Some Technical Facts and Key Organizational/Management Issues

Presentation at CCIH Annual Meeting on May 26,2007 Larry Casazza, MD MPHDirector, ACAM-African Communities Against Malaria

Malaria Train ing forFood for the H ungry H Q and field staff

L a r ry C a s a z z a , M D M P H

D ire c to r , A C A M - A fr ica n C o m m u n it ie s A g a in s t M a la r ia

J a n u a ry 1 0 - 1 2 , 2 0 0 7

To mobilize FBOs for their participation and contributions to confront malaria in their host countries in collaboration with other public and private actors committed to reducing the incidence and impact of malaria.

To increase knowledge of SOTA for current Malaria interventions

To be able to prepare future malaria curriculum materials to train trainers and field staff in malaria programming implementation

To improve skills on malaria interventions for inclusion in grant proposals

To understand and participate in strategies for improved funding of FBOs through PMI, Global Fund, private sector partners, and other malaria program granting mechanisms

To appreciate and leverage the main strength of FBOs as partners in malaria programming at Regional and national levels

These objectives cannot be fully answered in this presentation alone, but hopefully it serves to encourage you to discover what more there is to learn

Inhibits economic growth in SSA by estimated $12 billion GDP per year

SSA excluding Southern tier is28% of 0-4 yr mortality57% of 5-14 yr mortality 6% of 14+ mortality

40%+ of household and health system effort

Climate changes Development of drug resistance Complex emergencies (Geopolitical Issues) Development of insecticide resistance Weak health infrastructure to deal with the

problem of malaria Limited local resources Human and behavioral factors

ALL Key Factors to be considered in your programming!

Yet Malaria is a curable disease if promptly diagnosed and adequately treated, while prevention methods are relatively cheap and simple.

Malaria is a disease of the poor and the world’s poorest people living in rural communities are particularly affected

Children suffer an average of five bouts of malaria/year

Rural and urban populations affected in new areas where malaria was not a threat previously

To understand the disease and its vector better

Malaria epidemiology differs by place Malaria epidemiology is not static over time Malaria control is context-specific Malaria is a challenging disease in all

respects

Where do they breed?When do they bite?Who/what do they bite?How ubiquitous are they?How resistant to insecticide are they?

The term endemicity is used to describe the degree of malaria transmission intensity in an area◦ Endemic areas : where the incidence of malaria

has been constant for many years (i.e. stable malaria transmission intensity but may still have seasonal variations)

◦ Epidemic areas: where increases in malaria are occasional and sharp (i.e. unstable malaria transmission intensity)

Level of endemicity

Spleen rate Parasite rate (PR) in 2–9 year-old children

Hypoendemic area

<10% in 2–9 year-old children

Less than 10%

Mesoendemic area

<11–50% in 2­–9 year-old children

11–50%

Hyperendemic area

<51–75% in 2–9 year-old children and >25% in adults

51–75%

Holoendemic area >75% in 2–9 year-old children and low in adults

Over 75%

Source: adapted from (Eds) Gilles and Warrell. Essential Malariology, Oxford University Press

• The most effective way to prevent malaria is through the selective and safe use of insecticides that kill the malaria transmitting mosquito.

• There are two options for getting these insecticides into the homes of those most at risk: indoor residual spraying (IRS) and insecticide-treated nets (ITNs).

IRS is best suited for areas of unstable malaria, epidemic prone malaria, in urban settings when local transmission of malaria is well documented, and in refugee camps.

In each of these settings IRS has important advantages: it has rapid and reliable short-term impact and can be targeted to communities at highest risk.

IRS is, however, relatively demanding in terms of the logistics, infrastructure, skills, planning systems and coverage levels.

The consensus is that in endemic Africa (south of the Sahel and north of the Zambezi River) ITNs are the most practical and effective means for protecting the population

ITNs have been shown to be highly deployable in rural Africa using the existing NGOs, commercial sector, community groups and public sector infrastructure.

• ITNs provide significant protection to those sleeping under them, and can reduce all cause mortality in children by one-fifth and episodes of malaria by half.

• Maintaining supply chains and behavioral promotion activities to keep ITNs widely available, insecticidally-active and effectively used is a challenge

Sustained insecticide treatment of nets (not a problem with LLINs)

Disparity between demand and supply of prevention interventions –but much improved now due to private sector responsiveness

Limited number of insecticides for public health use◦ Pyrethroids for ITNs/LLINs

Efficacy of insecticides on different surfaces (IRS)◦ Short list of insecticides –check with your NMCP

Short residual efficacy of larvicides

Rich

Poor

A

B

C

D

E PublicSector

Commercial Sector

FBOs/NGOs

Re

lati

ve

We

alt

h

ITM Coverage

Vector resistance ◦ No immediate threat to ITNs

Impact on mass effect◦ Immediate threat to IRS

Malaria vectors Nuisance mosquitoes–confuse the clients

But what about access and sustainability of prevention interventions for those millions

at the “Bottom of the Pyramid” not targeted by current program efforts?(4/5

DDT can be used for IRS, provided that stringent measures are taken to avoid its misuse and leakage outside the public health system

DDT is used only/strictly for Indoor Residual Spraying A country that decides to use DDT for disease control is

required to notify WHO (Secretariat of the Stockholm Convention) & UNEP

Every 3 years, each country that uses DDT will be required to provide detailed information on amount of DDT used, the conditions under which it is being used, and how such use relates to the country’s disease control strategy etc

Countries need to develop and establish regulatory mechanisms ( where will the FBOs be in this process?)

22 countries have included or consider to include IRS in their malaria control strategy◦ 14 are applying IRS routinely

5 spray to control endemic malaria 9 spray to control epidemic malaria

◦ 4 have piloted ◦ 4 planning to pilot

A total of about 4 million unit structures are sprayed About 230 000 kg of insecticide is used

◦ DDT, pyrethroids, malathion, carbamate

Where are the FBOs and CBOs in the national programs? (They do implement IRS in CHEs.)

#6 MALARIA 101 – clinical syndromesChronic Disease

Chronic or Recurrent Asymptomatic

InfectionPlacental Malaria

& AnemiaAnemia

InfectionDuring

Pregnancy

Developmental Disorders

Transfusions

Death

LowBirth weight

IncreasedInfant

Mortality

Acute Disease

Non-severeAcute Febrile

disease

CerebralMalaria

Death

Effect of HIV on malaria:

• HIV infection increases the incidence and severity of clinical malaria

• In non-pregnant adults, HIV infection has been found to roughly double the risk of malaria parasitemia and clinical malaria.

• In East and southern Africa, where HIV prevalence is near 30%, it is estimated that about one-quarter to one-third of clinical malaria in adults (including during pregnancy) can be accounted for by HIV.

•Acute malaria infection increases viral load, and one study found that this increased viral load was reversed by effective malaria treatment.

•This malaria-associated increase in viral load could lead to increased transmission of HIV and more rapid disease progression

•This malaria-associated increase in viral load could lead to increased transmission of HIV and more rapid disease progression, with substantial public health implications

So why do these diseases remained stovepiped programatically ?

Artemisinin-based combination therapies (ACT) are the treatments recommended for all cases of uncomplicated falciparum malaria including:◦in infants, ◦in people living with HIV/AIDS ◦for home-based management of malaria ◦pregnant women in the 2nd and 3rd trimesters

Exception: 1st trimester of pregnancy**only use when there are no alternative effective

antimalarials

Malaria Treatment Guidelines 2006: Medicines must be discontinued before resistance reaches

10% New medicines must have an efficacy of > 95%This is because: Drug resistance has a high morbidity, morbidity and social and

economic costs New medicines are very effective

New medicines must be highly effective and efficacious in curing malaria infections, and have a long, useful therapeutic

life

ACT saves lives

RDTs reduce ACT use when the fever is not clinically

caused by malaria

ClinicalMicro-scopy

RDT ClinicalMicro-scopy

RDT

Households

Traditional Healers

Private Pharmacies

Aid Posts/Volunteers

Private Clinics

Health Centers

District Hospitals

Referral Hospitals

Past and Future Outlook

Expanding parasite-based diagnosis

The private sector flourishes especially in areas with limited or no public sector health care facilities (+informal sector, 35-65%)

Public sector HWs are poorly remunerated yet face a heavy workload – attitude and “moonlighting” during working hours

All categories of people use the private sector (age, wealth)

Private sector HW feel marginalised more so now with “free ACT” distribution through the public sector and impending community distribution

Lack of consistent & high coverage post-qualification training and supervision

Poor prescribing behaviour Quality and types of medicines prescribed is

questionable ACTs still prescription-only medicines but in

reality are over-the-counter medicines

“Unqualified” people successfully operate in the private sector

Lower cadres of health workers (HW) are often in charge of clinics

Presumptive treatment is widespread Diagnostic results often not respected Profit-driven sector with less emphasis on

technical quality

FBOs can help to support good treatment practices to curtail emerging drug resistance

Up to 15% of maternal anemia

35% of preventable low birthweight

Also MTCT in HIV positive mothers

Two treatment doses of sulfadoxine-Pyrimethamine (SP) given to all pregnant women in areas of high malaria transmission, even without symptoms, can significantly reduce the negative consequences of malaria during pregnancy

For each respective country, consult and abide by the current IPT national policy especially for areas of high HIV prevalence

Rates of severe malaria by an average of 45%

All-cause child mortality by 17% to 63%(roughly 25% reduction)

Pre-term births by 40%

Public

Private, Commercial

FBOs, CBOs, NGOs

Demand Creation

Consumer Information

Clinical/ANC ServicesSchools

Policy/StandardsRegulatoryTrainingM&E

Clinical Services

Drug Sellers

MarketingDistribution

Equity & Vulnerable Groups

DistributionSustainability

Clinical and ANC Services

Household and Community Demand Creation

Development of new Services

• When preparing a malaria proposal or engaging in a project, get the facts:

• Data on the burden of disease due to malaria locally and nationally

• Data on epidemiology of malaria • Information on the vector involved• National policies on malaria prevention and treatment• Availability/local access to ITN’s and IRS supplies• Monitoring and evaluation requirements and protocols• Think outside the box toward developing new strategies to

build up from your existing strengths/programs

Coupling Technical Expertise With Management & Implementation Capability

Strong implementation expertise

Provide established focal point for technical input

Often lack minimal leadership, management, or administrative capabilities

Governments have no clear model of how to work with NGO’s (and vise versa)

Seven +/Secretariats now under formation

Events

• National Malaria ‘Fresh Air‘ workshops

• Malaria ‘Fresh Air’ local and community workshops

• Event methodology and follow-up activities

Management Tools

• Strategy & roadmap planning and tracking

• Project management fundamentals• Transfer of competency model/

techniques• LQAS

Marketing & Communication

• Internal and external communication management framework

• Common communication and reporting templates

Relationship & Governance

• Governance framework• Relationship and network

management framework • Government relations• NGO relations• Community relations

SecretariatVision

Strategy

& Roadmap

Lea

ders

hip

Partnership

Ownership

Accountability

Secretariat Toolbox

Where does the Leadership come from?

Where are the resources to do it?

What if we fail?

See: www/acamalaria.org for more details

We simply can explore frameworks and tools that will help us lift our horizons, enliven imagination, and deepen our thinking.

FBOs have done this in the past for centuries

Leadership development is a life-long, non-linear process.

Being a leader is a dynamic condition that changes constantly.

Leadership is not a position or role. It is who we are, what we know, and what we do.

We need to nurture leadership at all levels, not just at the top!

Leadership

Coping

Management

Leadership

Coping

Management

1. Panic reactions; depression and burn out

2. Confusion and chaos 3. Waste of time, human and other

resources 4. Error chains 5. Problems continue tomultiply 6. No strategic thinking takes place—NO

CHANGE occurs

1. Leadership is about transformational change.

2. Leaders deal with issues that are “beyond imagination”, “impossible”, “difficult”.

3. Leaders define problems in terms of why there is a difference between a shared vision and the current situation?

Interestgroups

Policymakers,planners

Managers,providers

Communities, households

MIS

Evaluations

Research,pilot projects

The top–down, or “blueprint” intervention strategy disconnects

learning from action

Health

Learning Action

Policymakers,planners

Managers,providers

Communities, households

Needs

Tasks

Outputs

Competencies

Dem

and

Dec

isio

ns

The “Learning Organization” strategy will link knowledge to action

Interestgroups

Learning

Health

Where does the Leadership come from?

Where are the resources to do it?

What if we fail?

See suggestions for Learning Organization approach at: www.jhuccp.org/training/scope/starguide/begin.swf

WHO-AFRO Malaria Consortium Global Fund Staff in EARN PMI staff and USAID Hdqrts. contacts Johns Hopkins Bloomberg School of Public

Health-Gates Summer Institute Gates Foundation for Leadership training

support

THANK YOU