Archive for the 'Operations' Category

Fighting malaria on the front line

Good sentences:

Malaria can not be won by fighting from the meeting room. It is won by fighting in the frontline where decision, appropriate for the situation, is implemented with decisiveness. The key to malaria elimination is the frontline worker and its supervisor… Seeing the result of his work will motivate the front line workers to perform better and lift up his spirit that he is contributing to the improvement of the world.

From Gil de la Cruz, a government medical officer in the Philippines, who shares his experiences directing local malaria elimination efforts.

Malaria in Brazil: achievements, lessons, and assessment of elimination

The title of this paper could also be “How to write about malaria programs and operations”. It is among the most astute, careful descriptions of policy and long-term changes in malaria incidence I have seen. The article deserves broad reading as it contains many lessons on research and control for other countries.

In the past 20 years, Brazil not only reduced reported cases but did so while inverting its falciparum:vivax ratio. While other cases of success have recently been reported, in Equatorial Guinea, The Gambia, Zanzibar, etc relatively short-term changes in small geographies are not as impressive as a sustained decline in a large country with a complex federal structure. In describing this achievement the authors focus on the systems they built (staff, financial, managerial) – and not simply on biomedical tools. They also recognize the danger of success for future efforts:

In summary, the inversion of the P. falciparum/P. vivax cases ratio in Brazil in the last two decades was a major achievement of the National Control Programme, leading to a substantial decrease in the number of deaths. However, this may be troublesome regarding the future perspectives of eliminating malaria in Brazil, since policy-makers are less prone to privilege investments in a disease with low fatality rates and with a massive incidence outside the economic axis area of the country.

With an admirable open and critical tone, they also explicitly address the possibility of elimination from an ecological perspective:

The present difficulties in reducing economic and social risk factors that determine the incidence of malaria in the Amazon Region render impracticable its elimination in the region.

It is a sober but wise assessment which avoids needless platitudes used by so many other leaders.

President's Malaria Initiative and Angola Part 2

Below is a comment, on the PMI clarification, from one of the authors of the WHO Bulletin article.

In regard to the Director’s response to criticisms about the PMI program in Angola, I would like to make a few comments, having written the article in English, with the approval of my two colleagues, especially Martinho Somandjinga, the first author and an experienced and highly competent malaria control official.

The primary fault in the whole story was the use of administrative reports on malaria, based on clinical diagnoses of malaria, which in fact were simply diagnoses of fever and headache.  No blood slides were taken to confirm these administrative reports.  Therein lies the problem.

The secondary problem we pointed out is that WHO, in their global planning and analysis, uses the same faulty administrative reports of fevers, instead of making lab diagnoses for the malaria parasite.

Thirdly, although Mr. Somandjinga and I worked out and recommended to PMI a monitoring plan complete with labs, blood slide collections, and microscopic diagnoses, PMI has continued to ignore the need for this more precise process for monitoring and evaluating their effort in Angola and in the rest of Africa.

The First Law for attacking malaria in Africa is that it is like building a huge cathedral or mosque, it will take generations.  So evaluation and monitoring is essential if we are to make progress over the next several decades.  You cannot control malaria in Africa with public relations, it is a tough disease.

A really good sign however, is the increased role of epidemiologists from CDC in PMI and in Geneva.  These folks know the score.  Some have run studies showing that the false positivity rate of these clinical diagnoses is erratic and can be very high, like 50%!  And a recent study in Khartoum showed a false positive rate of 90%.  So the administrative data is useless, and I trust Robert Newman and Larry Slutsker will work towards establishment of microscopic diagnoses on appropriate sentinel populations.  Then we will know what the problem really is, and where to put our efforts.

It will take a while, but we can do it.  And now is a wonderful time to capture the popular enthusiasm for malaria control in Africa.

Bill Jobin
Cortez, Colorado

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.