Implementing the Abuja Declaration and Plan of Action: the journey so far The Abuja Declaration African leaders who met on 25 April 2000 in Abuja, Nigeria, laid out the foundation for a sustained battle against malaria by agreeing to strengthen national health delivery systems. The ultimate goal of the Abuja Declaration is to ensure at least 60% coverage of major interventions for malaria prevention and treatment by 2005. To reach these targets, the leaders pledged to implement the Abuja Declaration Plan of Action in their respective countries. The plan of action deals with management of the health system; disease management; provision of antimalarial drugs and malaria control materials; disease prevention; surveillance, epidemic preparedness and response; sustainable control; human resources development; and research. The Declaration also requested the Regional Directors of the WHO African and Eastern Mediterranean regions (AFRO and EMRO) to follow up on implementation of the Plan of Action, seek collaboration with UN agencies and other partners, and report regularly on progress made in the implementation of the Abuja Summit s Plan of Action to the African Union. The publication of the first progress report on the implementation of the Abuja Declaration Plan of Action shows that the two regional offices, in collaboration with WHO headquarters, have fulfilled their mandate to provide a progress report with regard to the implementation of the plan agreed at Abuja. Although the report draws on information from several data sources, it is based primarily on the analysis of the responses to a standard questionnaire sent to Member States. A total of 39 countries in Africa submitted reports to the Regional Office. During the five years that followed the Abuja Summit, countries have intensified efforts to implement the core content of its plan of action, using support from WHO and partners in Roll Back Malaria (RBM) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Organization and management of the health system The Abuja Declaration calls on countries to improve the managerial capacity of national health authorities in order to prioritize action against malaria. It also looks at ways of decentralizing the health systems of African countries and making them more efficient. It is the responsibility of national malaria control programmes to develop strategic and annual plans based on national priorities in malaria prevention and treatment policies. The Regional Office has been instrumental in the development of the first generation of strategic plans for malaria control in the African Region. These plans play a critical role in countries efforts to develop successful applications to GFATM. According to the progress report on the Abuja Plan of Action, all 39 countries reported having a national health policy and most (92%) reported having district health plans that reflect a national health policy. Almost all countries (97%) have basic health intervention packages, including those for malaria. These intervention packages are being implemented in more than 80% of health facilities of more than half (54%) of the countries. In any health system, financing health care related to malaria control is critical. Among 34 countries, national health expenditures ranged from 1% to 14.5% of the total government budget. Only Zimbabwe (14.5%) and Sao Tome and Principe (14%) are close to meeting the Maputo Declaration of July 2003, during which African governments agreed to allocate at least 15% of government budgets to health. 8 AFRICAN HEALTH MONITOR JANUARY JUNE 2006
Of the 32 countries that reported on the routine collection and use of health-related data, more than 80% indicated that all their districts were using health information system data for planning. Most countries (92%) have adopted the Integrated Disease Surveillance and Response approach, but only 50% are in the implementation phase. All countries reported having a national antimalaria drug policy. About two-thirds have changed their antimalaria drug policy, and one-quarter of these have either adopted or are implementing artemisinin-based combination therapy. Disease management The Abuja Declaration requests countries to develop packages of interventions, implementation guidelines and efficient mechanisms to address priority diseases. In order to reduce levels of childhood morbidity and mortality due to malaria and other diseases, WHO and UNICEF have developed the Integrated Management of Childhood Illness (IMCI) approach. IMCI is designed to deliver an effective package of curative and preventive care services by front-line health workers. Since 1995, many African countries have introduced and expanded implementation of IMCI. In addition to supporting Member States to adopt and implement IMCI and assess its impact, WHO has provided guidelines to shape up and strengthen collaboration between IMCI and malaria programmes at regional, national and sub-national levels. As a result, all reporting countries, except Mauritius, reported implementing IMCI, although at different levels. More than half of the countries (58%) are in the expansion phase of IMCI, and about one-third (36%) are in the early implementation phase. Among countries that are in the expansion phase, about one-quarter have 50% or more of their districts implementing IMCI. Provision of antimalarial drugs and malaria control materials Countries are urged to develop mechanisms to ensure adequate, uninterrupted and prompt delivery of effective malaria control drugs and materials as well as malaria education and communication. As a result of efforts made by RBM partners and WHO, there has been significant progress both in the provision of antimalarial drugs in the African Region and in the availability of drugs within health facilities. As a response to the fact that a rapidly increasing number of countries have reported intolerable levels of malaria-parasite resistance to the commonly used antimalarial drug monotherapies (chloroquine, sulfadoxine-pyrimethamine and amodiaquine), WHO recommends that treatment policies for P. falciparum malaria in all countries experiencing resistance to those monotherapies should be based on the highly effective artemisinin-based combination therapy (ACT). In 2004, more than 10 countries in the African Region were supported to adopt ACT. This accelerated adoption of ACT policy has been described as one of the fastest drug policy changes in public health history. Following these changes, countries were supported to update malaria treatment guidelines and training manuals. Data from health facility surveys in 15 countries (2000 2003) show the availability of firstline antimalarial drugs in the facility during the day of the survey ranging from 60% to 100%, with a median of 97%. These surveys were mainly done in countries where national policies were using chloroquine, sulfadoxine-pyrimethamine and amodiaquine. In addition, 17 countries reported that malaria parasite detection services (microscopy or rapid diagnostic tests) were available in 10% to 100% of health facilities. Disease prevention According to the Abuja Declaration, the promotion of preventive measures for malaria should be in the forefront of control efforts in the African Region. The three core malaria prevention strategies include insecticide-treated nets (ITNs), indoor residual spraying (IRS) and the use of sulfadoxinepyrimethamine (SP) for inter-mittent preventive treatment (IPT). Under trial conditions, ITNs have been shown to reduce malaria transmission by as much as 90%, with concomitant reductions in malaria-related morbidity. WHO and RBM partners have provided substantial support to countries in planning the procurement, management and distribution of commodities such as ITNs and SP tablets. Efforts to scale up coverage of ITNs are underway in most African countries and are greatly assisted by global initiatives such as the GFATM, the Dutch Project, the World Bank Booster Programme and the US President s Malaria Initiative. Residual spraying should also be scaled up in settings where it is appropriate to do so. AFRICAN HEALTH MONITOR JANUARY JUNE 2006 9
Prevention of malaria during pregnancy has often been sidelined in mainstream policy discussions because of lack of understanding of the impact of malaria on pregnant women in endemic countries. Despite the enormity of these adverse effects, malaria prevention and control during pregnancy has not received broad programmatic support until recently (Figure 1). The level of support to the prevention and treatment of malaria during pregnancy is expected to be scaled up as a result of the publication by WHO of the strategic framework for malaria prevention and control during pregnancy in areas of stable malaria transmission. Figure 1: Status of malaria intermittent preventive treatment implementation and adoption, July 2005 Low levels of ITN coverage in the Region remain a main challenge for the RBM partnership and to malaria control campaigns. Results from Demographic and Health Surveys or Multiple Indicator Cluster Surveys conducted between 1999 and 2003 (mostly in 2000) show that the proportion of children under-five years who slept under a treated net the night preceding the survey ranges from 0.1% to 23%. Unlike other major malaria interventions, intermittent pre-ventive treatment for pregnant women has not been adopted and implemented widely. Among 14 countries surveyed, only one-third are fully implementing the strategy. The number of countries using indoor residual spraying for mosquito control in Africa is increasing. At the end of 2003, one-half of the countries surveyed reported using this method. Surveillance, epidemic preparedness and response In order to strengthen malaria surveillance and epidemic preparedness and response, the Abuja Declaration calls on countries and their partners to develop information capabilities that can facilitate the generation of timely and complete malaria data. Malaria surveillance data are indispensable not only for programme planning, monitoring and evaluation, but also for early detection and response to disease epidemics. An efficient epidemic preparedness and response system is expected to prevent malaria epidemics from becoming human tragedies. In order to strengthen epidemic preparedness and response efforts in the Region, the WHO Regional Office initiated a programme called Integrated Disease Surveillance and Response (IDSR). As an element of the overall Health Management Information System, the role of IDSR is to collect, compile, use and report morbidity and mortality data for 19 diseases. These include seven epidemic-prone diseases; four are targeted for elimination, and eight (including malaria) are of public health importance. These data are collected on a weekly or monthly basis, depending on the epidemiology of each disease in a given country. Since IDSR has recently been introduced, it is not widely implemented in all districts of many countries. About one-half of the countries reported at least one malaria epidemic within the past five years. The number of epidemics reported over the five years ranges from one to 42, with a median of six per country. Given that only one-quarter of countries have weekly malaria surveillance, it is unlikely that most of the reporting countries are able to detect and respond to malaria epidemics within twoweeks. Of the 39 countries, 34 (90%) have sentinel sites for monitoring antimalaria drug efficacy. The number of reported sites in all countries is about 200, ranging from two to 12 sites, with a median of six sites per country. Countries are urged to develop 10 AFRICAN HEALTH MONITOR JANUARY JUNE 2006
Sustainable control Human resources development Research mechanisms that would sustain efforts to control malaria within their boundaries. Since the Abuja Declaration, an increasing number of national authorities have offered tax reductions or waivers on antimalaria drugs, ITNs or malaria control materials. More than 70% of countries have reduced or waived tax on antimalaria drugs, with reductions as high as 60% on ITNs and 30% on other malaria control products. To reduce the risk of increasing mosquito-breeding sites, 24 of the 39 countries (60%) reported conducting environmental risk assessment for new development projects. Most countries (60%) have included malaria prevention and treatment-seeking behaviour in the primary school curriculum. Skilled health workers constitute the backbone of malaria control efforts in all endemic countries. Over the years, the number of professional personnel involved in malaria prevention and control has been increasing gradually. In 1999, the professional staff for national malaria control programmes in 34 countries numbered 251 as compared to 378 in 2003 (about a 50% increase). Besides the expansion of IMCI training, malaria-specific in-service training, such as case management and vector control, has increased over the years. More than 50 000 professional health workers and about 37 000 community volunteers received training in malaria case management in the past five years. In collaboration with national and international partners, countries are urged to develop or strengthen malaria-related research capabilities within their boundaries. Since the Abuja Declaration, a new antimalaria drug, chlorproguanil-dapsone has been developed. New interventions, tools and strate-gies such as combination therapy and home-based management of malaria have also been developed for use at community and national levels. Table 1: Progress towards the Abuja targets, selected countries Product % U5 who used ITN the night before survey % pregnant women (15-49 yrs) who used ITN the night before survey Of women who had a live birth 5 yrs preceding the survey, % who took any antimalarial for prevention during pregnancy for the most recent birth Of women who had a live birth in 5 yrs preceding the survey, % who received IPT during ANC visits for the most recent birth % U5 with fever or convulsions in 2 wks preceding the survey who took an antimalarial the same day or next day of onset of symptoms Burkina Faso 1 More than one-half of the countries reported conducting several operational research studies on new antimalaria drugs, particularly on combina-tion therapy. Nine of 10 countries reported having effective collaboration between national research institu- Cameroon Mauri- 2 Ghana 1 Kenya 1 tania 1,2 Nigeria 1 Uganda 3 Zambia 4 1.6 0.9 3.5 4.6 4.1 1.2 3.2 6.5 2.6 1.3 2.7 4.4 6.6 1.3 0.5 7.9 64.0 46.6 58.1 21.0 42.8 41.2 33.8 35.8 0.3 1.8 0.8 3.9 0.3 1.0 4.0 0.5 34.8 39.8 44.2 83.0 20.5 24.6 11.1 36.8 1 DHS 2003-2 DHS 2004-3 DHS 2000-01 - 4 DHS 2001-02 AFRICAN HEALTH MONITOR JANUARY JUNE 2006 11
tions and ministries of health, while one-fifth have established mechanisms for developing and coordinating priority research agenda. Progress towards the Abuja targets In 2000, African countries committed themselves to providing, by the end of 2005, prompt and effective treatment and ITNs for 60% of the people at highest risk of malaria and intermittent preventive treatment (IPT) for 60% of pregnant women. Despite progress made by countries in implementation, Table 1 shows that considerable gaps exist. Estimates indicate that progress has been slow in the attainment of the Abuja targets. These data suggest the need for the intensification and scaling up of efforts in order to increase the coverage of strategic interventions. As indicated in Table 1, implementation of these measures has been severely limited by a shortage of commodities. Since the beginning of the disbursement of GFATM funds for malaria that took place in 2003, some countries have reached or exceeded at least some of the targets. Conclusions and recommendations This review has provided a brief description of the journey accomplished so far in the implementation of the Abuja Declaration Plan of Action. It clearly indicates that all countries are taking some positive action. In spite of progress made, there is need for the intensification of scaling up of efforts because considerable gaps still exist. Member States and their partners should use the progress report on the implementation of the Abuja Summit Plan of Action as a source of inspiration to accelerate their efforts to achieve the established malaria targets. Based on the assessment of the level of implementation of the Plan of Action, the following recommendations were made: National authorities should intensify their efforts to scale up all core malaria control interventions for greater impact. Intensive efforts should be made to accelerate the adoption and implementation of intermittent preventive treatment in all endemic countries. Data collection, processing and reporting through national health management information systems should be strengthened at all levels. Appropriate and targeted information materials should be developed and used at all levels, particularly in areas where disadvantaged families live. With support from global initiatives such as RBM and the GFATM, Member States should initiate the process of generating coverage data that will be used to report on progress made towards the achievement of the Abuja targets in 2006 and 2010. *Dr Robalo is the Regional Advisor for Malaria Control at the Regional Office. 12 AFRICAN HEALTH MONITOR JANUARY JUNE 2006