Did USAID, President's Malaria Initiative blunder malaria control in Angola?

The title of this post is a bit sensational for my tastes but honest in regards to the charges levied by Somandjinga et al in the Bulletin of the WHO. The history of malaria control is replete with stories of gaffes small and large. However, the “policy and practice” article contains frank and detailed criticism, which rarely ever appear in print, about USAID/PMI (previously introduced here) operations in Angola. Before summarizing the alleged mistakes, it should be stressed that all human efforts will be imperfect. Seems obvious but we often fail to recognize the difficulties faced in executing programs. This does not excuse lapses in critical thinking – rather it is to stress the importance of process. That the ability to acknowledge errors, learn from them, and iterate efforts may be more important than our propensity to commit mistakes.

Here are the USAID/PMI mistakes as stated, sometimes directly and at other times in between the lines, by the authors:

– Failure to gain demonstrated national commitment (in the form of increased malaria staff or local funds) prior to beginning the program

– Rush to implement the program

– Poor understanding and use of routine data

– Selection of a single control measure

– No pretreatment evaluation

– Disregard for objections from the authors (one of whom is the regional public health manager)

– False assurances regarding CDC support and data collection

– Communication barriers from a lack of language proficiency (Portuguese)

– All of which culminated in the spraying of the homes of 500,000 people in an area without adult mosquitoes or breeding sites, i.e. likely no to minimal malaria transmission

– Overall, inexperience of PMI-Angola leadership in malaria control

Does PMI accept these critiques? Have they learned from their mistakes? I emailed PMI asking if there was a public response to the article or if they wished to provide another perspective on this post. I was pleased to receive a kind and prompt reply which is posted below in its entirety. Readers can draw their own conclusions.

PMI Clarification:

Dear Mr. Naman Shah,

Thank you for your query sent to “Ask the Malaria Coordinator” regarding the recent World Health Organization Bulletin article authored by Somandjinga et al., which critiques some aspects of the President’s Malaria Initiative’s (PMI) work in Angola in 2005/2006.  The indoor residual spraying (IRS) program referred to in the article was the very first round of IRS supported by the PMI in any country.  Although important lessons were undoubtedly learned during implementation of this first spray round in Angola, the implementation of this campaign was considered a success with a 90% acceptance rate among householders in the communities targeted for spraying, more than 590,000 people residing in houses sprayed were protected from malaria, and with no outbreaks of malaria detected in these areas following the spraying campaign.

There are several statements found within the article that are factually incorrect.  It is inaccurate to state that PMI failed to secure national commitment prior to beginning the spray program.  Angola was selected as one of the first three PMI countries.  The process for country selection for the President’s Malaria Initiative has always included high level consultation between US Ambassadors and the host country leadership including Ministries of Health, and Angola was no exception.  The first annual operational plan for PMI support in Angola including support for the aforementioned IRS campaign, as with subsequent annual plans, was prepared in consultation and collaboration with the Angola National Malaria Control Program (NMCP).

Although the article points out that the target areas for the first spray round were areas later found to have low levels of malaria transmission, PMI selected the areas targeted for spraying with the support of the Ministry of Health of Angola and with direct guidance from the Angola National Malaria Control Program Director.  It is important to note that this first spray round was part of a multi-donor effort in the southern provinces of Angola, with PMI support complementing the IRS program supported by WHO in an adjacent province.   Furthermore, the spraying of these malaria-epidemic prone areas was consistent with current WHO guidance for selecting areas appropriate for IRS and the success of the first IRS campaign in Angola carried out in these low transmission areas provided the experience and confidence to enable successful targeting of IRS in higher transmission areas in future spray rounds.

Finally, PMI, working in direct collaboration with NMCPs in the 15 PMI countries and together with other donors and partners, has demonstrated significant progress in scaling-up malaria prevention and control interventions, with clear evidence of reductions in malaria burden in many of the PMI countries.  Specifically related to IRS, since 2005/2006 PMI has been leading efforts to incorporate IRS as a major component of malaria control programs in Africa.  PMI-supported IRS programs work in close collaboration with national and district government counterparts and have expanded emphasis on building local capacity to implement quality IRS activities, including placing significant attention to environmental issues and best practices surrounding the intervention.  Prior to the launch of PMI, IRS was only being implemented by NMCPs in a few southern African countries and in Ethiopia and Eritrea, in addition to limited private sector investments in a handful of African countries.  PMI has played a key role in re-introducing IRS as an effective malaria control tool in Africa.  Currently many African countries that are not among the 15 PMI countries, have begun or are planning implementation of IRS programs after having learned from the successful experience demonstrated by their neighboring NMCPs in collaboration with PMI.

It is important to note that two of the three authors of this article were former contract employees of the PMI IRS implementing partner.

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