TURNING RESOURCES INTO RESULTS ANNUAL REPORT 2003 MALARIA UNIT

Transcription

1 M A L A R I A C O N T R O L I N T H E W H O A F R I C A N R E G I O N TURNING RESOURCES INTO RESULTS ANNUAL REPORT 2003 MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES REGIONAL OFFICE FOR AFRICA WORLD HEALTH ORGANIZATION

2 M A L A R I A C O N T R O L I N T H E W H O A F R I C A N R E G I O N TURNING RESOURCES INTO RESULTS ANNUAL REPORT 2003 MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES REGIONAL OFFICE FOR AFRICA WORLD HEALTH ORGANIZATION

3 World Health Organization, 2004 The designations and presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. This document is not a formal publication of the World Health Organization, and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. Photographs: World Health Organization Design and Print: SP Litho (Pvt.) Ltd.

4 Contents Foreword v Acronyms and Brand Names vii Executive Summary ix Introduction Preventive Interventions Promoting Access to Effective Treatment Community-Based Interventions Epidemics Preparedness and Response Capacity Development and Support to National Health Systems Monitoring and Evaluation Operational Research Economics of Malaria Partnerships Development Program Management Issues Associated with Implementation of the 2003 Work Plans West and Central Africa East and Great Lakes and Southern Africa Regional Level Conclusion MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES iii

5 List of Figures and Tables Figures Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: The malaria algorithms are an easy-to-use tool for case management using the IMCI approach Current treatment policies for uncomplicated malaria in the African Region (31 Dec 2003) Sub-regional technical support networks for monitoring antimalarial treatment Availability of 1st and 2nd line antimalarial drugs in various health facilities of Debub and Gash Barka zones of Eritrea, November Percentage of suspected malaria cases that received CQ+SP on the day of the survey in Debub and Gash Barka health facilities, November Figure 6: Global Fund support to fight malaria in the African Region Figure 7: Status of malaria-related databases at country level as of December Figure 8: Sample menus of the composite database in Access Figure 9: AFRO malaria epidemiological blocs Tables Table 1: Table 2: Availability and use of ITNs in selected districts of The Gambia (2002) before and after implementation of NICs Status of the promotion and/or the implementation of the IPTp policy in Table 3: Studies on antimalarial efficacy tests involving ACTs in Burundi.. 10 Table 4: Levels of appropriateness of fever treatment in selected districts in Uganda Table 5: Areas of coordination/collaboration with other programs MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS iv

6 Foreword Children are the flowers of our fight, the main reason for our struggle and the future of our people. AMÍLCAR CABRAL Malaria is still a complex public health problem in sub-saharan Africa, causing 300 million to 500 million episodes of acute illness per year. While the disease affects the lives of nearly everyone across the continent, children under the age of five years and pregnant women are the most vulnerable groups. Furthermore, the disease contributes to the entrapment of disadvantaged communities in a vicious cycle of poverty. The most daunting challenge faced by national malaria control programs over the past three decades is the significant increase in parasite resistance to commonly used, safe and affordable antimalarial drugs. This poses a serious threat to effective efforts to achieve significant malaria-related mortality and morbidity reduction. Efforts to make effective drugs more available and more affordable to at-risk groups are hampered by the limited availability and the high costs of the drugs. Coverage of at-risk groups with preventive interventions such as insecticide treated nets (ITNs) and intermittent preventive treatment (IPTp) for pregnant women is still very low. However, a favorable environment for funding malaria control activities now exists. There is a unique opportunity for governments of endemic countries and their national and international partners to increase programmatic coverage of cost-effective interventions to control malaria in the African Region. During 2003, and in line with the Regional Strategy for malaria control, the Regional Office strengthened, in various ways, the existing capacity of malaria prevention and control programs in several countries. The aim of this Annual Report is to share information with countries and partners on progress made at country level towards malaria control. It spreads a message of hope and confidence on the strengths of Africa to significantly slow down the current trend of malaria morbidity and mortality in the Region. Provision of technical support to countries for the adoption of appropriate antimalarial drug policies received priority as did development of strategies for increasing access to malaria control interventions at all levels of national health systems, particularly at community level. Also among the priorities were epidemic detection and response, capacity development for planning, management, implementation, monitoring and evaluation, operational research, partnership development and resource mobilization, advocacy and communication for behavioural changes. We strongly believe that broad partnerships involving all interested stakeholders and focused action will turn available resources into results. We also believe that malaria can be controlled in the African Region. Dr Magda Robalo Correia e Silva Malaria Regional Advisor Division of Prevention and Control of Communicable Diseases MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES v

7 Acknowledgements The achievements highlighted in this report would not have been possible without the support of all our partners, whose financial contribution was turned into results as described in the various sections of the report. We wish to thank DFID, USAID, CIDA, and the World Bank for having remained the major financial partners of the Unit. We are also grateful for the various forms of support that were provided by MoHs, WRs, and NMCP management and technical teams. Our gratitude also goes to ICP team leaders and staff and NPOs/IPOs for the wonderful technical work they do everyday in the subregions and countries where they are stationed. Finally, we wish to thank all the members of professional and general service staffs of the Division of Prevention and Control of Communicable Diseases and other Departments in AFRO for their hard work and dedication, and for their commitment to malaria control in the African Region.

8 Acronyms and Brand Names ACT AFRO AIDS ANC AQ ASU CBIs CIDA CSR/IDSR DFID DHS EPR EPI GFATM GMP HIV HMIS HMM HOMAPAK HQ ICIPE ICP IDSR IEC IMCI IPO IPR IPTp IRS ITN Artemisinin-based Combination Therapy Regional Office for Africa/World Health Organization Acquired Immune Deficiency Syndrome Antenatal Care Amodiaquine Artesunate Community-Based Interventions Canadian International Development Agency Communicable Disease Surveillance and Response/ Integrated Disease Surveillance and Response Department for International Development Demographic and Health Survey Epidemic Preparedness and Response Expanded Program on Immunization Global Fund to fight AIDS, TB and Malaria Gates Malaria Partnership Human Immunodeficiency Virus Health Management Information System Home Management of Malaria Brand name of a pre-packaged antimalarial drug World Health Organization Headquarters International Center for Insect Physiology and Ecology Intercountry Programs Integrated Disease Surveillance and Response Information, Education and Communication Integrated Management of Childhood Illness International Program Officer Intellectual Property Right Intermittent Preventive Treatment Indoor Residual Spraying Insecticide Treated Net (Bed Net) MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES vii

9 KidCare IVM MAL-AFRO MDGs M&E MIPESA MoH MPS NGO NIC NMCP NPO PaluStop POA PSI RAOPAG RBM REAPING SP SWAPs TB TBAs THPs UNICEF USAID WRs WCO WHO WHO/AFRO Brand name of an antimalarial drug approved by the Federal MoH of Nigeria Integrated Vector Management Malaria Unit at the Regional Office for Africa United Nations Millennium Development Goals Monitoring and Evaluation Malaria in Pregnancy Coalition for East and Southern Africa Ministry of Health Making Pregnancy Safer Program Non-Governmental Organization Mosquito Net Impregnation Campaign National Malaria Control Program National Program Officer Brand name of an antimalarial drug approved by the MoH of Madagascar Plan of Action Population Services International Réseau d Afrique de l Ouest Africain pour la Prévention et la Lutte contre le Paludisme pendant la Grossesse Roll Back Malaria Roll Back Malaria Essential Actions, Products, Investments and Gaps Sulphadoxine-Pyrimethamine Sector Wide Approaches Tuberculosis Traditional Birth Attendants Traditional Health Practitioners United Nations Children s Fund United States Agency for International Development WHO Representatives World Health Organization Country Office World Health Organization Regional Office for Africa of the World Health Organization MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS viii

10 Executive Summary During 2003, the Malaria Control Unit of WHO/AFRO set priorities that included the provision of technical support to countries for adoption of appropriate antimalarial drug policies and the development of strategies for increasing the coverage of malaria control interventions at all levels of the health system, particularly at the community level. Priorities also included strengthening epidemic detection and response, program management, monitoring and evaluation systems, operational research, partnership building, advocacy and resource mobilization. In collaboration with the Vector Biology and Control Unit, the Malaria Unit supported seven countries in preparing national action plans for scaling up insecticide treated nets (ITN) interventions. In the selected districts of these countries, utilization of insecticide treated nets increased from around 5% to more than 90%. The proportion of children under-five years of age and pregnant women sleeping under ITNs increased from around 10% to more than 80%. In addition, countries in southern Africa (Angola, Zambia and Zimbabwe) received support in planning, organization and timely implementation of indoor residual spraying (IRS) of insecticides for malaria control. At present, intermittent preventive treatment (IPTp) in two doses of sulphadoxinepyrimethamine (SP) has been shown to reduce significantly the prevalence of anemia and placental malaria infections during pregnancy. In 2003, the Unit supported several countries (DRC, Gabon, Mozambique, São Tomé and Príncipe, and Senegal) to adopt and/or implement IPTp. Five countries (Cameroon, Ghana, Madagascar, Nigeria, and Sierra Leone) were supported to build national consensus on IPTp strategy. The Unit also supported establishment of a Malaria in Pregnancy Network in West Africa and the functioning of the East and Southern Africa Coalition (RAOPAG and MIPESA, respectively). The year also witnessed three countries implementing artemisinin-based combination therapy for treatment of malaria. Burundi and the island of Zanzibar implemented amodiaquine plus artesunate treatment policy, and Zambia phased in artemetherlumefantrine treatment in seven districts. During the past 12 months, with the support of the Regional Office, four countries (Mozambique, Gabon, São Tomé and Príncipe, and Senegal) adopted combination treatment for uncomplicated malaria. In the area of case management, 14 countries were supported to improve capacity of health workers for malaria case management and supervision. Three of these countries also adapted new treatment guidelines. In five countries, algorithms for case management were field tested. Factors that constrain efforts to scale up prompt access to appropriate malaria treatment include limited availability and affordability of efficacious drugs (e.g., artemisinin-based combination therapy - ACTs) and the lack of a tool to estimate MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES ix

11 accurately drug needs for malaria treatment. The focus for 2004 will be to support countries to accelerate decision-making processes for treatment policy review, to develop tools for estimating and forecasting needs for ACTs at country level, and to explore possibilities for establishing a global drug facility for ACTs. Community-based interventions (CBIs) are crucial for attaining the Abuja targets by increasing coverage of prompt and effective treatment and the use of ITNs. In collaboration with the Integrated Management of Childhood Illness (IMCI) strategy, various countries received technical support to complete development of strategic and operational plans for scaling up CBIs. An assessment of the impact of CBIs in various countries has shown that greater community participation in malaria control activities translates into more households using ITNs and lower malaria-related morbidity and mortality. Scaling up home management of malaria (HMM) in 2003 was confined to a few project areas. Its focus has been to empower mothers and caretakers with knowledge and skills about malaria management and, where feasible, to make prepackaged drugs available to communities. Statistical evidence shows that the districts implementing HMM achieved high levels of appropriate treatment of fever. Greater commitment of countries for implementation of CBIs, a good working relationship with national program officers (NPOs), the support of other partners such as UNICEF and the collaboration with other programs such as IMCI, CSR/IDSR, Reproductive Health, Health Promotion and Education are major facilitating factors. However, limited availability of antimalarial commodities (e.g., ITNs, insecticides, efficacious antimalarial drugs) within communities, limited capacity building for stronger advocacy and IEC for behavior change, and weak drug regulatory and drug management structures for assuring drug quality and management at all levels are serious challenges to scaling up HMM. The focus of the fourth Joint Malaria and IMCI Task Forces Meeting held September 2003 in Harare, Zimbabwe, was on community-based actions for prevention and control of childhood morbidity and mortality. Countries and partners shared experiences on how to scale up community-based interventions and reinforced their partnerships with emphasis on advocacy and resource mobilization efforts. Concrete recommendations on how countries can progress towards achieving the Abuja targets and the Millennium Development Goals were also made. Roll Back Malaria (RBM) has been supporting efforts to improve the recognition and response to malaria epidemics. Guidelines for setting up an epidemic management committee and a rapid response team at national and district levels for epidemic control have been elaborated. Fifteen epidemic-prone countries developed a preparedness plan for timely detection of epidemics and timely response. The Regional Office carried out many activities to support countries facing major malaria epidemics (Burundi, Ethiopia, Madagascar, Mauritania, and Senegal). MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS x

12 To meet countries increasing demands and needs, the Gates Malaria Partnership (GMP) seconded a capacity development coordinator to the Malaria Unit to help take forward the strategic plan for capacity development in the African Region. During the year under review, 81 malaria program managers and health workers from 34 countries were trained in courses in Ethiopia, Benin and Mozambique on Malaria and Planning Its Control. Furthermore, 14 senior laboratory health professionals from Anglophone countries were trained in Ndola, Zambia, to cascade capacity for laboratory health workers at district level. By the end of 2003, 35 of 43 malarious countries had completed their strategic plans and had begun scaling up implementation of malaria control activities. Considerable staff time and financial resources were committed in supporting countries to develop and submit fundable proposals to the Global Fund to fight AIDS, TB and Malaria (GFATM). During rounds one to three, 33 countries had their malaria proposals approved for funding. GFATM committed more than US$300 million to national malaria programs for two years. Factors contributing to the development of health systems throughout the African Region include increased political, policy and program support from governments and partners and increased investments and interest from the international community in diseases of poverty. Some of the factors constraining the work of AFRO include limited financial and human resources, delays by national authorities in clearing missions, limited availability of consultants to undertake missions, and mismatch between the time the national authorities are ready to receive the mission and the time consultants are available to undertake the missions. The Malaria Unit has strengthened monitoring and evaluation systems in many malariaendemic African countries. Capacity for monitoring and evaluating the implementation of malaria control activities was strengthened in 14 countries by establishing composite databases and by training in data management more than 100 health workers and data managers/clerks from the NMCP, IDSR, HMIS, IMCI, EPI, the university and research institutes. The first edition of the Malaria Country Profiles, intended to be a useful tool in policy and decision-making, was published in At country level, limited human resources are a major constraint to develop and sustain effective malaria-related monitoring and evaluation systems. However, with the growing interest of partners in malaria monitoring and evaluation and the new window of opportunity created by the GFATM initiative, an anticipated increase for monitoring and evaluation activities will facilitate the harmonization and integrated approach within countries. The Malaria Unit, in collaboration with WHO-HQ, supported the Mozambique Ministry of Health in evaluating the effectiveness of selected traditional herbs or plants in malaria treatment and prevention efforts. In Uganda, the Malaria Unit and CIDA supported the MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES xi

13 Ministry of Health in community resource mobilization to increase the access of pregnant women to IPTp. Results from studies undertaken with the support from the Unit have confirmed that the rate at which malaria impedes economic growth in the African Region ranges from 0.41% in Ghana to as high as 3.8% in Nigeria and 8.9% in Chad, based on preliminary results. The burden of malaria treatment is particularly enormous for the poorest households. In Ghana, for example, the direct cost to the household of treating malaria is US$6.87 for each episode of malaria. Although this amount is well beyond the capacity of most households in Ghana, when the indirect costs are computed, the cost of malaria treatment comes to an even higher figure of US$8.92. During the period under review, the Malaria Unit worked closely with its traditional partners and embraced new partners in the fight against malaria. As a key partner in the Global RBM Partnership, and the base for the Partnership Secretariat in the Region, the Unit hosted the third RBM board meeting in Harare in September and, in February, it hosted a meeting of African representatives on the RBM Partnership Board with members of their constituencies. The Unit facilitated African representatives to represent the Region on the RBM board and countries to nominate RBM focal people at country level for partnership development. At the technical level, the Malaria Unit provided input into deliberations of RBM Partnership on key developments during the year, such as meetings on access to and financing of ACTs, the development of malaria-related monitoring and evaluation systems, malaria in pregnancy, etc. DFID, USAID, and the World Bank remained the principal financial partners of the Unit. With funds from these partners, the Malaria Unit was able to strengthen its human capacity at regional, intercountry and country levels, and extend its technical support in quality and quantity to countries of the Region. The Malaria Unit, working with its Malaria Action Coalition (MAC) partners, provided technical support to several countries during the year, particularly in the areas of drug policy change and malaria prevention and control during pregnancy. The current staffing levels of the Malaria Unit represent a strengthened capacity to meet the malaria control needs of Member States. After the Country Office, intercountry teams provide the second level of communication for procurement of technical and managerial support in the context of country planning and management on a periodic basis. National or international program officers (NPOs/IPOs) work specifically with the Ministry of Health to focus on malaria control activities that include prioritizing, planning and budgeting, especially at the district level and implementation of key activities at community and household level. NPOs and IPOs provide day-to-day support that ranges from technical to strategic and tactical. AFRO is committed to ensure that Member States receive the highest quality of required technical support to curb the malaria burden. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS xii

14 Introduction Malaria is still a complex public health problem for which there is no magic bullet, no quick or easy solution, particularly in Africa, where approximately 80-85% of cases and 90% of deaths worldwide due to malaria occur. While the disease affects the lives of nearly everyone across Africa south of the Sahara, children under the age of five years and pregnant women are the most vulnerable groups. The economic loss due to malaria in Africa is an estimated US$12 billion annually. Furthermore, the disease contributes to the entrapment of disadvantaged communities in a vicious cycle of poverty. Over the past three decades, parasite resistance to commonly used, safe and affordable antimalarial drugs has increased significantly. This poses a serious threat to efforts to achieve significant malaria-related mortality and morbidity reduction. Despite the concerted efforts of national authorities and partners, coverage of at-risk groups with preventive interventions such as insecticide treated nets (ITNs) and intermittent preventive treatment (IPTp) is still very low. Cost-effective tools for malaria control are available but largely inaccessible to the needy, due to the weaknesses of the health systems and the high costs of such interventions, among other factors. However, there is now a favorable environment for funding malaria control activities, as illustrated by various initiatives including the emergence and functioning of the Global Fund to fight AIDS, TB and Malaria (GFATM). This initiative offers a unique opportunity for governments of endemic countries and their national and international partners to increase programmatic coverage of cost-effective interventions to control malaria throughout the African Region. During 2003, and in line with the regional strategy for malaria control, the Regional Office strengthened the existing capacity of malaria prevention and control programs in several countries in various ways. Providing technical support to countries for the adoption of appropriate antimalarial drug policies received priority, as well as developing strategies for increasing access to malaria control interventions at all levels of the health system, particularly at the community level. Epidemic detection and response, capacity strengthening for planning, management, implementation, monitoring and evaluation, operational research, partnership building, advocacy and resource mobilization also received special attention. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 1

15 Insecticide treated nets and IPTp are preventive measures being promoted to ensure that expectant mothers deliver healthy babies Preventive Interventions The two core prevention strategies that must be implemented in all malaria-endemic African countries are the use of insecticide treated nets (ITNs), which can cut malaria transmission by more than half, and the protection of pregnant women by using both ITNs and IPTp as part of routine antenatal care. IRS should also be promoted where appropriate. A comprehensive approach for the prevention and management of malaria during pregnancy is based on a combination of IPTp, support for the use of ITNs and prompt access to effective treatment for pregnant women ill with malaria. At present, the standard IPTp regimen is a therapeutic dose of sulphadoxine-pyrimethamine (SP) given at least twice during the second and third trimester. IPTp in two doses of SP during pregnancy has been shown to reduce significantly the prevalence of anemia and placental malaria infections at the time of delivery. In 2003, priority in vector biology and control was given to strengthening technical capacity in selected countries for: 1) research entomology to inform planning and ensure evidence-based implementation of vector control activities, 2) scaling up the use of ITNs and IRS; and 3) developing and implementing integrated vector management (IVM). Throughout the year, efforts to strengthen vector control operations MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 2

16 focused on supporting countries to expand their coverage of ITNs and ensuring adequate preparations for indoor residual spraying. Achievements To assist countries plan and implement ITNs toward achieving the Abuja targets of 60% of ITN coverage of high-risk groups by 2005, the Unit provided technical support to seven countries preparing national action plans for scaling up ITN programs. In the selected districts of these countries, the proportion of adequately treated mosquito nets increased from around 5% to more than 90% and the proportion of children under five years and pregnant women sleeping under ITNs increased from around 10% to more than 80%. A regional database on the use of ITNs monitors the progress made in distribution and use of ITNs and, ultimately, is used to evaluate the impact of ITNs on disease burden. The illustrative example of The Gambia follows. ITN Coverage in The Gambia NIC campaigns have translated into greater availability and use of ITNs Mass mosquito nets impregnation campaigns (NICs) were initiated in 2001 to increase the re-treatment of nets owned by communities. In 2001 and 2002, this strategy was tested and documented in Cameroon, Eritrea, The Gambia and Mali. Table 1 shows the availability and use of ITNs in The Gambia in These data suggest that NICs can translate into greater levels of availability and use of ITNs. Table 1: Availability and use of ITNs in selected districts of The Gambia (2002) before and after implementation of NICs Niamina East ITN indicators Before NICs After NICs % of households with at least one mosquito net % of households with at least one ITN % of ITNs among the total number of nets % of children under 5 sleeping under an ITN % of pregnant women sleeping under an ITN Source: VBC Unit, 2003 MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 3

17 Southern African countries (Angola, Zambia and Zimbabwe) also received support in planning, organizing and implementing indoor residual spraying (IRS) of insecticides for malaria control. IRS was implemented timely and appropriately in these countries. In the area of malaria prevention and control during pregnancy, countries were supported to adopt sound policies based on IPTp and ITNs, along with anemia prevention and malaria case management. The Malaria Unit provided support to eight countries (Burkina Faso, Democratic Republic of Congo, Gabon, The Gambia, Mali, Mozambique, São Tomé Príncipe, and Senegal) to adopt and/or implement IPTp in Five The promotion of use of ITNs, particularly by at-risk groups, other countries (Cameroon, Ghana, is one of the major strategies of Malaria Control Madagascar, Nigeria, and Sierra Leone) were supported to build national consensus about the IPTp strategy. The Unit supported the establishment of Malaria in Pregnancy network in West Africa (RAOPAG) and the functioning of the East and Southern Africa Coalition for Malaria Prevention and Control during Pregnancy (MIPESA). Table 2 shows the level of promotion and implementation of the IPTp policy. Table 2: Status of the promotion and/or the implementation of the IPTp policy in 2003 Building consensus Building consensus IPTp policy adopted IPTp policy adopted on the adoption of on the adoption of and not yet and implemented IPTp policy (IPTp IPTp (IPTp tested implemented at a small scale non implemented) in Pilot sites) Senegal Democratic Ghana Burkina Faso Gabon Republic Sierra Leone Mali São Tomé and of Congo Nigeria Príncipe Madagascar Mozambique MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 4

18 Challenges To predict the magnitude and the profile of resistance to an antimalarial drug such as SP; To better understand the adverse effects of malaria during pregnancy in low transmission areas; To obtain collaboration between Reproductive Health and Malaria Control in efforts to promote IPTp strategy; To make effective drugs more available and more affordable during pregnancy on a sustainable basis; To increase the level of ITN coverage to protect at least 60% of children under five and pregnant women by 2005 in as many countries as possible; To surmount cultural barriers to drug use during pregnancy. To reduce the high costs of ITNs; To increase the availability of safe drugs for use during pregnancy for malaria case management. Perspectives Technical support will be strengthened to enable countries to implement effective interventions for malaria prevention and control during pregnancy and to promote the use of ITNs. Given the current limitations in human resources, the challenge during the next two years will be to increase significantly the number of countries in which the IPTp strategy is widely implemented. Also, the impact of malaria infection during pregnancy in low transmission areas needs to be studied, and strategies to increase ITN coverage needs to be incorporated within other programs and/or initiatives such as immunization campaigns. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 5

19 Malaria is the leading cause of morbidity and mortality in children under the age of five years in the African Region. In most cases, early diagnosis and prompt treatment would prevent progression to severe malaria and death. Promoting Access to Effective Treatment Three years after the Abuja Summit, many countries in the Region recorded appreciable progress in pursuit of the Abuja targets. Several countries are increasing the proportion of the at-risk population with prompt access to malaria treatment, through interventions such as home management of fever. In 2003, products and services planned for delivery included the following: Production and dissemination of guidelines on the use of combination therapy in the African Region; Support countries to adopt and/or implement effective treatment policies; Support countries to operationalize combination therapy; Update Practical Handbook for Antimalarial Drug Therapeutic Efficacy Testing for the District Health Worker; Support capacity strengthening in malaria case management and supervision; Produce and disseminate training materials and algorithms for case management. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 6

20 Achievements A rapidly increasing number of countries have reported intolerable levels of malariaparasite resistance to the commonly used antimalarial drugs, namely chloroquine and sulfadoxine-pyrimethamine. This phenomenon has changed the approach to malaria case management, based essentially on monotherapies for several decades. During the past 12 months, with the support of the Regional Office, four countries (Mozambique, Gabon, São Tomé Príncipe and Senegal) adopted combination therapy for treatment of uncomplicated malaria. Figure 1: The malaria algorithms are an easy-to-use tool for case management using the IMCI approach Classify ANAEMIA Severe pallor Some pallor SEVERE ANAEMIA ANAEMIA Give first dose of IV Quinine or suppositories of artemisinin or suppositories of artesunate Refer URGENTLY to the hospital Give first line oral antimalarial if high malaria risk Give iron and folic acid Give mebendazole if child has not had a dose in the previous 3 months Give mother or patient advice on malaria prevention and use of ITN In pregnant women, start IPT for malaria and give iron and folic acid Advice on when to return immediately Follow-up in 14 days No pallor NO ANAEMIA Give mebendazole if child has not had a dose in the previous 3 months Give advice on malaria prevention and use of ITN In pregnant women, start IPT for malaria and give iron and folic acid Advice on when to return immediately MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 7

21 The current configuration of treatment policies for uncomplicated malaria throughout the African Region is presented in Figure 2. Figure 2: Current treatment policies for uncomplicated malaria in the African Region (31 Dec 2003) ACT Policies Burundi, Comores, Gabon, Ghana, São Tomé & Príncipe, South Africa, Zambia and Zanzibar Island (Tanzania) CT Policies Eritrea, Ethiopia, Mozambique, Rwanda, Senegal, Uganda, Zimbabwe SP Policies Botswana, DRC, Kenya, Malawi, Tanzania ACT Policy = 8 CT Policy = 7 SP Policy = 5 CQ Policy = 22 EMRO Region CQ Policies Algeria, Angola, Benin, Burkina Faso, Central African Republic, Cape Verde, Chad, Congo, Côte d Ivoire, Equatorial Guinea, Guinea, Guinea-Bissau, Liberia, Madagascar, Mali, Mauritania, Namibia, Niger, Nigeria, Sierra Leone, Swaziland Togo Countries used various processes in reaching consensus for adopting national antimalarial drug policies. Senegal used the "classic approach" involving drug efficacy studies, assessing provider and client views on current policy in public and private sectors, piloting combination therapy in a few districts and, finally, holding a national consensus meeting to review policy. Unique in the process leading to the national consensus meeting was that 15 workshops involving target groups discussed the results of the efficacy studies. The target groups were: the Medical Council; associations of general practitioners, pediatricians, gynecologists, pharmacists, paramedics, nurses; the Military Medical Services; trade unions; regional and district medical officers; manufacturers and distributors of pharmaceutical products; private practitioners; technical partners; funding agencies; and NGOs. The workshops facilitated decision making at the national level, where the consensus meeting took only two days to agree to change policy from chloroquine to combination therapy. More countries are expected to make similar evidence-based decisions in the future. In response to the need for countries to be oriented and guided on the selection and use of combination therapy, after wide consultation, the Unit developed guidelines on combination therapy for treatment of uncomplicated malaria. The year also witnessed three countries implementing artemisinin-based combination therapy treatment policies. Burundi and the island of Zanzibar (Tanzania) began implementing amodiaquine plus artesunate treatment policy, and Zambia phased in artemether-lumefantrine treatment in seven districts. The illustrative example of Burundi follows. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 8

22 Burundi: The drug policy change process Moving from Policy Decision to Implementation In 1983 Burundi recorded high resistance of Plasmodium falciparum to chloroquine (55%) in health centres of Ninga and Bujumbura, and in 1992 resistance to SP (14%) at Nyanza-Lac. In various sites in 2000/2001, treatment failure to chloroquine ranged from 51.2% to 73.7% and to SP from 8.9% to 49.1%. In addition to the human cost, Burundi estimated that in 1987 malaria cost the country US$730 million nationally and US$117 per capita. In response to the high levels of resistance, during a national consensus workshop in July 2002, the Ministry of Health decided to withdraw chloroquine as a drug of choice for treatment of uncomplicated malaria and to make SP the first-line treatment of malaria during a transitional period while it sought to find a durable, alternative, longterm drug policy for malaria. Table 3 shows the results from ACT studies. Comparisons of the efficacy of each combination, artemether-lumefantrine (99.3%) and AQ / ASU (95.3%), show no statistically significant difference. They were equally effective and well tolerated. No major adverse reactions were reported. 1. Based on the studies, the Ministry of Health changed the national drug policy to AQ+ASU for treatment of uncomplicated malaria and for use in epidemic situations and parenteral quinine for the treatment of severe malaria. To meet the costs of procuring an estimated 12,150,000 tablets each for ASU and AQ for six months, the Ministry requested financial assistance from its partners. 2. With input from the Malaria Unit, the MoH revised its training manuals in June 2003 to include the new protocols. The Unit also participated in training the trainers, and WHO and UNICEF funded the training of health workers. The MoH with the support of WHO and UNICEF developed a communication plan to inform the public about the new protocol. The MoH set up a technical committee in August 2003 to oversee implementation of the new protocol and, in November, launched the new protocol officially once it had obtained a stock of nearly 6 million tablets of AQ and ASU. The sustainability of new protocols is supported by drug procurement from GFATM and by the establishment of a regular monitoring system with assistance of a consultant fielded for three months from the Malaria Unit. In addition, Burundi is being assisted to set up a pharmaco-vigilance system. Conclusion The high-level political commitment of the national authorities, the effective and active participation of development partners and organizations were key for the successful implementation of the new drug policy in Burundi. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 9

23 Table 3: Studies on antimalarial efficacy tests involving ACTs in Burundi ACPR LTF ETF ETF+LTF Products Sample % % % % AQ+ASU Artemether/ Lumefantrine ACPR: Adequate Clinical and Parasitological Response LTF: Late Treatment Failure ETF: Early Treatment Failure To strengthen AFRO s capacity to provide technical support, 17 consultants were briefed at a training workshop in Accra, Ghana, on drug policy formulation and implementation. The consultants were from Anglophone, Francophone and Lusophone countries and they are already providing technical support to countries. Goal of Antimalarial Treatment Policy in Africa From August 2003, the Malaria Unit consulted with 16 experts from 13 countries to examine the scientific evidence and advise the organization on whether the goal of treatment policy needs to change from clinical cure to eradication of parasites. Data in the literature and presentations from meeting participants were examined critically. The meeting resolved that the current goal of antimalarial treatment policy is adequate, with clinical cure and parasitological cure as primary and secondary objectives, respectively. Based on available data, parasitological failure following treatment is associated with increased risk of clinical episodes of malaria, anaemia and increased gametocyte carriage. Noted further was that failing drugs often resulted in inadequate clinical response and failed to clear parasites. It was agreed that endemic countries with intense transmission should take into account rates of parasitological failure in addition to rates of clinical failure in decision-making aimed at revising malaria treatment policy. The key recommendation from the consultation was to set new cut-off points at which malaria treatment policy should be updated. Countries should revise policy before Adequate Clinical and Parasitological Response (ACPR) reaches below 75% and/or Adequate Clinical Response (ACR) below 85%. The previous cut-off point was ACR below 75%. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 10

24 Technical Support Networks for Monitoring Antimalarial Treatment The Malaria Unit also strengthened the capacity of subregions to conduct surveillance of antimalarial drug resistance by establishing technical networks for monitoring antimalarial treatment. These networks are modeled on the lines of the East African Network for Monitoring Antimalarial Treatment (EANMAT), which has been functional since The goal of the networks is to contribute to a better understanding of the epidemiology of antimalarial drug resistance in the subregions and to use the information to develop appropriate treatment policies and improved case management. In 2003, two new networks were established and two were supported to become functional. The Central African Network for Monitoring Antimalarial Treatment (CANMAT), whose membership includes Angola, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, and Gabon, was launched in Kinshasa in May The first West African Network for Monitoring Antimalarial Treatment (WANMAT I), consisting of Cape-Verde, The Gambia, Guinea, Guinea-Bissau, Mauritania and Senegal, was launched in November 2003 in Dakar. The second West African Network for Monitoring Antimalarial Treatment (WANMAT II) held its first meeting in June 2003 in Ouagadougou. Its members are Benin, Burkina Faso, Ghana, Mali, Niger, Nigeria, Sierra Leone, and Togo. SANMAT, comprising countries of southern Africa, had its inception meeting in 2002 and will organize its second meeting in The generic objectives of the networks are as follows: To detect, map and monitor the therapeutic efficacy of antimalarial drugs using standardized tools and methods; To develop and maintain a database on the therapeutic efficacy of antimalarial; To share and disseminate information on the database with member countries of the network and AFRO; To support the process and share experiences of antimalarial treatment policy review in countries of the subregion; To advocate for effective and efficient malaria treatment policies in the subregion. Figure 3: Sub-regional technical support networks for monitoring antimalarial treatment It is our vision that, in the long run, subregions will adopt and implement single treatment policies, which will increase WANMAT 1 local purchasing power and, consequently, influence the WANMAT 2 price of antimalarial drugs. EANMAT Figure 3 summarizes the CANMAT geographical distribution of the networks. SANMAT MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 11

25 In the area of malaria case management, 14 countries were supported to improve the capacity of their health workers in malaria case management and supervision following training (see Figure 4). Three of these countries also adapted new treatment guidelines. Algorithms for malaria case management were developed (see Figure 5), field tested in five countries and finalized for publication. Eritrea Health Facility Survey In 2002, Eritrea changed its national antimalarial drug policy to a combination of chloroquine (CQ) and sulfadoxine-prymethamine (SP), as an interim solution before adopting a WHO-recommended artemisinin-based combination therapy. This decision necessitated change of national malaria treatment guidelines and re-training of frontline health workers on case management. Training efforts have translated into significant progress in the implementation of malaria control in Eritrea, particularly in the area of IMCI and malaria case management. To assess the quality of malaria case management in the light of recent drug policy shift and the re-training of a large number of health workers, in November 2003, the Malaria Unit conducted a health facility survey (HFS) in two administrative zones of Eritrea called zobas: Debub and Gash Barka. As Figure 4 demonstrates, most health facilities (70%) in both zones were observed to have first and second line antimalarial drugs in stock on the day of the survey. In addition, the survey results show that the vast majority of outpatients with suspected malaria (about nine out of ten) were given or advised to take a combined treatment of CQ and SP, according to national standards (Figure 5). MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 12

26 Figure 4: Availability of 1st and 2nd line antimalarial drugs in various health facilities of Debub and Gash Barka zones of Eritrea, November 2003 CQ+SP Quinine Both % of facilities Hospitals Health Centers Health Stations Clinics Overall Facility type Figure 5: Percentage of suspected malaria cases that received CQ+SP on the day of the survey in Debub and Gash Barka health facilities, November % of malaria cases Hospitals Health Centers Health Stations Clinics Overall Facility type MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 13

27 The fourth Joint Malaria and IMCI Task Forces Meeting was held from 23 to 25 September 2003 in Harare, Zimbabwe. The 151 delegates focused on communitybased actions for prevention and control of childhood morbidity and mortality. The meeting enabled countries and partners to share experiences on how to scale up community-based interventions and further reinforced their partnership, advocacy and resource mobilization efforts. The deliberations also enabled the gathering to make concrete recommendations on how countries can make progress towards achieving the Abuja targets and the Millennium Development Goals. Challenges Problems related to availability, affordability and accessibility of ACTs, ranging from quality assurance, negotiated prices etc.; Improving supply of efficacious antimalarial drugs in health facilities, including those for the treatment of severe malaria; Lack of a tool to assist countries accurately estimate drug need for malaria treatment; Assessment of the impact of case management training on quality or improvement in care for malaria patients; Need for local production of ACTs within Africa. Perspectives In 2004, the Unit will focus on supporting countries to accelerate decision-making process for treatment policy review, develop tools for estimating and forecasting needs for ACTs at country level, advocate for harmonized subregional treatment policies and assess the impact of case management training on treatment practices. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 14

28 Praising community awareness and communication for behaviour change are key in promoting malaria control interventions Community-Based Interventions Community-based interventions (CBIs) are crucial for attaining the Abuja targets. The different aspects of CBIs that are critical components of malaria control efforts are home management of malaria (HMM), promotion of insecticide treated nets (ITNs), indoor residual spraying (IRS) and intermittent preventive treatment (IPTp). The last three are dealt with in detail elsewhere in this report. The main problem in implementation of CBIs has been that the efforts have not been coordinated. As a result, these efforts do not lead to anticipated outcomes. To address this, the Malaria Unit proposed to conduct several technical support missions to identify country-specific bottlenecks and, based on these, assist in addressing the challenges of scaling up CBIs. The main strategies to improve implementation of CBIs include raising community awareness, building capacity, communication aimed at behavior change, advocacy, social mobilization, establishment of partnerships for resource mobilization at all levels, efforts to ensure the availability of malaria control products and services, and monitoring and evaluation. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 15

29 In 2003, supporting countries in scaling up community-based actions for malaria control was a top priority, as was providing support for the establishment of technical networks of individual and institutions involved in CBIs. Achievements During 2003, missions to countries provided technical guidance for scaling up implementation of CBIs. The following guidelines were based on the outcomes of two workshops on scaling up CBIs held in November 2002 in Lomé, Togo, for Francophone countries, and in Harare, Zimbabwe, in December 2002 for Anglophone countries: Guidelines for training community members on prevention of malaria and protection during pregnancy; Guidelines for implementation and supervision of community-based interventions in malaria control; Guidelines for community-based surveillance in malaria control aimed at tracking morbidity and mortality events in the general population and mainly in children under five and pregnant women. In addition to these technical guidelines, a framework for developing national policy and strategic plans to scale up implementation of CBIs was developed. Throughout 2003, six countries were supported to complete the development of strategic and operational plans for scaling up CBIs. Technical support missions were also conducted at country level in Benin, Burkina Faso, The Gambia, Ghana, Guinea-Bissau and Senegal, in collaboration with IMCI. Three of these countries completed the development of a national policy and/or a national strategic plan to scale up the implementation of CBIs: Benin, Senegal and Guinea-Bissau. These countries also developed a national plan for communication and social mobilization for malaria control. In addition, technical support was provided to Benin for developing training modules for traditional practitioners. Other countries that received orientation for development of national policy and national strategic plans to scale up implementation of CBIs included Côte d Ivoire, Ethiopia, Guinea-Conakry, Liberia, Mali, Mauritania, Niger, Nigeria, and Mali. The 25 countries implementing community-based interventions are: Angola, Benin, Burkina Faso, Congo, Côte d Ivoire, DRC, Eritrea, Ethiopia, The Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Madagascar, Malawi, Mali, Mauritania, Niger, Nigeria, Senegal, Togo, Uganda, Tanzania, Zambia and Zimbabwe. In the area of HMM, the focus was on the empowerment of mothers and caretakers with knowledge and skills about malaria management to recognize its symptoms, take immediate action at home, and to know when and where to seek help when MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 16

30 danger signs are present. Where feasible, communities were provided with prepackaged drugs. The current evidence about implementation of HMM indicates that the approach still is confined to a few project areas in countries. In this year, at least 11 countries (Benin, Burkina Faso, Eritrea, Ethiopia, Ghana, Kenya, Madagascar, Mali, Nigeria, Senegal and Uganda) had plans to scale up HMM from the existing small-scale projects. The Malaria Unit provided technical support to some of these countries for implementation of the strategy. In scaling up, different models can be adapted depending on the specific country experience. In Benin, for example, mothers were trained to give the right treatment whenever there was suspicion of malaria/ fever. The unique feature of this model was that the Malaria Control program planned the activities jointly with IMCI. As a result, IMCI key practices were also addressed for the proper management of children with fever and scaling up was much faster in the implementing areas. The major lesson learnt was that building on existing programs helps achieve the required coverage and better results. Benin has also made several innovative interventions for HMM, training community health workers in 1,335 Guinea worm-endemic districts to treat malaria in the home. About 225 traditional healers were sensitized on the detection of danger signs in support for HMM and 55,000 mothers were trained in managing malaria in underfive-year olds. These innovative interventions provided a basis for implementing activities to expand and scale up phases of HMM. In Uganda however, the approach was to use an intermediate group to reach mothers/caretakers. In this case, community resource people were trained and given prepackaged antimalarial drugs for children presenting with fever. These prepacks (HOMAPAKS) were color coded for the different age bands to allow mothers to determine which pack to give to which child. In addition, resource people were trained in counselling mothers on the IMCI key practices relating to the child with fever. The program expanded to cover an additional 20 districts from the initial 10 of In terms of geographical coverage, however, only five achieved 100% of all communities implementing the strategy. For the remaining 15 districts, the range was between 30-50%. The ease of implementation was assessed in the districts implementing the strategy for at least one year. The main objective was to review implementation and validate data collected by the distributors to help other areas scaling up. As presented in Table 4, the districts that were implementing had achieved high levels of appropriateness of fever treatment. In almost all implementing districts, more than 90% of episodes had been treated within 24 hours of onset of symptoms. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 17

31 Table 4: Levels of appropriateness of fever treatment in selected districts in Uganda Intervention districts Control districts Chloroquine given for 62.1% 37.9% 3 days and once daily as recommended SP (Fansidar) given once 74.1% 25.9% HOMAPAK given for 3 days and 67.6% HOMAPAK not being once every day distributed Table 4 shows that the correct treatment was given in more that 60% of cases with fever, even when HOMAPAK was not available, unlike the below 40% in the control group. Other countries have also recorded major achievements. Madagascar, with the assistance of Population Services International (PSI), launched prepackaged drugs for private vendors under the brand name "Palustop". Efforts are underway to expand distribution to cover most malaria-endemic areas. In Nigeria, the Society for Family Health, working with the BASICS 2 project in collaboration with the Federal Ministry of Health, launched the prepackaged antimalarial drugs in three states. This is promoted under the brand name "KidCare". Distributors of KidCare target drug vendors, from whom about 70% of mothers receive treatment. Further support is expected from the Global Fund. Partners, including local manufacturers, have helped get the product on the market. Challenges Sustain commitment of countries for developing policies and strategic plans for implementing and scaling up CBIs; Greater advocacy for more visibility of community-based malaria control interventions at country level to spread awareness about the importance of CBIs; Scale up efforts (i.e., training community health workers) for CBIs to win support of other partners, such as UNICEF and the Core Group, and collaboration of other programs, such as IMCI, CSR/IDSR, Reproductive Health, Health Promotion and Education; Ensure availability of malaria control commodities, e.g., efficacious antimalarial drugs, ITNs and insecticides within communities; MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 18

32 Ensure capacity building for stronger IEC campaigns for behavior change; Better compliance efforts on use of prepackaged drugs; Improve drug regulatory and drug management structures for assuring drug quality and management at all levels. Perspectives Priority in 2004 should be given to providing technical support to countries for scaling up implementation of CBIs, and specifically HMM. Other priorities include promoting prepackaging of antimalarial drugs for better compliance, providing evidence-based guidance on the feasibility/acceptability of home management of malaria using ACTs, advocacy and IEC efforts for CBI-related community education and behavioral change. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 19

33 Indoor residual house-spraying remains the key intervention for epidemic prevention in areas of unstable malaria transmission Epidemics Preparedness and Response Areas on the northern and southern fringes of the malaria-endemic belt of Africa, as well as highland and desert areas, are at risk of epidemic malaria. Unlike in highly and moderate endemic areas in Africa, malaria in epidemic-prone countries south of the Sahara typically affects people of all ages and can have a high case fatality rate. The Malaria Unit has been supporting efforts to improve the recognition and response to malaria epidemics. Malaria early warning systems have been established in southern Africa to improve outbreak detection and response and are being developed in other parts of Africa prone to epidemics. Furthermore, preparedness plans of action developed by 15 epidemic-prone countries constitute strengthened capacity in EPR. Achievements In 2003, Malaria carried out many activities to support countries for malaria epidemic control. Through the regional strategy for disease surveillance, many countries have improved malaria surveillance system (43 countries are implementing this strategy in the MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 20

34 Region). Some countries (Mali, Madagascar, Niger, and Senegal) were supported in setting up malaria epidemic early warning and detection systems. Sahelian countries submitted a joint proposal for malaria epidemic control to the Global Fund with Regional Office support. A training module on malaria epidemic control was tested during courses in Benin, Ethiopia and Mozambique. Guidelines have been elaborated to set up a country epidemic management committee and rapid response teams at national and district levels. On request, countries at risk of facing major malaria epidemics have been supported (Burundi, Ethiopia, Madagascar, Mauritania, and Senegal). Contingency stocks have been monitored and strengthened. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 21

35 Most health systems in the African Region are confronted with challenges such as limited skilled and motivated human resources and lack of support for logistics and operations. The problem is further compounded by frequent drug and supplies stock outs. Capacity Development and Support to National Health Systems To ensure achievement of the long-term goal of locally sustainable malaria control efforts, capacity development and the strengthening of health systems should be high on the agenda of African governments and their partners. However, at all levels, the number of trained malaria specialists is shrinking, from the specialized medical entomologists and more general mid-level technicians to the community health worker. The corps of expertise in health work must be strengthened throughout the African Region and, in some disciplines, rebuilt entirely. The shortage of human resources faced by health systems in Africa and limited support to domestic training institutions are some of the major constraints in achieving the Abuja targets, RBM and MDG goals. In 2003, priority in building up capacity in the Region was given to: (1) strengthening malaria managerial skills and knowledge through MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 22

36 international courses on malaria control; (2) updating skills of malaria consultants; and (3) linking Gates Malaria Partnership (GMP) and WHO/AFRO. National malaria control programs have to struggle to maintain a critical presence within changing and unstable health systems. The main concern is their ability to ensure that malaria control is high on the national health agenda, mobilize health policy support and develop strategies that can rapidly, effectively and equitably deliver access, coverage, quality and impact with the available tools (diagnostics, drugs, ITNs, house spraying). Capacity Development Achievements A review meeting of the international courses on Malaria and Planning its Control, held April 2003 in Harare, Zimbabwe, recommended that international courses on malaria be evaluated, the current curriculum reviewed, and a national curriculum for malaria management for district level developed. In 2003, three courses on Malaria and Planning Its Control were held at Nazareth Training Centre, Ethiopia (for Anglophone countries), from 8 September to 29 November 2003; IRSP, Ouidah, Benin (for Francophone countries), from 1 September to 21 November 2003; and CRDS, Maputo, Mozambique (for Lusophone countries), from 15 September to 5 December Eighty-one malaria program managers and other health workers from 34 countries in the Region were trained. To develop a pool of African consultants able to provide technical support to countries and establish a network, a workshop for malaria consultants was jointly organized with the Malaria Consortium, the Liverpool School of Tropical Medicine and the London School of Hygiene and Tropical Medicine in Harare from 7-12 April 2003, bringing together 17 experts from the public and private sector. The Malaria Unit, in collaboration with Gates Malaria Training Centre in Blantyre, Malawi, conducted training on malaria case management for focal persons in southern Africa. In collaboration with the Tropical Diseases Research Centre (TDRC) in Ndola, Zambia, 15 participants from 14 countries attended a training of trainers course on malaria laboratory diagnosis. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 23

37 Many countries have just begun to appreciate the importance of continually strengthening capacity for malaria control programs. They realize that human resource and capacity building should be assessed and innovative training methods introduced to meet the countries demands and needs. The Minister of Health of Zambia (centre) at the laboratory training workshop, Ndola, Zambia, 2003 Challenges Inadequacy of international courses on malaria curriculum to meet current needs; Lack of national curriculum for malaria program managers at district level; Insufficient follow-up and appropriate support to past trainees from international courses on malaria; Lack of follow-up on malaria consultants; Insufficient knowledge on the human resource and institutional capacity needs at country level; Poor and fragmented involvement of the domestic training institutions in support capacity development at district level. Perspectives The focus for 2004 will be on: evaluation of international courses on malaria control and review/develop the course curricula for international and national courses; follow up of former trainees; assess human development and institutional capacity need; support countries to develop appropriate human resource policies for malaria control; introduce innovative approach for scaling up training; and involve domestic institutions in scaling up capacity at district level. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 24

38 Support to National Health Systems Achievements The Malaria Unit provided robust technical support to countries to develop malaria control strategic plans. Rwanda is one of the countries that were supported to develop a national strategic plan for malaria control (see box). By the end of 2003, 35 of 43 malarious countries had completed their strategic plans and had begun scaling up implementation of the control activities. Most of these countries now have work plans for reaching the Abuja targets, RBM and Millennium Development Goals. The Global Fund to fight AIDS, TB and Malaria (GFATM), formed in January 2002, promises to provide additional funds to fight malaria. The Malaria Unit committed considerable staff time and financial resources in supporting countries to develop fundable proposals. During rounds one to three, 33 had their malaria proposals approved for funding. US$327,850,815 was committed to the malaria programs in these countries for a period of two years (Figure 6). Figure 6: Global Fund support to fight malaria in the African Region First Round Second Round Third Round Benin Niger Togo Chad Madagascar Liberia The Gambia Rwanda Cameroon Angola Democratic Republic of Congo Swaziland Comores Mauritania Namibia Burkina Faso Eritrea Guinea Ghana Somalia Burundi Multi-Country Southern Africa Sudan (South) Mozambique Sudan (North) Kenya Uganda Malawi Nigeria Ethiopia Tanzania (Zanzibar) Madagascar Mali Benin Senegal Zimbabwe Tanzania Zambia MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 25

39 Challenges Sustain the optimal amount of political, policy and program support from governments and partners; Sustain the optimal level of investments and interest from the international community in diseases of poverty; Limited funding; Difficulty having adequate human and financial resources to devote to malaria control. Perspectives During the next 12 months, support to countries has been packaged according to country needs for achieving the Abuja targets, RBM and MDG goals. Countries have been grouped into three categories: Category 1 Countries to be supported to develop district business plans for scaling up implementation. Category 2 Countries to finalize or review their malaria control strategic plans and to make functional their in-country partnerships. Category 3 Countries to be supported to develop malaria proposals for submission to the GFATM. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 26

40 Strengthening monitoring and evaluation systems at country level is key to ensure that information collected is properly analyzed, shared and used for planning and resource allocation Monitoring and Evaluation One of the challenges faced by malaria control programs in the African Region is the availability of timely, complete and accurate data on malaria-associated morbidity and mortality and on implementation and effectiveness of the control efforts. Monitoring and evaluation data are not expected to provide all the information necessary for program management by identifying the gaps and constraints that need to be addressed. Nevertheless, these data are needed to demonstrate to policy makers, partners and stakeholders that planned products are being efficiently delivered and that program efforts are having measurable outcomes and leading to impact. They also help program management by providing information on the practices that need to be promoted and by providing insights as to where resources are being used most efficiently, versus where new strategies should be considered. The overall goal of evaluation analysis is to measure program effectiveness and impact. Achievements During 2003, capacity for monitoring and evaluating the implementation of malaria control activities was strengthened in 14 countries (see map, Figure 7) through the establishment of composite databases and the training of more than 100 health MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 27

41 workers and data managers/clerks from the NMCP, IDSR, HMIS, IMCI, EPI, the university and research institutes in data management. The first edition of the "Malaria Country Profiles", intended to be a useful tool in policy and decision-making, was published. Figure 7: Status of malaria-related databases at country level as of December 2003 Malaria Monitoring and Evaluation Data Bases Established (14) Data Bases yet to be established (29) Non-AFRO countries At the level of the Regional Office, the EPI-INFO database developed previously was converted into Access 2002 format for easy inclusion of components into the integrated database of the DDC division under development. In addition, components of community-based interventions made up of resource institutions/ngos and projects were developed and incorporated into the composite database (see sample menus, Figure 8). Briefly, the composite database on malaria control interventions consists of: Routine malaria morbidity and mortality data; Community surveys; Health facility surveys; Management surveys; Monitoring of the implementation of planned activities and financial accountability; Regional core and supplementary indicators; Monitoring of antimalarial drug resistance and training of health personnel in malaria control; MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 28

42 Vector biology and control interventions; Community-based interventions; and Other information such as Roll Back Malaria Partnership, Operational Research on Malaria Control and Malaria Epidemic Preparedness and Response. Figure 8: Sample menus of the composite database in Access 2002 The pop-up menu of the composite database looks like this once you open the database: A click on the "Go to Data Entry Menu" will open the following pop-up menu: Among the challenges related to the update/development of this database are inclusion of data on the economic impact of malaria and development of a data warehouse providing easy access to malaria data through the server and Internet. Challenges Problems related to the availability of appropriate human and financial resources make it difficult for national malaria control programs to develop and sustain effective malariarelated monitoring and evaluation systems. However, with the growing interest of partners in malaria M&E and the new window of opportunity created by the GFATM initiative, adequate resources for M&E are expected to increase soon. At AFRO level, the strengthening of the M&E team made a significant impact on the support to countries during Perspectives For many years to come, countries will continue to expect technical support from AFRO in their efforts to develop comprehensive and efficient national M&E systems for malaria control. Channels through which that support will be provided include development and dissemination of appropriate guidelines for malaria M&E systems and technical support missions. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 29

43 Research on and development of new, effective antimalarial drugs are needed to replace failing treatment regimens Operational Research Throughout 2003, the Malaria Unit committed an enormous amount of staff time and financial resources in supporting operational research at country level. It established and maintained a database on operational research projects, organized a data analysis workshop, supported the MIM/AFRO/TDR initiative, and provided technical support mission to countries. The program called "Strengthening Traditional Heath Systems for Malaria Control and Prevention in the African Region" is a novel 5 year contributory project between WHO and CIDA, which came into operation in November It supports improvement of African traditional medicine practices and promotes research and production of safe, effective and quality traditional medicines for malaria prevention and treatment. Achievements The gap between scientific knowledge and health policy and theoretical health policy and practice is widening. Many public health tools and strategies with proven laboratory or field trial efficacy do not realize tangible benefits in terms of disease control. Unfortunately, research on translating results from field efficacy trials into field MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 30

44 effectiveness is lacking. Given this background, AFRO invests and supports capacity strengthening for operational research to address problems identified during implementation. The products and services planned for delivery in 2003 are as follows: Operational research projects funded and implemented; WHO Collaborating Centres in malaria identified. Furthermore, two research institutions have been identified for designation as WHO Collaborating Centres. These are the Tropical Diseases Research Centre in Zambia and the National Institute for Communicable Diseases in South Africa. Regional databases on operational research, research institutions and staff have been established and made accessible to countries and other users. Linkages with HQ have been strengthened through creation of a new AFRO/RBM/TDR/MIM Research Initiative, whose aim is to support operational research for malaria control. With initial capital of $700,000, eight operational research projects from four countries have been approved for funding under this initiative. In addition, 12 projects from 10 countries received financial support and 12 projects funded in 2002 received supervisory visits. A data-analysis workshop was held for 16 investigators from 14 countries whose projects were funded in The workshop updated participants on data analysis techniques, analyzed and interpreted findings from their studies and produced project reports. Participants identified some constraints in the field, proposed solutions to the constraints and made recommendations on future directions on how operational research could be supported. Key recommendations included: Conduct supervisory visits to projects sites; Support the creation of a regional network on operational research in malaria; Convene a special workshop on computer skills for data-analysis for young scientists; Continue to hold proposal development workshops for operational research in malaria until a critical mass of trained manpower is achieved; Identify and support mechanisms for enhancing capacity to link research, implementation and control. During the past 12 months, traditional medicines were researched for their potential role in the fight against malaria. With support from WHO-HQ and CIDA, linkages were established with institutions and country programs for quality research on potential traditional medicines for malaria treatment and prevention. The Ministry of Health in Mozambique together with experts from the University Eduardo Mondlane of Maputo were supported to carry out comparative trials of herbal tea from Artemissia annua versus SP to treat malaria. The Tropical Diseases Research Centre in Ndola, Zambia, is performing clinical evaluations for preliminary efficacy and safety profiles of an herbal concoction called Mbosha for treatment of uncomplicated malaria. In the area of MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 31

45 malaria prevention, the Malaria Unit is working with the International Centre for Insect Physiology and Ecology (ICIPE) to evaluate the effectiveness of a mosquito-repellent plant called Ocimum kilimandscharichum when used as a traditional fumigant in villages. In addition, the Malaria Unit supported the Ugandan Ministry of Health and the National Malaria Control Program to harness community resources. The program used traditional health practitioners and traditional birth attendants in two rural districts to deliver IPTp within a minimum package context of IEC materials and SP. This strategy is intended to capture the largest number of pregnant women possible and provide them with appropriate advice for antenatal care at the nearest health facility at least four times during pregnancy. Challenges By promoting the role of science and operational research in decision making, countries and their national and international partners have sought to assist health care decision makers and policy makers in managing malaria control activities. The concern here is that guidance from operational research is irrelevant to the millions of people who live in communities where health systems are breaking down and where access to effective treatment and/or preventive tools is limited. This is a new area for operational research, and some potential partners and countries show some hesitation. There is a significant, and probably justified, fear of loosing intellectual property rights (IPR) and traditional medicine knowledge. This fear has often created distrust about transparency between traditional healers and scientists. Strong popular advocacy and institutionalization of legislation and guidelines for IPR would help minimize this concern. Member Countries are generally supportive and display tremendous will to have traditional medicines promoted and evaluated. They are concerned about the lack of guarantee of continuing financial support from partners. Perspectives In Africa, the potential impact of traditional medicine practice is poorly understood and appreciated. The attempt to couple traditional and conventional medicine practice on a common platform of evidence-based practice is the most plausible strategy for the future. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 32

46 Economics of Malaria During 2003, the Malaria Unit set out to obtain evidence of the economic burden of malaria on countries in the Region. At the end of the year, there was a better understanding of the economic burden of malaria. Financing malaria control activities remains a critical challenge. Efforts to maintain routine program activities and ambitions to scale up coverage of the major interventions have been hampered by financial constraints. For some countries, however, the period under review was marked by significant expansion of the fiscal space, primarily from new resources linked to debt relief, grants from the Global Fund (described elsewhere in this report) and commitments from donors through sector-wide approaches (SWAp) and budget support. Achievements Studies to assess the economic burden of malaria were completed in Ghana and Chad during the year. A study is partially completed in Nigeria, and one was commissioned in Mali and Uganda in the latter part of the year. Results from the completed studies have confirmed that as a single disease, malaria significantly inhibits economic growth. The evolving evidence from preliminary results obtained in three countries confirm that malaria impedes economic growth in African countries, MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 33

47 ranging from 0.41% in Ghana to as high as 3.8% in Nigeria and 8.9% from Chad. These results will provide significant impetus to national advocacy efforts in giving malaria the due attention of policy makers and those in charge of allocation of resources to ministries of health. Most of the costs of preventing and treating malaria in Africa today are borne by the people themselves. For example, people buy nets, insecticide sprays and coils, and people spend a considerable amount of money and time on malaria treatment. Data from recent studies are revealing a pattern of immense burden, particularly for the poorest households. In Ghana, for example, the direct cost of treating malaria to the household is US$6.87 for each single episode of malaria. Although this amount is well beyond the capacity of most households in Ghana, when the indirect costs were computed, the cost of malaria treatment comes to an even higher figure of US$8.92. Throughout the year, Regional Office has investigated financial and non-financial barriers to scaling up malaria control in the Region. Using Ghana as a pilot, the Regional Office worked in collaboration with staff of the World Bank and RBM Secretariat to review the financing of malaria at the district level. Their findings have been used to identify obstacles and gaps and recommendations for overcoming them. This initiative, conducted in the context of the SWAp arrangement in place in Ghana, provides a good starting point for providing similar support to countries with decentralized systems or those implementing SWAp. Over the years, several countries, such as Burkina Faso, Cameroon, Malawi, Mali, Mauritania, Mozambique and Tanzania, have increased their health budgets significantly, expanding the capacity of the health sector to finance more easily their recurrent health costs. Specifically, the government of Cameroon made significant allocations to malaria control from its debt relief support under the Highly Indebted Poor Countries (HIPC) initiative. During the period under review, about 450,000 ITNs were procured for free distribution to pregnant women. Challenges Expanding the resource envelope for malaria control activities, particularly taking advantage of in-country sources such as HIPC; Fostering collaboration with country partners, while strengthening the capacity of national programs for resource mobilization and negotiations; Raising the level of commitment of teams participating in studies on the economic burden of malaria; and Increasing the capacity of national programs and WHO Country Offices in health economics. MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 34

48 Perspectives Countries will continue to expect technical support from AFRO for understanding the economic ramifications of malaria. AFRO will build the capacity of national programs on costing of interventions. More specifically, AFRO will support countries that have adopted new drug policies for costing the implications of the change. Support will also be provided to national programs to enable them to engage in ongoing health sector reforms and sector wide approaches. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 35

49 Partnerships Development During the period under review, the Malaria Unit worked closely with its traditional partners and embraced new partners to join in the fight against malaria. As a key partner in the Global RBM Partnership, and the base for the Partnership Secretariat in the Region, the Unit hosted the third RBM board meeting in Harare in September. In February, the Unit hosted a meeting of African representatives on the Partnership Board with members of their constituencies. The Unit facilitated African representatives to represent the Region on the RBM Partnership Board and countries to nominate RBM focal people at country level for partnership building and improving consultations, communications and information sharing. So far, 18 countries have nominated RBM focal people. The Unit participated in several activities of the board meetings, teleconferences, etc. At the technical level, the Malaria Unit provided input into deliberations of RBM Partnership on key developments during the year. Specific meetings on access to and financing of ACTs, monitoring and evaluation of RBM, malaria in pregnancy, etc. hosted by different RBM partners and Working Groups received substantial inputs from the Malaria Unit. The Joint Malaria and IMCI Task Forces meeting, which brings together countries, partners, researchers and WHO, was held during the year (reported earlier in this report). MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 36

50 DFID, USAID, and the World Bank remained the principal financial partners of the Unit. With funds from these partners, the Malaria Unit was able to strengthen its human capacity at regional, intercountry and country levels and extend its technical support in quality and quantity. Working with its Malaria Action Coalition (MAC) partners, the Unit provided technical support to several countries during the year, particularly in the area of drug policy change and malaria prevention and control during pregnancy. With support provided by CIDA, the Unit was able to extend it support to countries for strengthening their traditional health systems for malaria control, with Mozambique, Kenya, Tanzania, Uganda and Zambia benefiting from direct technical support in this area. The celebration of Africa Malaria Day 2003 in Kenya demonstrated the strengthened partnership built by the Unit. The highest level government representatives and principal officers of the major RBM partner agencies participated in the event. At the occasion, the first Africa Malaria Report was launched. This high-level focus on malaria on the day was replicated in malaria-endemic countries across the Region, with the participation of a wide range of in-country partners, including the private sector. In some countries, the Malaria Unit fielded consultants to provide support for planning the Day. The Unit provided advocacy and campaign materials to all countries. On Africa Malaria Day, a special site was opened on the Unit s web page, a special edition of the Malaria Bulletin was published and countries of the Region held events marking the day, which were described in the first Africa Malaria Day Report ever published. MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 37

51 Regional Malaria Control Advisor Dr Magda Robalo (MAL) Technical Officer Mr G. Baugh (MTO) Administrative Officer Mr E. Kagoro (MAO) RBM Partnership Focal Person Dr E. Afari (MRP) Effective Treatment Drug Policy / Team Coordinator Dr T. Sukwa (MDP) Home-based Management Dr J. Namboze (MHM) Case Management Dr I. Sanou (MCM) Community-based Interventions Dr T. Diarra (MCI) Traditional Systems for Malaria Dr A. Oloo (MTS) Monitoring and Evaluation Monitoring and Evaluation / Team Coordinator Dr A. Alisalad (MMO) Monitoring and Evaluation Dr J. Uchudi (MEO) Malaria Prevention Prevention Officer / Team Coordinator Dr A. Ba (MPO) Support Team Support Team Coordinator Mr R. Agyarko (MSS) Health Systems Dr K. Kamanga (MHS) Communication Ms M. Lengor (MCA) Economics and Financing Dr T. Okorosobo (MEF) Capacity Development Dr F. Silveira (MCD) Capacity Development Dr A. Davies (MGP) Intercountry Programs ICP Coordinator Dr S. Fall (MIC) ICP West Africa Dr S. Tohon ICP East Africa Dr S. Paluku ICP Central Africa Dr C. Ngabonziza ICP Southern Africa Dr S. Murugasampillay Operations Research Dr E. Kamau (MOR) Malaria Control Unit, WHO Regional Office for Africa, December 2003 Program Management The Malaria Unit s role in the battle against malaria within the context of Roll Back Malaria is to guide countries and partners to scale up massively the agreed upon malaria control strategies and policy orientations. While this requires an increased presence in countries for designing and implementing these strategies, the current staffing levels of the Unit have the capacity to meet the malaria control needs of the Member States. An attempt was made to match staff profiles with changing needs, and by year-end 2003, 92 malaria staff were employed within a three-tiered structure: 24 staff at Regional Office (including other units), 21 in intercountry teams and 47 Malaria Program Officers in the Country Offices. Regional Level The Unit acts as a center in the major malaria intervention areas, linking and coordinating with relevant units, ensuring that technical standard guidelines and agreed strategies for malaria control are updated regularly and disseminated to countries and partners. The Unit is also responsible for providing a level of technical MALARIA CONTROL IN THE AFRICAN REGION TURNING RESOURCES INTO RESULTS 38

52 Figure 9: AFRO epidemiological blocs Lomé Libreville Kampala Non-AFRO West Africa Central Africa Harare East and Great Lakes Southern Africa support that is consistent with countries demands and needs. Five teams provide clarity of vision in the key technical areas and approaches. Intercountry Level The intercountry teams constitute a solid, decentralized and reliable structure for providing technical support to operationalize priority areas of the malaria control program. After the Country Office, the intercountry teams provide the second level of communication of procurement of technical and managerial support in the context of country planning and management on a periodic basis. Country Level The primary responsibility of the WHO Country Office (WCO) is to ensure that national authorities and their partners are able to carry out cost-effective malaria control measures as part of developing health systems. To meet the challenge of sufficient coverage, national and district implementation plans must be developed with key, time-bound targets and adequate financing. In 33 of 43 malaria-endemic countries, the WHO Country Office provides a Malaria National Program Officer (NPO) and in some cases an International Program Officer MALARIA UNIT DIVISION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES 39