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Saving the failing WHO fight against malaria in Africa

December 21, 2012 - 17:20 -- Bart G.J. Knols

This contribution was posted as a comment by Dr. Bill Jobin, Director of Blue Nile Associates in response to the meeting report of the WHO Malaria Policy Advisory Committee that was held in September 2012.

It is ironic that a WHO policy meeting in September will ignore the terrible truth outlined by the WHO  Director General Margaret Chan in December - that the malaria program is going to crash.....  With due respect to Rob Newman and Margaret Chan in Geneva, I would like to suggest 6 steps to save their Global Malaria Program.  My suggestions are simple applications of rational approaches to a problem, the same things we would do with any other problem in life.  It does not take a Rocket Scientist to figure this out.  Simply put, I suggest that they Narrow their Focus, Expand their Base, add 2 more Components to their Strategy, establish a valid Monitoring and Evaluation system, and set Realistic Goals against which they can Measure their Progress ......

1.  I agree that they are headed for a brick wall.  It is not just shortage of funds, but also the recurring historical problem of resistance to drugs and biocides.  This is inevitable, given the WHO focus on a single Chemically Dependent Component for their entire Malaria Suppression Strategy,  which is ephemeral and financially unsustainable anyway.  Thus....
 
2.  They should ...Narrow their Focus... ( they don't have enough money to do the whole world ) - to only the stable, most democratic countries - only in Africa - which have already demonstrated commitment and competence in fighting malaria. Then they can expand from success.......
 
3.  They should... Broaden their Base... by reaching out to the Water Program of the African Development Bank and to the US Presidential Malaria Initiative.  This will strengthen their epidemiology (from CDC of the PMI ) and add the water engineers (from AfDB)......
 
4.  Then they should ....Add a Community Component.... to their current Chemically Dependent Component.  Thus each existing community should form a Malaria Task Force to reduce nearby mosquito breeding sites by local drainage efforts in streets, fields and around ponds. and to improve and screen homes.  In this Community Component they should turn to Faith-Based organizations instead of Ministry of Health, to broaden their reach.  In new water resource projects and rehab of existing projects, the resettled communities should be designed and constructed with adequate drainage and screened houses, located at safe distances from breeding sites.....
 
5. Next they should ...Add a Mosquito Reduction Component to their current Chemically Dependent Component....  This should include larval management, breeding source reduction and other proven methods of directly reducing anopheline populations......
 
6.  Finally they should establish a scientific and statistically valid system for ....Monitoring and Evaluating Malaria Prevalence..... in stable, sentinel communities, based on stratified and random sampling with sample sizes large enough to give valid comparisons..... including monitoring of mosquitoes and rainfall.  This system should monitor Before/After Intervention and also provide Treated/Untreated Comparisons, normal components for evaluating any intervention.  This system should be the basis for their annual report and for strategy planning.  Perhaps this is the only thing WHO will be able to do in the future as their funds shrink.  But at least this should be done carefully and right..... 
 
With Accurate Monitoring, they can then set Realistic Goals and Measure Progress against those goals.  This will probably do a lot to reduce the Donor Fatigue and Exasperation which they are currently feeling.  It will also give them sustainable and growing success in suppressing malaria in Africa.
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Comments

1. As malaria continues to decline, it is important to take a more integrated approach to vector control, attacking multiple fronts, to drive transmission to zero. Larval source management is an important component of the tool box and, in some situations can dramatically reduce exposure to malaria transmission.
2. Over the last decade, malaria interventions have been vertically implemented by national governments with very little involvement of the community. In poor resource setting, community participation in disease control is a must and not an exception. Despite this knowledge that community participation is vital in strengthening primary health interventions little progress has been made to involve communities in malaria control planning and implementation. Add a community component is critical. As other have pointed out, each existing community should form a Malaria Task Force to reduce nearby mosquito breeding sites by local drainage efforts in streets, fields and around ponds and to improve and screen homes – and to respond to the need for early diagnosis and treatment.
3. Malaria is a particularly important disease that illustrates the interactions between livelihood, ecosystems and health systems – in a matter of fact – malaria is now a development problem than ever thought before. Several sectoral activities including construction, water resources, agriculture, etc. contribute highly to malaria mosquito breeding and hence transmission. It is important therefore, to examine the links within a broad framework that considers the different pathways, given the multiplicity of interactions that can produce unexpected outcomes and trade-offs. Consequently, these situations require innovative re-thinking on the strategies to prevent and control malaria.

Submitted by Burton Singer on

Bill,

I just read your comment on how to foster an effective malaria program at
WHO. This is, of course, right on target. Hopefully, someone at WHO will act
on your recommendations.

Regards,

Burt
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