ACKNOWLEDGEMENTS
1.1 Roll Back Malaria Strategy
The first CORE Group malaria-focused workshop, “Malaria Update: PVO Roles in Global Malaria Initiatives” was held at the Africare House in Washington, D.C. on September 30, 1999. More than 50 public health professionals from Private Voluntary Organizations (PVOs), USAID and its contracting agencies, and the international organizational members of Roll Back Malaria and the Centers for Disease Control and Prevention met to launch intensified cooperative collaborations with PVOs in the malaria sector. As a direct result of this workshop, it is anticipated that international organizations and PVO participants will join and work together in enhanced field-level collaboration in the fight against malaria.
The CORE Group (Child Survival Collaborations and Resources Group), a consortium of 35 U.S. PVOs implementing USAID-funded child survival projects, coordinated the workshop through its Malaria Working Group, chaired by Ms. Janet Meyers (Africare). The CORE Group received financial and technical assistance for the workshop from Basic Support for Institutionalizing Child Survival (BASICS) and Child Survival Technical Support Group (CSTS).
The Malaria Working Group organized the workshop as a mechanism to update the PVO community on the latest malaria strategies and technologies employed by the international organizations involved in Roll Back Malaria, and as a means to convey information back to international organizations on innovative malaria-focused PVO field projects. Even more importantly, the workshop served as a way to jump-start a practical dialogue between PVOs and international organizations engaged in the Roll Back Malaria initiative.
The workshop capitalized on the tremendous support and participation of international malaria technical experts fielded by the Centers for Disease Control and Prevention, UNICEF, the World Bank, the World Health Organization, and USAID and its contracting agencies. The collective array of malaria expertise (individual and organizational) among workshop participants is an example of the CORE Group's collaborative initiatives and development of multi-sector exchanges.
Goal:
The Malaria Update: PVO Roles in Global Malaria Initiatives workshop was intended to encourage and build practical collaboration among PVOs and the other partners of the Roll Back Malaria initiative.
Objectives:
The workshop had two broad objectives:
Outputs:
Expected outputs of the workshop were the following:
Output 1: PVO Malaria Programming Issues
Intended to provide PVOs with a brief overview of current strategy to increase and enhance their level of malaria programming. The final post-workshop report includes an “issues” section with such useful data as where to find summaries of scientific support of strategy, standards and guidelines for appropriate programming, and decision-making tools for PVO executives.
Output 2: Overview of PVO Activities Related to Malaria in Child Survival Initiatives
A briefing paper written by Uzo Okaoli, a consultant hired by Child Survival Technical Support (CSTS) in collaboration with the PVOs, is included as Annex D. The paper provides an overview of selected PVO activities in malaria.
Output 3: Recommendations for Collaboration in Malaria Programming
To promote PVO involvement, the post-workshop report includes a section which documents the identification of local, national and international discussion hubs and contact points, programming needs and issues, as well as funding opportunities.
Output 4: Resources List
To ease PVO identification of valuable planning and field implementation resources, a list of proven resources (documents, organizations with individual contact names, web resources, etc.) is available to participants.
Output 5: Informational Exchange
A mechanism for information exchange will be created during Session 5 to establish and promote long-term cooperation and communication among PVOs and the international malaria community.
Output 6: CORE Malaria Working Group Follow-up Agenda
Outcomes of the workshop provide a direction for the Working Group in terms of narrowing down potential activities within a manageable scope.
Activities:
The workshop consisted of three types of session activities: 1) presentations, including written outlines/summaries; 2) panel discussions; and 3) a resource table.
The content of this post-workshop report consists of a summary of the speaker presentations as listed in the workshop agenda (please refer to Annex B), additional information identified by the presenters and workshop recommendations, which are included as annexes. Presenters were provided the opportunity to review the summary of their presentations prior to publication.
Malaria is a killer disease resulting in well over a million deaths each year. With 300 million cases reported annually, the disease is a primary cause of debilitating morbidity of global proportions. The scope of the problem is magnified by the fact that a disproportionate number of malaria victims are pregnant women and children, who are particularly vulnerable to the disease.
To implement available and affordable solutions intended to cut malaria deaths in half, Roll Back Malaria was launched in October 1998 by the United Nations Development Programme (UNDP), UNICEF, the World Health Organization (WHO) and the World Bank. WHO provides technical leadership while UNDP and the World Bank provide resources and expertise. UNICEF's strong field presence provides a necessary and important link to governments and NGO partners.
The purpose of Roll Back Malaria (RBM) is to:
There are six elements of the RBM strategy:
1.2 The CORE Group
The Child Survival Collaborations and Resources (CORE) Group is a network of Private Voluntary Organizations (PVOs). All member organizations have been awarded Child Survival funds by the United States Agency for International Development (USAID)'s Office of Private and Voluntary Cooperation in the Bureau of Humanitarian Response since the program's beginning in 1985. As of September 1999, the CORE Group membership totaled 35.
The CORE Group's member PVOs are U.S.-based non-profit organizations supported by individuals, corporations and governments. Collectively, CORE members have an enormous impact throughout the world addressing not only the challenges of survival for children but of agriculture, education, economics, poverty alleviation, medical care, sanitation, environmental problems, and growth of democracy. CORE represents the health agenda of these PVOs and seeks to promote coordination and collaboration among the organizations as well as with other agencies. CORE provides a networking function which facilitates the exchange of knowledge among organizations. It also plays an advocacy role in promoting the work of these organizations to donors, agencies, corporations, universities, and the general public– all with the goal to increase Child Survival.
The CORE Group has six organized working groups: Behavior Change Communication; Integrated Management of Childhood Illnesses; Malaria; Maternal Reproductive Health and Safe Motherhood; Monitoring and Evaluation; Nutrition; and Quality Assurance.
The working groups promote the sharing of program expertise, and build capacity for delivering ever more effective health programs. The CORE Malaria Working Group was the leadership entity within the CORE Group which conceived of and organized the Malaria Update: PVO Roles in Global Malaria Initiatives workshop.
CORE Group Member Organizations (35)
Personal protection using insecticide treated nets (ITNs) and other materials is increasingly becoming integral to PVO CS programs, as part of an integrated malaria control strategy. The community component of the IMCI paradigm recommends the promotion of insecticide treated nets for personal protection of children from malaria.
Most rural communities have little or no access to treated nets, and find the initial cost, and cost of retreatment of the nets prohibitive. For PVOs involved in ITN as part of their CS malaria strategy, the major challenge is to provide adequate coverage of their target groups thus impacting the malaria burden and achieving sustainability through cost recovery.
An increasing number of PVOs are engaged in dialogue with governments over lowering the tariffs on netting and materials. They are also increasingly engaging in inter-agency collaboration in procurement, and delivery and distribution.
Regarding affordability:
As a component of their malaria prevention activities, a number of PVOs are engaged in encouraging communities to practice environmental control activities such as draining or covering standing water, and cleaning brush from around households. In addition, projects utilize teams responsible for organizing regular community-wide clean-up campaigns to destroy mosquito breeding sites, and hold clean village competitions. While such activities might be effective in promoting cleaner environments and good hygiene and sanitation practices, in most cases, they have little impact on the community's malaria burden as they are small in scale and in most localities, reduce the density of mainly non-malaria parasite carrying mosquitoes.
Examples of Collaborative Efforts:
PVOs have demonstrated a willingness to meet the challenges of finding and implementing sustainable integrated malaria strategies that reduce the disease burden in vulnerable groups. A community based multi-sectoral approach will increase access to many communities and ideally foster positive relationships between PVOs and the communities they serve.
Presenter: David Nabarro
Malaria's challenge is a development issue, not a health issue. Malaria keeps societies poor. It is a worsening threat: serious epidemics are being reported. Climate changes and population movements increase the threat. Adding to the problem, the parasite is resistant to commonly used drugs in much of the world.
3.3 Progress in RBM
3.4 Support Networks for the Development of Technical Capacity to RBM
3.5 PVO Roles
Dr. Nabarro was appointed by Dr. Gro Brundtland, Director General of WHO, to manage the World Health Organization's RBM project in October 1998. He took the post in January 1999.
4.0 PVO Collaboration in Operations
4.1 World Bank Malaria Program
4.1.2 Spotlight Countries
4.1.3 Opportunities for World Bank-PVO Collaboration in RBM
4.2 Malaria and Complex Emergencies
4.2.1 What is a “Complex Emergency”
4.2.2 RBM Complex Emergencies Network
Africa:
Asia:
4.2.3 Progress to Date
4.2.4 Potential PVO Contributions to RBM in Complex Emergencies
4.3 Malaria Control in Complex Emergencies: Highlight South Sudan
4.3.1 Background and Terms of Reference
4.3.3 Requesting Network Assistance
A request should include a terms of reference with a detailed plan of action. The terms of reference should reflect a general consensus of the situational needs as defined by all involved agencies. All agencies involved, including donors, should receive copies of the request for assistance to facilitate open communication. Specific areas of expertise needed should be specified.
4.4 Malaria and Behavior Change
Jeanne Brown (BASICS) led participants through the key behaviors of mothers/care givers, providers and the community, as related to malaria and behavior change. She concluded by outlining potential activities and mechanisms to consider for enhanced collaboration between PVOs and international organizations with respect to malaria behavior change initiatives.
4.4.1 Key Behaviors
It is important to understand key behaviors before efforts can be made to change them. There are several dimensions to consider: whose behavior is being targeted (that of the mother/caregiver, provider or community), and what kind of behavior is being targeted (preventive, curative or sustaining). While there is an important need to influence and support behavior change at all levels, Ms. Brown emphasized the role of sustaining behavior, and the important role of communities, without which preventive and curative behavior change has limited impact.
Preventive behavior:
Curative behavior:
Sustaining behavior:
4.4.2 Recent Efforts
In the CORE Group, both Malaria and Behavior Change Communication Working Groups have been formed. There is recent research on care giving and care seeking behaviors in Zambia, Kenya and Mozambique as well as some research on efficacy of bednets.
5.0 Presentation by USAID Global Bureau
On behalf of USAID's Global Bureau, Hope Sukin stated that malaria is a “top priority issue,” and the role of PVOs is absolutely critical. USAID and WHO agree that PVOs have to be at the forefront in this sector. Studies by the Special Programme for Research and Training in Tropical Diseases (TDR) of the World Health Organization in Geneva which covered six countries in the past three years showed that over 80 percent of mortality is due to malaria, and it happens in communities. It is essential that we reach those communities with treatment and caregiver assistance.
6.0 Collaborations in Technical Focus Areas
The panel provided an update on innovative strategies and collaboration for operations research. It was designed to be very PVO focused: how can PVOs become involved in operations research (including funding mechanisms), and how to acquire information and contribute to the policy discussions on current strategy and best practices. Panelists were Kopano Mukelabai (UNICEF), Monica Parise (CDC) and Michael Macdonald (BASICS and NetMark). The panel was moderated by Elise Jensen (Project HOPE).
6.1 Improved Community-Based Activities
Kopano Mukelabai's presentation provided an overview of UNICEF's partnership within RBM, and focused on improving UNICEF/NGO collaboration at the community level. Major points discussed were:
6.1.1 UNICEF's Role in RMB; Major Focus Area at Country Levels; RBM Support Activities during 1999
Dr. Kopano Mukelabai, Senior Health Advisor to UNICEF in New York, introduced his topic by thanking the CORE Group for inviting UNICEF to the workshop, and having the opportunity to discuss how to improve the collaboration between RBM partners and NGOs/CBOs in implementing malaria control programs at the community level. UNICEF appreciates the role of PVOs/NGOs in health care delivery.
6.1.2 Validated Approaches to Control Malaria; Lessons-learned from UNICEF-supported Malaria Control Programs
UNICEF has been active in malaria control activities for approximately ten years, and some validated approaches and lessons-learned can be concluded, which Dr. Mukelabai shared with workshop participants.
6.1.3 Key Challenges for the Future; Reaching Marginalized Populations
The “difficult to reach” are people from diverse ethnic groups and cultures who are being deprived of their fundamental human rights to health, nutrition, education and participation in society. They are among the poorest and most marginalized groups and include those living in remote regions or on the streets, ethnic minorities, indigenous peoples, nomads, single mothers, children with disabilities, children abandoned upon the loss of parents due to AIDS, refugees and internally displaced persons (IDP) due to wars or natural calamities. They are people who lack access to basic social services and opportunities because they cannot afford the fees. They do not have transportation, and may have physical disabilities or face social, political and cultural barriers. They have the highest rates of malnutrition, morbidity, mortality, and illiteracy. These “difficult to reach” people and populations require special attention.
6.1.5 Conclusion
UNICEF is in a good position to enhance the work of NGOs/CBOs through its country-based programs. Private voluntary organizations and NGOs can play a pivotal role in reducing malaria mortality and morbidity. Communities know what they need, even though they may not always know how to achieve their objectives or have the means to do so. The greatest contribution of NGOs/CBOs is the ability to work within communities and provide appropriate health services coordinated with government services at district and national levels.
6.2 Facility-Based Activities (IMCI and Drug Resistance)
Anti-malarial drug resistance poses challenges to malaria control. The adverse public health impact includes increased malaria incidence, increased case-fatality rates, changes in species distributions (increased P. falciparum), and increased malaria-associated low birth weight. In the face of increasing drug resistance, PVOs can impact on many of the factors that are needed to enable effective treatment.
6.2.1 Resistance
Resistant parasites have the ability to survive and/or multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended but within the tolerance of the subject. Dr. Parise briefly summarized R3, R2 and R1 type resistance, which measure parasites. What is more useful than measuring parasites, however, is decreasing children dying from malaria. Therefore, measures that incorporate the clinical response to drugs, rather than solely the parasitologic response, are now felt to be more useful.
6.2.2 Impact of Anti-malarial Drug Resistance
Dr. Parise provided a brief summary of the state of drug-resistance malaria: there are now higher malaria-specific mortality rates; an increased proportion of P. falciparum infections; increased case-fatality rates; epidemics with significant fatalities being reported when ineffective drugs are put to use; and an increase in malaria-associated LBW when ineffective drugs are used.
6.2.3 Geographical View of Status of Drug Resistance
The main areas where chloroquine-resistant P. falciparum (CRPF) has not been reported are the island of Hispaniola, most of Central America, small areas in South America, and parts of the Middle East.
6.2.4 Current Policy Changes/Studies (focus on Africa)
Many countries are beginning to re-evaluate their current policies (which mostly favor chloroquine as the treatment of choice). In the short-term, Fansidar will likely be the next drug that many choose. In the longer-term, other possibilities include Lapdap (chlorproguanil/dapsone), Lapdap and artesunate, Fansidar and artesunate, and chloroquine or amodiaquine and artesunate.
6.2.5 PVO Involvement in Effective Treatment
Dr. Parise suggests five major areas where PVOs can become involved in supporting effective treatment:
6.2.6 Recommendations
Dr. Parise emphasized that providing an effective anti-malarial drug is the number one solution to reduce morbidity and mortality in malarious areas. Other recommendations include: rational drug policies based on surveillance data, and new protocols which are based on these policies; adequate supplies of appropriate drugs; and education is needed for patients, caretakers and community health workers.
Malaria infection during pregnancy leads to adverse consequences for both the mother and her infant. These consequences include a contribution to maternal anemia, LBW of the infant, severe disease, spontaneous abortion/stillbirth, and premature delivery. Consequences vary with the level of malaria transmission. Effective anti-malarial medication for prevention or intermittent presumptive therapy (IPT) can decrease placental malaria, LBW, and maternal anemia. PVOs can impact the delivery of effective interventions.
6.4 Insecticide-Treated Materials
Michael Macdonald (Technical Officer, Malaria for BASICS and the Technical Advisor for NetMark) provided an overview of the NetMark public-commercial partnerships project for the sustainable marketing of Insecticide-Treated Materials (ITMs) in Africa. There are four primary areas for PVO technical and operational collaboration with the NetMark Project: demand creation, affordability of ITM services, accessibility and appropriate use (i.e. that targeted pregnant women and children under five are using the ITMs in an appropriate way). A fifth area for PVO involvement is in market or consumer research, or in public health terms, formative and operations research.
6.4.1 Introduction
The tremendous potential of ITMs to reduce mortality, especially in Africa, has been documented through pilot projects. Efforts by Mr. Charles Gursky (Bayer) and others to make ITMs more readily available have led to the development of public-commercial partnerships, and the NetMark Project.
6.4.2 NetMark and PVO Collaboration for Malaria Control in Africa
One of the focal areas for NetMark will be raising malaria awareness and demand for ITMs. Issues related to caretaker recognition and demand for quality curative services lie outside the NetMark mandate but offer a very good potential for collaboration with PVOs.
An important area for two-way collaboration between NetMark and PVOs is that of capacity-building and operations research. There is particular need to focus on consumer/market areas of research, i.e. formative research.
6.5 Summary of Question and Answer Period
Monica Myers, Project Manager of the NASA Goddard Space Flight Center's Climate Change and Human Health Initiative, provided an overview of how PVOs and NASA could work together effectively in the health field.
The NASA Earth Science Enterprise is a new Earth-observing program of satellites, data systems, networks and technologies that will be taking new, integrated measurements of the planet at resolutions not before available. This data will be available at either no charge or only the cost of reproduction. The Division of Applications, Commercialization and Education (ACE) is developing new applications for this data and a key focus is human health and the development of Early Warning Systems (EWS) examining infectious disease outbreaks as they are linked to the local environment. Early warning systems (EWS) using environmental data are now in validation and are expected in some cases to predict infectious disease outbreaks up to two years in advance. The research approach is now being used to investigate malaria, dengue, encephalitis, and ebola. In Kenya, Tanzania, Uganda, Ethiopia, Cote d'Ivoire, Madagascar, and South Africa the approach is in use for malaria; in Thailand, Burma, Cambodia, and Viet Nam for dengue. Currently NASA is using eight different sources of data for integrated environmental assessment.
8.0 Communications and Collaboration
Session 5 was a panel entitled “Communications and Collaboration”, focusing on communications and contact points for follow-up. Representatives from WHO (Maire Connolly); UNICEF (Kopano Mukelabai); the CDC (Monica Parise); and USAID (Kate Jones) each presented a very brief closing commentary on how communications should be carried forward. This was followed by a general discussion/question and answer period.
Kate Jones said she was discussing collaboration as both a grants manger and a Foreign Service field health officer, because the collaboration really takes place at the country level. USAID/PVC encourages the PVOs to work together at the country level to better influence national policy, collaborate with the donors, and to improve all the PVO programs. She said that she has just heard of CORE Group “clusters” being formed in Kenya and Tanzania. Ms. Jones paraphrased the CEO of one of the PVOs, who is a former executive of a large corporation. He expressed his admiration for the CORE Group and the selfless sharing of technical information that benefits all. He told her that this kind of collaboration is unheard of in Industry.
Kopano Mukelabai is looking forward to active collaboration at the country level. He would like to know where PVOs are geographically, and to begin to share lessons-learned. It may be possible to visit work going on in-country among agencies.
Maire Connolly sees great progress at the international level, with governments, during the last 12 months, but challenged the participants to discover how to get contact with PVO field representatives, and encourage them to meet with the malaria people in their countries. She would like to see a group of 5-6 PVOs together to distribute ITNs in northern Kenya, for example.
Monica Parise emphasized that the CDC does many of the technical consultations. She does not know which PVOs are working in each country, but the CDC is open to dialoguing with PVOs in-country if they are aware of the organization's presence. The CDC can provide technical advice, and comment on protocols. Dr. Holly Williams mentioned that the CDC can do mentoring through some drug trials, such as is happening with HAI.
8.5 Summary of Question and Answer Period
Janet Meyers (Africare, Chair of the CORE Group Malaria Working Group) summarized the workshop, noting that speakers have gone into a fair amount of depth, their presentations have been very technically informative, and that there has been great opportunity for good contacts. Much of the future collaboration needs to be focused in the field, and this is where we need to make our contacts. On behalf of Africare, Ms. Meyers intends to get the information shared in this workshop to Africare's field staff, along with technical updates. She thanked the speakers and participants for providing plenty of ideas for the CORE Group's Malaria Working Group to use in future planning.
Victoria Graham (CORE Group) closed the workshop, noting it as a very stimulating day, and thanking all speakers and participants for their part in making it a success.
Uzoamaka (Uzo) Okoli worked most recently as a Malaria Consultant to CARE's Somalia and South Sudan office, and has previously worked with MERLIN (South Sudan) and the Tear Fund (Sierra Leone) on malaria programs. She has a Masters degree in Applied Parasitology and Medical Entomology from the Liverpool School of Tropical Medicine, UK.
3.0 The Roll Back Malaria Initiative
A summary of Dr. Nabarro's presentation, “Rolling Back Malaria: How PVOs Can Contribute to the Success of the Roll Back Malaria Partnership,” can be obtained in its entirety via email from
nabarrod@who.ch.
David Nabarro's presentation served to provide structure to the workshop as a whole by defining the strategy and approach of the international partnership called “Roll Back Malaria” with which PVOs are urged to coordinate their own malaria activities at regional and national levels. He introduced five issues he would be covering, which serve as sub-sections in this synopsis of his presentation:
RBM has its roots in the Accelerated Programme of Malaria Control in Africa, which came about during the 1990's through an agreement of Organization for African Unity (OAU) Heads of State. The African Initiative on Malaria was launched 1997 by governments and development partners, WHO and the World Bank. Success of the Initiative was made a priority by Dr. Brundtland, Director General of WHO in 1998. The Global Initiative to “Roll Back Malaria” was launched in October 1998 by WHO, in full partnership with the World Bank, UNICEF, and the UNDP. It is significant that this initiative came out of needs expressed by African entities, not the west.
3.1 The Malaria Challenge
Malaria primarily affects the poor. Dr. Nabarro referred to a commentary by economist Jeffrey Sachs (please see Annex G for commentary) which demonstrates how malaria promotes, precipitates and maintains poverty. Since the 1970s there has been a rising death rate in Africa from the disease.
Malaria is making a comeback in a number of nations: Armenia, Azerbaijan, Chechnya, Dagestan, Russia, Tajikistan and Turkey to name a few, where the disease was previously eradicated. While chloroquine resistance is nearly everywhere, Fansidar resistance is also widely reported, and in the Mekong grouping of six countries, there is multi-drug resistance. Anti-malarials are frequently unavailable in health centers, but can be found in local shops, which presents another special challenge.
There are promising interventions. Insecticide-treated nets (ITN) can reduce malaria-specific death by over 20 percent (with a range of 18-50 percent). Prompt management of persons with malaria using effective treatment—ideally within 8 hours of the start of symptoms in children—can reduce mortality even further. Malaria mortality now can be halved, but there is strong need for health sector development, community action, social marketing, PVO support and public-private action (including franchised care) to intensify the response.
Dr. Nabarro mentioned the cost per DALY (disability adjusted life years ) averted, an important mechanism used by the World Bank to convey the cost effectiveness of activities such as malaria interventions. Intermittent treatment during pregnancy, improving access to drugs, improving compliance with treatments and distributing ITNs have a DALY averted of less than $50 (U.S.).
3.2 RBM Concept, Strategy and Approach
RBM calls for a massive effort, a 30-fold increase in:
Coordinated action is essential. Fragmented action encourages drug-resistant parasites and insecticide-resistant mosquitoes. It is for this reason that RBM is a global partnership, and not merely a “U.N. only” driven malaria program. The challenge of malaria is more important than individual organizations.
RBM is a 10-year effort, which will extend to 2010. Its real power stands in partnerships at the country level.
The six elements of RBM strategy are:
Since 1998 WHO has sponsored a Malaria Cabinet Project to provide a strategic umbrella to RBM, serve as a secretariat for partnership, encourage consistency of technical support, and promote coordination. This project is authorized through 2003.
Concept, strategy, and consensus-building took place in early 1999 in regional meetings. Country partnerships began in May 1999 and will continue with the development of national intentions for action, with intensification from 2000 forward. There are already several strong examples in Africa, the eastern Mediterranean, Asia and the West Pacific, with extensive NGO involvement.
Capacity-building actions are being focused by WHO Country Offices, especially in Africa. There is a need to locate resources and technical support for national actions: PVOs have a definite role here.
Situational analysis is taking place at regional and country offices. Countries in Africa with RBM action underway are: Botswana, Chad, Eritrea, Ethiopia, Gambia, Ghana, Mali, Mozambique, Niger, Sudan (North and South), Swaziland, Tanzania, Uganda, Zambia, Zimbabwe and Mauritania. In other regions, RBM countries are: Afghanistan, Azerbaijan, Bangladesh, Cambodia, southern China, India, Indonesia, Laos, Myanmar, Nepal, Oman, the Philippines, Sri Lanka, Tajikistan, Thailand, and Vietnam.
Some examples of active partnerships include:
PVOs can have a pivotal role.
Dr. Nabarro shared with the group 12 areas of technical support for national RBM actions, which are designed to help develop national capacity:
He noted the strong support from key strategies including IMCI and Making Pregnancy Safer (MPS) with PVOs and UNICEF, and the upcoming 2ndInternational Conference in Tanzania in October 1999. Please refer to Annex H for a brief report on this conference, which took place very soon after this workshop and was attended by Malaria Working Group member Larry Casazza (World Vision).
Dr. Nabarro provided a substantive list of potential PVO contributions to RBM, which outlines specific kinds of activities PVOs should be building into programs they support:
PVOs are urged to establish RBM partnerships at the country level (note that there may be some funding available to PVOs at this level). If national partnerships are difficult to find, link up with national malaria initiatives, or with representatives of WHO, UNICEF, UNDP or the World Bank. Information on technical support networks can be requested via email (rbm@who.int).
RBM is interested in hearing success stories to post on the web or use in their newsletter. Dr. Nabarro shared a success story from Afghanistan where covering cattle with insecticide resulted in decreased malaria in the home, decreased ticks on the cattle and increased milk production. Success stories are the “motor of the movement.”
David Nabarro qualified as a physician in 1973. He worked in the UK National Health Service, as a District Child Officer in the isolated Dhankuta District of East Nepal with the Save the Children Fund. He has served with the London School of Hygiene and Tropical Medicine, and again with the Save the Children Fund in 1982 as Regional Manager for the Fund's work in South Asia. Other assignments include the Liverpool School of Medicine as a Senior Lecturer in International Community Health, the British Overseas Development Organization (ODA) as a Strategic Adviser for Health and Population Work in East Africa, based in Nairobi; and Chief Health and Population Adviser at the ODA London Office and Department for International Development.
3.6 Summary of Question and Answer Period
David Oot (SAVE) introduced the four panel members for Session 3: Stephen Osika of the World Bank, Maire Connally of WHO/Geneva, Holly Williams of the CDC who serves on the RBM Technical Resources Network, and Jeanne Brown of BASICS. The panel focused on how to expand collaboration between PVOs and the international organizations partnering in RBM, with a view toward PVO partnering potential, expansion and larger-scale operations. Panelists gave short presentations outlining their organizations' malaria-focused activities and/or their own specialty area in the operations arena. A question and answer session followed.
Stephen Osika's presentation provided workshop participants with an understanding of the World Bank's role in RBM and in malaria programming in general, from his perspective as the malaria specialist on the Malaria Team at the World Bank headquarters in Washington, D.C.
He covered three main topic areas:
4.1.1 World Bank Role
The World Bank, together with WHO, UNICEF and the UNDP, jointly launched RBM in November 1998. Early activities included joint consultative missions by all partners to Eastern African countries with common borders (a choice based on convenience): Eritrea, Ethiopia, Kenya, Malawi, Mozambique, Tanzania and Uganda. The missions provided an overview of country-specific needs, opportunities and partnerships. PVOs at country levels were consulted during the joint missions.
While the consultation reports have yet to be distributed, a summary of the key findings include:
Within the concept of RBM, the Bank is engaged in additional malaria-related activities, including: involvement in pharmaceutical policies; consideration of the economics of malaria; a workshop on infrastructure and malaria (a copy of the workshop report, “Identifying Opportunities to Address Malaria through Infrastructure Projects,” dated June 9-10, 1999, was included as a handout to participants); cross-sectoral work in education, infrastructure and the environment; involvement in easing taxes and tariffs on bednets; and direct financing. The World Bank has invested over $200 million (U.S.) in over 25 countries for malaria-related activities, a portfolio of both stand-alone and integrated projects. Refer to Annex I for a listing of World Bank projects with malaria components.
Dr. Osika compared the above malaria investment with the Bank's overall Health Nutrition Population cumulative lending which totals $10.7 billion for 162 projects in 82 countries. While investment in current malaria-related programs is relatively small, investment is likely to increase within the context of RBM.
The World Bank together with other RBM partners have selected the following countries for focused malaria-related activities. These countries are referred to as “spotlight” countries: Angola, DRC, Ethiopia, Kenya, Mali, Mauritania, Mozambique, Senegal, Tanzania, Uganda, and Zambia.
There are opportunities in the spotlight countries to work with PVOs. PVOs should meet with Bank staff at resident missions at the country level, with Bank public information center staff, with the “malaria team,” NGO group and country teams at Bank headquarters. Since much of the Bank's financing is through government entities, PVOs should participate as part of a Bank-government-PVO “trialogue.”
Mechanisms for collaboration include the “small grants program” whereby a PVO can bid for funds for activities. Dr. Osika also mentioned the “development marketplace,” an initiative within the Bank in which PVOs and other interested parties can present innovative ideas to be supported by the Bank. Additionally, PVOs can be sub-contracted for training and project work, especially for capacity-building.
The Bank is also a “knowledge bank” which has its own institute which provides training and other technical resources. The Bank can work with PVOs/NGOs in procurement (within the context of a Bank financed project), research and analysis, and through dialogue on policy issues with countries.
Stephen Osika is a Public Health Physician with specialist training in Health Management Planning and Policy. He has worked in countries covering both developed and developing health care systems including Belarus, Uganda—his home country, England and Wales. He is currently the malarialogist for the World Bank's Malaria Team based in Washington D.C., joining the team in November 1998. This team is the focal point for the Bank's response to the global Roll Back Malaria (RBM) initiative.
His most recent posting before joining the World Bank's malaria team was that of Lecturer in Public Health Medicine at the University of Wales, U.K., which also included a concurrent appointment as Senior Registrar in Public Health Medicine within the UK National Health Services (NHS).
Dr. Osika has written on health issues covering both the more industrialized and less industrialized countries including topics on decentralization of health services in Uganda, AIDS prevention and care in Uganda, outbreaks of SRSV (Norwalk-like viruses), winter outbreaks of acute diarrhea, notified travel-associated infections, stroke care, breast disease, cardiac rehabilitation, osteoporosis, malaria, and complex emergencies.
Maire Connolly is the Coordinator of the RBM Complex Emergencies Network at WHO. Her presentation examined the special challenges of dealing with malaria in the context of complex emergencies, and explained how the RBM Complex Emergencies Network evolved as a result of these special needs. The Network provides specific support to the work of PVOs engaged in complex emergency situation. There are a variety of ways PVOs can contribute toward rolling back malaria in these difficult working environments.
“complex emergency” is a situation affecting large civilian populations with war or civil strife and population displacement resulting in excess mortality and morbidity. Whether refugees or internally displaced persons are moving into host countries or areas of their own countries with or without stable government or government control, or if the area is in a post-conflict rehabilitation mode, Dr. Connolly stressed that these are all very difficult environments.
There are over 40 million refugees/displaced persons reported globally, and over 120 million people affected by complex emergencies. Of the countries with complex emergencies, 80 percent are malaria-endemic. Malaria has been shown to be the biggest health problem faced by those affected by complex emergencies.
PVOs are often the only health providers available, and everyone should realize that dealing with malaria control in complex emergencies may differ from that in stable situations. The displaced populations are more vulnerable through malnutrition or other exacerbating factors; there is an increased risk of epidemics, with the movement of non-immunes to high malaria transmission areas; environmental deterioration encourages vector breeding; local health services may break down, or become overwhelmed; there may not be a stable government, or any government, to work with; there may be many partners responsible for providing health services; with an on-going conflict, insecurity can make long-term planning difficult; and physical and transport barriers can delay access to needed supplies.
Dr. Connolly attended a meeting in December 1998, at which PVOs highlighted problems relating to malaria programming in complex emergencies. These included lack of technical knowledge of malaria among operating agencies; lack of information on drug resistance; delays in access to supplies, and transport barriers; poor coordination among PVOs, UN agencies and local authorities; many gaps in knowledge and few funds available for operational research; and lack of data on the malaria burden in complex emergencies.
As a result of this background understanding, the following key elements have been identified as part of a strategy for malaria control in complex emergencies:
The RBM Complex Emergencies Network was established and exists to deal with malaria in complex emergencies. It consists of a core group of malaria and emergency experts from organizations including WHO, UNHCR, UNICEF, the CDC, IFRC, ICRC, MSF, Merlin, and the Malaria Consortium, as well as a wider group of 20 additional malaria experts on a roster and available for field support. These experts are based at country, regional and HQ levels. The Secretariat is in EHA/WHO. Subgroups exist for rapid response, training, surveillance, operations research, and advocacy.
The Network is always trying to add people at country levels who are available for 2-3 week missions. Dr. Connolly would appreciate assistance from PVOs to identify possible candidates.
The Network's Terms of Reference are:
The Network has 16 current target countries:
Angola, Congo Brazzaville, DRC, Liberia, Sierra Leone, Somalia, Sudan, Great Lakes-Burundi, Rwanda, Uganda and Tanzania.
Afghanistan, Cambodia, Indonesia, Myanmar and Tajikistan.
The Network can support the work of PVOs in complex emergencies in many ways, including provision of set standards, guidelines and training material. The Network also provides up-to-date information on malaria in each complex emergency situation. Dr. Connolly gave a current example of a five-page document outlining malaria-related activities in East Timor. The Network monitors the malaria burden in each locale—a database is under development and should be ready by early 2000. Operations research priorities are also identified.
The Network can provide field support as well. Dr. Holly Williams (next presenter) went to South Sudan to work with CARE on their planning. The Network can facilitate communication between RBM partners at the country level, where necessary.
The Network was formally established in April 1999 and has moved rapidly to develop a strategy for malaria control in complex emergencies; prepare case studies in seven countries; prepare epidemiological profiles for nine countries including East and West Timor in Indonesia; develop its Terms of Reference, method of work and functions of its Secretariat; and complete a mission to South Sudan in August 1999 to review malaria control activities and plan next steps with CARE and other PVOs.
An inter-agency manual has been completed on malaria control in emergencies. There is connection with the WHO manual on communicable disease control in emergencies. A malaria database is under construction for the 16 target countries. The following operational research priorities have been identified: vector control, use of ITMs, delivery of ITNs, protection from malaria in pregnancy, and IMCI. Additional priority operational research projects will be identified, and a mechanism created to assist agencies in applying for funds.
The next steps include a rapid response team to East Timor within the next week, together with IRC; a PVO/donor meeting for European-based agencies in London, similar in scope to the CORE workshop; a mission to Angola and DRC to provide technical assistance for malaria control activities; finalizing and disseminating technical guidelines; and a Partners' Meeting on complex emergencies in Nairobi, Kenya in January 2000 to plan RBM activities at the country level. The Network needs expansion, with more involvement of PVO malaria expertise particularly at the country level.
Dr. Connolly presented a comprehensive array of ideas where PVOs can contribute toward RBM in the context of complex emergencies:
Maire Connolly has been a Medical Officer with WHO/Geneva since 1995. She has worked in the Department of Emergency and Humanitarian Action since 1997 as a focal point for communicable diseases and most recently as Co-ordinator of the RBM Complex Emergencies Network. She trained in public health/epidemiology in Dublin and London, and holds MD, MPH, DTM&H degrees and has field-level malaria experience in refugee camps in East Africa and South-east Asia.
Holly Williams of the CDC's Malaria Section and a member of the RBM Technical Resource Network, presented an example of the kind of assistance PVOs can expect from requests made to the Network, with a report of a recent trip she made to southern Sudan with Dr. Charles Delacollette of WHO/Geneva.
South Sudan has been affected by civil war since 1983. An estimated internally displaced population of 5.6 million has been assisted by relief efforts established by the United Nations in 1989, termed “Operation Lifeline Sudan (OLS).” OLS includes UNICEF, the World Food Program (WFP), WHO and about 40 NGOs. There are an additional 17 NGOs which operate outside of OLS.
An important aspect of relief assistance is to coordinate with the various rebel movements and their relief/rehabilitation agencies/associations. Relief efforts must tackle security risks, logistical problems, lack of currency, famine and extreme poverty. There is only a 10 percent literacy rate and a tremendous lack of trained health care personnel. Few women are in health care roles. Further, there is a lack of standardized salaries and incentives.
On the malaria front, no coordinating agency exists for overall malaria control standards, despite the major public health problem which malaria poses. Each NGO is setting its own policy; surveillance data is sketchy; and the overall approach continues to be relief-oriented, which may no longer be appropriate for parts of southern Sudan.
The Network mission's Terms of Reference was:
4.3.2 Mission Accomplishments and Summary of Major Findings
The mission itself consisted of a two-week rapid assessment by two consultants, Dr. Holly Williams and Dr. Charles Delacollette. The team met with rebel movement, NGO and UN representatives, in Nairobi, Kenya, Lokichoggio, Kenya (the staging point for OLS operations), and a number of locations within southern Sudan.
The team faced challenging logistical difficulties but was able to assess existing surveillance data, policy guidelines and training curricula; visit health care centers and units and training centers; and participate in informal discussions with villagers. The summary of major findings included:
Dr. Williams recommends that country-level PVO Health Coordinators should link with the relevant country RBM focal point. For proposed Field Missions please include network support in funding proposals to donors for malaria control.
Holly Williams is a behavioral scientist working for the Malaria Epidemiology Section at CDC. Her main areas of interest are malaria control in complex emergencies, socio-behavioral issues related to malaria control, and understanding the decision-making process related to setting national malaria treatment policy guidelines. She has had both clinical and research experience with various refugee situations, including the Thai/Cambodian border, self-settled Angolan refugees in northwestern Zambia, and in the Tanzanian refugee camps. Dr. Williams has just returned from a malaria assessment in southern Sudan on behalf of the Roll Back Malaria Technical Resource Network for Malaria Control in Complex Emergencies.
The CHANGE project and USAID have identified seven behaviors for long-term adoption, many of which correspond either directly or indirectly to positive malaria-related behaviors:
4.4.3 Collaboration
To foster collaboration between CORE Group members and international organizations with respect to malaria behavior change initiatives, it is important to share experiences, both successes and failures; to share information; to collaborate in developing effective behavior change strategies and interventions; and to share impact results.
Jeanne Brown is a specialist in communications development and marketing research with several years' experience working on communications and social marketing projects in Africa and the Middle East, including Morocco (where she lived for six years), Jordan, Tunisia, Senegal, Mali, Niger, Togo, Ghana, Uganda, Malawi, and Madagascar. Currently Ms. Brown is a Technical Officer for the BASICS Project
4.5 Summary of Question and Answer Period
If a PVO is considering requesting assistance, have a preliminary discussion with Holly Williams. The Network will discuss this (primarily Holly Williams and Maire Connolly), and respond by the end of the day.
By the start of 2000, there will be funds for the Network. In the interim funds have been provided by WHO for the South Sudan and East Timor missions. For NGOs, the Network must consider options, and prepare a sliding scale. During the first year of activity, it is suggested that PVOs organize themselves within a geographical area, similar to what CARE did in South Sudan. By June 2000 there will be more information available. Currently RBM country assessments receive funds through the WHO office of the country level MOH. Funding decisions are made by the MOH, or among RBM partners at the country level.
PVOs are making a difference. The challenge is, how can we take those instances where we are making a difference and scale up? What are the roles of PVOs and USAID?
Ms. Sukin envisioins CORE Group PVOs as part of a network to “scale up.” She considers today's meeting very important, and is pleased that partners from UNICEF and WHO participated. She plans to talk with organizers of the workshop and have a debriefing session to determine the next steps for the Global Bureau.
Dr. Kopano Mukelabai, M.D, DABP, FRCP(E) is Senior Health Adviser for UNICEF, at their New York Headquarters. Previously, he served as the UNICEF Country Representative in Eritrea, and as the Regional Health Adviser for UNICEF to countries in Eastern and Southern Africa. Dr. Mukelabai was formerly Dean of the School of Medicine at the University of Zambia, and Professor of Pediatrics, and Chairman of the Department of Pediatrics and Child Health at the University Teaching Hospital in Lusaka, Zambia. He is a Diplomate of the American Board of Pediatrics, and a Fellow of the Royal College of Physicians of Edinburgh.
UNICEF was mandated by the United Nations to help meet the basic needs of children so as to attain their maximum potential. UNICEF is an advocate for the protection of children's rights, as outlined in the 1989 Convention on the Rights of the Child (CRC); ensures the survival, protection and development of children which is integral to human progress; mobilizes political will to ensure “first call for children” i.e. ensure that children have priority to social services, at all times; helps protect the most disadvantaged children – victims of war, disasters, extreme poverty, victims of violence and exploitation and children with disabilities; mitigates effects of emergencies and mobilize humanitarian assistance; gives priority services to the most disadvantaged children and to countries in greatest need; promotes equal rights of women and girls and ensures their meaningful participation in development activities in their own communities; and works with other partners to attain sustainable human development goals.
UNICEF operates in over 136 countries. Through its programs, which are fully decentralized, UNICEF deals with health, nutrition, water and sanitation, education, gender and participation, capacity building, advocacy and social mobilization issues. Its mission emphasizes early childhood care, survival, growth and development, and continuing efforts to help all children to attain their maximum potential. The CRC guides UNICEF operations and collaboration with partners.
The World Summit for Children in 1990 set a goal of reducing under-five mortality by 50 percent by the year 2000. This goal is unlikely to be achieved unless malaria, HIV/AIDS, pneumonia, diarrhea, malnutrition, measles and neonatal tetanus are effectively controlled. It is important to link IMCI and malaria control, in this context.
To galvanize international support for malaria control, Roll Back Malaria was launched on October 30, 1998 by the Heads of WHO, UNICEF, UNDP and the World Bank. There is international commitment to RBM, including significant political will at the national level.
UNICEF currently supports malaria control programs in 33 countries, 27 of them in Africa, and will support the following activities in its country-based programs:
Dr. Mukelabai shared with participants some of UNICEF's supporting activities within RBM during 1999. These included an increased resource allocation to countries to help scale-up ITN projects ($2.4 million allocated to 11 countries over and above annual budgetary allocations); increased staffing for malaria at all levels; production of new promotional materials, including a revised chapter in the newest edition of Facts for Life, a malaria promotional booklet and a new edition of the Prescriber on malaria; coordination of the Technical Resource Network on ITNs; intensification of advocacy for reducing taxes and tariffs on bednets and insecticides (Tanzania has now withdrawn taxes on sale of mosquito nets); work with private sector to promote local production of mosquito nets; increased support to countries with WHO to improve GIS; and support to Health Sector reforms and UNDAF in several countries.
Lessons-learned include:
Dr. Mukelabai also pointed out a number of challenges to RBM. At the individual level, it is essential to recognize malaria symptoms early and seek appropriate treatment. Compliance in use and retreatment of nets needs improvement. At the community level, marginalized populations must be fully included. Drug vendors and village health workers need training and motivation. There needs to be an increase in local production and distribution of nets and insecticides.
At broader levels, a key challenge is good partnership coordination and resource mobilization, ensuring sustained political commitment and follow-up action. One necessary critical result should be a reduction of taxes on mosquito nets and insecticides.
Dr. Mukelabai suggested reaching marginalized populations by focusing on, and asking about, the poorest and most vulnerable women and children. In addition, program development should consist of a mixture of top-down and bottom-up planning, and there should be more designing of longer-term programs.
Programs need to be relevant to local needs, values and customs and utilize a wide variety of formal and non-formal approaches. Be creative and establish new communication channels. Promote community participation in planning and implementing programs. In whatever ways possible, enhance the status of women and girls in society.
To check a malaria program's impact, include the collection of disaggregated baseline data with respect to the most vulnerable groups up front. Suggested monitoring indicators include:
6.1.4 Enhancing Collaboration with NGOs/CBOs
UNICEF has decentralized authority to country offices, which have a mandate to work with governments, communities and NGOs through intersectoral collaboration in the areas of health, education, water and sanitation, information and communication.
UNICEF can assist in the procurement of nets, insecticides and drugs; development of IEF materials; advocacy; and social mobilization. Dr. Mukelabai mentioned a potential source of 100 dernier-strength nets, which cost $3.50 (U.S.) and take 6-8 weeks to arrive.
UNICEF recognizes some of the comparative advantages of NGOs/PVOs, including their ability to work in remote areas and reach disadvantaged populations, respond quickly to emergency situations when needed, and quickly earn the trust of communities. They generally have less bureaucracy and reduced overhead costs, and more flexibility in recruiting staff. In addition to monitoring the situation of malaria at community level, they train CHWs, traditional healers, drug vendors, etc., and distribute mosquito nets, drugs and insecticides to scale-up national programs.
This does not imply that CBOs/NGOs do not themselves face challenges, they do. They must, among other issues, deal with capacity building involving local staff; how to broaden services offered at the community level; consider how to assist communities form local CBOs; work with Youth and Women's groups in local production and distribution of nets; lobby donors and governments to reduce taxation on nets; and link up with other CBOs working in other sectors but in the same regions.
The presenter, Monica Parise, cited the following studies:
Dr. Parise's presentation, while providing a technical update, focuses mainly on operational issues. She introduced the following five topics, plus recommendations, which serve as sub-sections to this summary of her presentation:
Evaluations are currently underway regarding whether the use of combination therapy (artemisinin derivative with other drug) can decrease the rate of acquisition of resistance and decrease transmission (as was seen in South-east Asia). Safety information is being collected. Large demonstration projects are planned in Tanzania and South Africa.
Dr. Parise shared an interesting study on “cases correctly treated: 1994, end of training, 1-3 months after training, and in 1997,” which shows that correct use of protocols falls off with time, although malaria treatment with chloroquine had less errors than other procedures. It seems clear that health workers need more than instructions, they need a dialogue on why certain procedures work best.
Monica Parise is a physician trained in internal medicine and infectious diseases. For the past six years she had put her skills to use at the CDC. Her work is primarily international in scope and involves the prevention of malaria and its adverse affects in pregnant women and their infants, primarily in sub-Saharan Africa. She has also worked on malaria control and anti-malarial drug resistance issues. Initially trained as a registered nurse at the University of Pittsburg, Dr. Parise later attended medical school there and later specialized at Harvard University's Brigham and Women's Hospital.
In her second presentation, Dr. Parise cited the following useful, recent studies:
Dr. Parise recently gave a talk to the CORE Group's “Safe Motherhood” workshop: Effective Strategies to Promote Quality Maternal and Newborn Care. Please refer to Annex J for a short summary. Today's presentation included the three following topical sub-sections, plus recommendations for PVO involvement:
6.3.1 Public Health Impact
Adverse effects vary with maternal immunity and the level of malaria transmission. In high transmission areas, there will be significant low birth weight and anemia, with the most marked effects in primigravidae/secundigravidae. Some pregnant women will be asymptomatic. In low transmission areas, there is also severe malaria, spontaneous abortion and premature delivery, with all parties affected.
HIV-positive women have higher densities and prevalence of parasitemia. Fansidar efficacy appears reduced, and all gravidities are affected.
Attributable risk estimates are about 5-12 percent of LBW; 35 percent of preventable LBW; and 3-5 percent of infant mortality.
6.3.2 Potential Strategies
Studies to date have shown that children benefit more from bednets than pregnant women, and the effects can be seasonal in some countries. The main intervention is through drugs. Studies show that efficacious drugs (including chloroquine, SP, Maloprim, and mefloquine) can decrease LBW, but chloroquine's efficacy is increasingly limited due to drug resistance. Fansidar has been studied for IPT and other drugs will follow.
Intermittent treatment (IPT) is usually two doses to clear the placenta. Prompt case management is important in all areas.
6.3.3 Current Status
The WHO Expert Committee recommends that intermittent treatment with an effective, preferably one-dose anti-malarial drug delivered in the context of antenatal care should be made available to primi- and secundigravidae as an appropriate method for reducing the consequences of malaria during pregnancy in highly endemic areas. Such intermittent treatment should be started from the second trimester onwards and not be given at intervals of less than one month apart.
Malawi implemented IPT with Fansidar in 1993; Kenya has changed its policy and plan implementation; and other African countries are examining their current strategies. There are still remaining questions such as interaction with folate, which other drugs could be used for IPT, and dosing in HIV-positive women.
6.3.4 PVO Involvement for Effective Intervention
Dr. Parise suggests the following ways PVOs can become involved in helping take the necessary steps to provide effective interventions in pregnancy:
6.3.5 Recommendations
To conclude, Dr. Parise recommends that in areas of high malaria transmission where Fansidar is effective and drug resistance does not preclude its use, 2-dose IPT should be provided in the second and third trimesters. There is a need for PVOs and others to work on policies and programs to support this recommendation.
The manufacture and marketing of ITMs is a high risk business with low profit margin. NetMark is a partnership between the public and commercial sectors, to lessen the risk through sharing the costs of research and raising the general awareness of malaria and the benefits of using ITMs. NetMark is a five-year project to create demand for ITMs and create an environment for their sustainable marketing throughout Africa. The Project Partners are the S.C. Johnson Wax Company (a large consumer-products company throughout Africa); the Academy for Educational Development (AED); and group-contractors Group Africa Ltd., Johns Hopkins University, and The Malaria Consortium (London School/Liverpool School of Tropical Medicine), who will be dealing with issues of affordability and equity. There are precedents for this type of arrangement, including the Blue Circle in Indonesia, and the contraceptives distribution program used in Morocco.
NetMark aims to extend the geographic and economic reach of ITMs. PVOs can play a major role in improving access and affordability of ITM services to those who are truly beyond the reach of the commercial distribution network. NetMark also intends to promote the appropriate use of ITMs for children and pregnant women, positioning ITMs as a health product for women and children, not a luxury product, a message PVOs can complement through their antenatal care services and community-based programs.
Michael Macdonald, from Johns Hopkins University, splits his time between BASICS and NetMark. He started out in 1977 as a Peace Corps Volunteer with malaria programs in E. Malaysia (Borneo) and has since worked for the International Rescue Committee and various UN organizations, for malaria, dengue and refugee health programs in South East Asia and Africa. Dr. Macdonald has a doctorate in malaria entomology from Johns Hopkins, but now spends more time with budgets than with bugs.
The research team initiating the first model is the International Research Partnership for Infectious Diseases (IntRePID). IntRePID plans on developing a systems-approach to the use of Early Warning Systems. For example, surveillance data is expected to be collected over the Internet using a template derived from the WHO electronic surveillance system, FluNet, in Paris. Remote sensing data from the suite of NASA satellites will be subsetted at the Goddard Space Flight Center Global Change Data Center (GCDC). Predictive algorithms developed by participating researchers will be run at the GCDC with results returned to the monitoring organization.
Ms. Myers shared a satellite-derived predictive risk map for malaria in Africa, and a second overhead on the seasonality of malaria risk in Africa. A prototype study for malaria is going on now in 51 sites, using 8 km data.
NASA is interested to find out if any CORE Group organizations are willing to partner with this project by providing malaria surveillance data to enable the development of predictive models for Africa or South America. Ideal data sets are those from five to ten years in length. Please contact Monica Meyers (myers@daac.gsfc.nasa.gov).
Larry Casazza (World Vision) moderated the panel. He pointed out that RBM is moving rapidly to the national level, and up until now there has not been strong PVO involvement. With the stage now set, and with PVOs and international organizations having the same client, all are ready for the networking that can move RBM forward even more effectively. The CORE Group is about moving beyond old “competitions” and focusing on issues and points of contact.
Of the USAID BHR funded child survival programs, there are 22 Child Survival programs with malaria components, and of these, one is in Asia. This meeting (in Africare) is a start, bringing together PVOs and the other organizations working in malaria. This can continue at the country and even the local level.
As with IMCI, the challenge is to document successes of the PVOs. To do this, Ms. Jones challenged participants to include national and international universities as partners, which are a source of valuable in-country expertise. Some of the PVOs are already doing this.
Katherine (Kate) M. Jones has been a U.S. Foreign Service health officer with USAID for 19 years. She is currently Chief of the Child Survival Division of BHR/PVC, managing the PVO Child Survival Grants Program.
He suggests establishing working groups in-country. It is important to work with women's groups and youth groups. In Eritrea, a study was done of radio listening behavior, and this was used to target information. Schools can be targeted, because teachers and children can be agents of change. UNICEF is working with Ministries of Education to change curriculum (for example, in Malawi with AIDS).
UNICEF and WHO are sponsoring a consultant on IMCI and applying this to malaria. We need a list of knowledgeable national and PVO contacts who can be called upon in-country as consultants.
For communication/contact at international levels, both WHO and UNICEF maintain websites, and hold international meetings like the one coming up in Dar es Salaam (please refer to Annex I for details on this conference).