Transcript Casazza
Some Technical Facts and Key Organizational/Management Issues Presentation at CCIH Annual Meeting on May 26,2007 Larry Casazza, MD MPH Director, ACAM-African Communities Against Malaria Malaria Training for Food for the Hungry HQ and field staff Larry Casazza, MD MPH Director, ACAM-African Communities Against Malaria January 10-12, 2007 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 is 28% of 0-4 yr mortality 57% 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 residual efficacy of larvicides ◦ Short list of insecticides –check with your NMCP Rich A B Commercial Sector C D E FBOs/ NGOs Public Sector Poor 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 Chronic Disease Acute Diseasesyndromes Non-severe Chronic or Recurrent Acute Febrile Asymptomatic disease Infection Cerebral Malaria Anemia Developmental Disorders Transfusions Death Death Infection During Pregnancy Placental Malaria & Anemia Low Birth weight Increased Infant Mortality 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 Past and Future Outlook Expanding parasite-based diagnosis Clinical Households Traditional Healers Private Pharmacies Aid Posts/Volunteers Private Clinics Health Centers District Hospitals Referral Hospitals MicroRDT scopy Clinical Microscopy RDT 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 postqualification 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 Clinical/ANC Services Schools Policy/Standards Regulatory Training Distribution M&E Equity & Vulnerable Groups Consumer Information Private, Commercial Demand Creation Clinical Services Drug Sellers Marketing Distribution Sustainability Clinical and ANC Services Household and Community Demand Creation Development of new Services FBOs, CBOs, NGOs • • • • • • • • 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 Relationship & Governance • Governance framework • Relationship and network management framework • Government relations • NGO relations • Community relations Ownership Strategy Secretariat Vision & Roadmap Partnership Management Tools • Strategy & roadmap planning and tracking • Project management fundamentals • Transfer of competency model/ techniques • LQAS Accountability Leadership • National Malaria ‘Fresh Air‘ workshops • Malaria ‘Fresh Air’ local and community workshops • Event methodology and follow-up activities Secretariat Toolbox Marketing & Communication • Internal and external communication management framework • Common communication and reporting templates 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 Management Coping 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. 2. 3. Leadership is about transformational change. Leaders deal with issues that are “beyond imagination”, “impossible”, “difficult”. Leaders define problems in terms of why there is a difference between a shared vision and the current situation? Interest groups The top–down, or “blueprint” intervention strategy disconnects learning from action Policymakers, planners MIS Evaluations Research, pilot projects Learning Managers, providers Communities, households Health Action The “Learning Organization” strategy will link knowledge to action Communities, households Health Interest groups Learning Policymakers, planners Competencies Tasks Managers, providers 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/be gin.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