, IPTp coverage remains low in countries with stable malaria transmission, reflecting missed opportunities for reaching ANC attendees with effective interventions for malaria control. A significant proportion of pregnant women attend ANC clinics only once in their pregnancy, whereas WHO recommends four visits, three visits after quickening each time with IPTp delivery. Zambia has effectively used antenatal clinics to deliver IPTp, reaching 61% of pregnant women with two doses; in Zambia, 94% of pregnant women attend ANC clinics once and 71% attend them at least 4 times. In several countries of sub-Saharan Africa, IPTp coverage is substantially lower than ANC coverage, clearly demonstrating the extent of missed opportunities in the delivery of IPTp and LLINs through antenatal care services. Scaling up IPTp and other MIP interventions will require concerted efforts to minimize missed opportunities and ensure that all women attending ANC clinics in high transmission settings receive the necessary interventions for malaria prevention and control.
- Challenges to MIP scale-up. Main challenges to MIP interventions include persistent stock-out of drugs for IPTp, inadequately trained personnel, poor supervision and tools for effective monitoring and evaluation of program effectiveness. Success in this regard requires strong collaboration between national malaria control and reproductive health programs and concrete actions to strengthen the health system to support the delivery of these interventions. Specific health systems strengthening aspects include improved availability of drugs, supplies and commodities, joint planning and capacity building of health workers, improved capacity of laboratories with sensitivity for comprehensive care of the pregnant woman and her unborn baby and strong supervision, monitoring and evaluation tools. Of critical importance is the need for communication and behavior change methodologies and support for engaging communities in the prevention and control of malaria during pregnancy. Such engagement ensures that the community develops an appreciation of the need for skilled care during pregnancy and that women receive all the interventions they need in a timely manner with community support.
Scale-up of interventions in humanitarian crises. Some countries that need to scale-up malaria control interventions are experiencing humanitarian crises situations where the appropriate interventions and the delivery strategies need to be adapted. Countries experiencing chronic crises (e.g. Sudan and the Democratic Republic of Congo) require tailored technical support. See Part IV - Chapter 10: Humanitarian Crises.
Rapid and Coordinated Global Support Needed to Reach the 2010 Targets
The Partnership’s main objective is to reduce malaria mortality and morbidity by 50% compared to 2000 by the end of 2010. To support countries in successfully achieving these targets, all partners (donors, politicians, local officials, NGOs, etc.) will need to work in coordination and align themselves behind a single strategy, as outlined in the Organization of Economic Cooperation and Development (OECD) Paris Declaration on Aid Effectiveness.Paris Declaration on Aid Effectiveness: Ownership, harmonization, alignment, results and mutual accountability. Paris, OECD, 2005.
Click for source If some countries do not meet the 2010 deadline, they will continue to strive for the achievement of the universal coverage scale-up targets.
In addition to strategies to strengthen health systems and increase coverage of interventions, global support is needed to speed up financing, planning and distribution if the RBM Partnership is to be successful by 2010. In particular, three main steps are needed.
Conduct robust country planning. A roadmap analyzing quarter-by-quarterQuarterly as an example; other time frames could be more appropriate depending on the objective. delivery needs and funding availability will be developed at the country level based on a country Needs Assessments. These plans will be developed with local RBM partners including governments, NGOs, multilateral and bilateral partners, civil society, NGOs, academia and others.
Accelerate and expand financing. An RBM Harmonized Working Group (HWG) analysis of country needs versus donor funding timelines indicates that funding will not be available for earliest distribution windows, even if the major donors (such as the Global Fund and the World Bank) accelerate their disbursements. New national and international funding sources are needed for the near term to cover this gap.Update from the Harmonization Working Group presented at the RBM 14th Board Meeting, May 2008.
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Speed up procurement and distribution. There are several ways to speed up procurement and distribution of interventions. For instance, the use of third-party procurement agents for LLINs proves to be 2-3 times faster than country-led procurement mechanismsFunding and procurement challenges facing rapid scale-up of Long-lasting insecticidal nets to reach the 2010 targets. World Bank, Presentation at RBM 14th Board Meeting, May 2008.
Click for source and will be a key success factor in achieving the 2010 targets for LLINs. See Figure II.8 for preliminary estimates of delivery needs aggregated for sub-Saharan Africa.A roadmap for reaching the LLIN target as part of a comprehensive package of malaria control interventions, RBM, June 2008.
Figure II.8: Projected LLIN deliveries in sub-Saharan Africa to reach universal coverage
Source: Achieving the Roll Back Malaria Partnership 2010 targets and fulfilling the United Nations SG's Call to Action - A Roadmap for reaching the LLIN target as part of a comprehensive package of malaria control interventions; RBM Harmonization Working Group
As interventions are rolled out, increased focus by countries and partners on communication, behavior change, monitoring and evaluation activities becomes all the more essential to ensure interventions are reaching those who need them and are being used appropriately.