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RESOLUTION OF THE
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103rd Session
EB103.R9
Agenda item 3
29 January 1999
Roll Back Malaria
fhe Executive Board,
Reaffirming the impact of malaria in constraining human development, and appreciating the
innovative concepts and operational mechanisms in the Director-General’s report on Roll Back Malaria,'
RECOMMENDS to the Fifty-second World Health Assembly the adoption of the following
resolution:
The Fifty-second World Health Assembly,
Having considered the report of the Director-General on Roll Back Malaria;
Concerned that the global burden of malaria is a challenge to human development and a
significant cause of poverty and human suffering, particularly in the poorest nations of the world;
Mindful of the efficacious tools currently available to reduce this burden, and the potential
for their more effective use within malaria-affected communities;
Welcoming the decision by the Director-General to establish a Cabinet project to support
rolling back malaria which works across the Organization;
Noting that Roll Back Malaria represents a new approach promoted by WHO, in which all
concerned parties are encouraged to work in a coordinated partnership, united by common goals,
consistent strategies and agreed methods of working, and that Roll Back Malaria is serving as a
pathfinder in bringing these concepts into operation in relation to other international health issues;
Commending the key features of the new approach, namely, increased focus on the needs of
people at risk, better response to those needs with evidence-based action, greater use of existing
tools, their full integration into the health sector as a horizontal programme, and innovative public
private partnerships to develop cost-effective products and tools in view of the emergence of drug
and insecticide resistance;
Appreciating the strong commitment to Roll Back Malaria from several heads of State, the
Administrator of UNDP, the President of the World Bank, the Executive Director of UNICEF, and
’ Document EB103/6.
EB103.R9
directors of other development banks, foundations and bilateral assistance agencies, expressed when
the global partnership was established in December 1998,
1.
ENCOURAGES Member States to reduce malaria-related suffering and promote national
development in a sustained way, by rolling back malaria and preventing its resurgence or
reintroduction, by:
(1) engaging a wide range of personnel and institutions involved in health systems, disease
control, and research, with representatives of civil society, the private sector, development
agencies and other sectors;
and, where relevant, by:
(2) ensuring that sufficient resources are available to meet the challenge of rolling back
malaria;
(3) establishing and sustaining country-level partnerships to roll back malaria within the
context of health sector and human development;
utilizing relevant technical expertise that exists within countries and regions in an
(4)
effective manner;
2.
REQUESTS the Director-General to draw on the whole Organization in supporting Member
States by:
promoting harmonized strategies and encouraging consistent technical guidance for
(1)
efforts to roll back malaria;
(2) working with them as they establish criteria for success in rolling back malaria, and
monitoring progress of country and global efforts within the context of health sector and
human development;
(3) promoting international investment in cost-effective new approaches and products
through focused support for research and for strategic public and private initiatives;
(4)
3.
brokering the technical and financial assistance that is required for success;
REQUESTS the Director-General:
(1) to report regularly on progress of the global Roll Back Malaria partnership to the
Executive Board and the Health Assembly, stressing the contribution that Roll Back Malaria
makes to the reduction of poverty, and reviewing the extent to which the partnership serves
as a pathfinder for effective joint action on other international health issues;
(2) to promote the aims and outcomes of the Roll Back Malaria partnership in relevant
intergovernmental bodies, organizations of the United Nations system, and - when
appropriate - other bodies committed to equitable human development.
Ninth meeting, 29 January 1999
EB103/SR/9
2
ROLL BACK MALARIA
BRIEFING DOCUMENT
INTRODUCTION
Governments and civil society in malaria affected countries will take the lead in
1.
rolling back malaria as a means to reduce poverty and mortality, and promote human
development. Partners, in considering health sector issues, will agree to work together, at
country level, towards common goals using agreed strategies and procedures. The national
authorities of countries will direct the partnership.
2.
WHO has established a Cabinet Project to help country Roll Back Malaria
partnerships become fully effective. The project is implemented with the support of WHO's
Clusters and Offices at Headquarters, Regions and Country, and other partners. It is
spearheaded in Africa. It promotes effective investment in new medicines and other tools to
reduce the burden of malaria through WHO/TDR, MIM and the public-private MMV
(Medicines for Malaria Venture).
The project helps increase the level of international financial investment in the efforts
3.
of countries to Roll Back Malaria through international advocacy emphasising the current
and potential investment outcomes and ensuring updated information on the global malaria
situation.
To provide countries with the specialised technical support required to address the
challenges of malaria, the project will establish a number of Resource Support Networks,
comprising experts in appropriate fields, particularly from relevant regions; thus making
implementation plans to reflect an evidence-based response to local needs and realities.
4.
MISSION
The Roll Back Malaria Cabinet Project will address a priority health issue through
5.
contributions to strengthen national systems, provide effective and strategic interventions
through partnerships with groups within and outside WHO, and act as a pathfinder in offering
a new approach to the sustainable control of infectious diseases.
GOAL
The Roll Back Malaria project will significantly reduce the global burden of disease
associated with malaria through interventions adapted to local needs and reinforcement of the
health sector.
6.
MAIN AREAS OF WORK
Strategy Development, Communication & Advocacy
Activating Progress at Country Level
3. Building and Sustaining the Global Partnership
4. Promoting Consistent Technical Guidance
5. Strategy Support for Research and Development
6. Monitoring Progress & Outcomes
1.
2.
RBM/page 3
BUILDING & SUSTAINING GLOBAL PARTNERSHIP
11.
A partnership representing Member States, organisations of the United Nations
system, development banks, bilateral development agencies, the private sector, the media and
civil society will be established at the global level to support country level action. Partners
will agree on the terms of their participation, approaches to international advocacy, means for
mobilisation and flow of resources, the basis for monitoring progress, and an appropriate
institutional framework to sustain the partnership; thus contributing to more effective action
on their part at country level.
PROMOTING CONSISTENT TECHNICAL GUIDANCE
12.
Technical support networks will be established to provide expertise that is required
for the implementation of RBM by countries. These networks will:
•
•
•
•
•
•
•
•
•
comprise experts (and institutions) in various disciplines with practical
experience available in countries within the region
provide direct support to control operations
address specific technical issues that are critical for control policy
address specific issues that can be more effectively dealt with in an inter-country
and/or regional setting
function in a “demand-responsive” manner with respect to the RBM needs of
countries
encourage collaboration between countries
be the link with international expertise between research and academic
institutions, and disease control operations in endemic countries
be financed by various partners
be a potent mechanism through which to build country and regional capacity
STRATEGIC SUPPORT FOR RESEARCH & DEVELOPMENT
13.
International Research and Product Development activities that address key
constraints to rolling back malaria will be incorporated into the global Roll Back Malaria
partnership. This will result in intensified collaboration with the private sector to develop
new and more cost effective tools for malaria control. The major institution for this
component is the cosponsored Tropical Diseases Research Programme, managed by WHO.
Another is the Medicines for Malaria Venture (MMV) which will operate as a commercial
enterprise, using public funds to accelerate the development of effective new anti-malarial
treatments and vaccines. A third is the Multilateral Initiative on Malaria, an independent
consortium of research groups seeking scientific responses to the challenge of malaria in
Africa. Roll Back Malaria will help these vital initiatives to agreed priorities to accelerate
global efforts to reduce the malaria burden.
MONITORING PROGRESS & OUTCOMES
14.
Support to monitoring and evaluation will be provided by RBM, and standardised
methods and criteria for monitoring and evaluation of interventions at the district level will be
developed. Further, a monitoring and evaluation system will be established within WHO to
track the global progress of Roll Back Malaria implementation and its impact on the health
sector.
Distribution: Restricted
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FIRST PARTNERS' MEETING
Geneva
8 and 9 December 1998
at the
World Health Organisation
Executive Board Room
DRAFT REPORT
19th January 1999
Comments to: Project Manager, Roll Back Malaria Project, World Health Organisation, Geneva
e-mail: nabarrod@who.ch.
"The contents of this restricted document may not be divulged to persons other than those to whom it has been
originally addressed. It may not be further distributed nor reproduced in any manner and should not be referenced in
bibliographical matter or cited."
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
TABLE OF CONTENTS
1.
CONCLUSIONS:
PARTNERSHIP .
PRELIMINARY PLAN FOR THE GLOBAL RBM
2
2.
INTRODUCTION
5
3.
ESTABLISHING A GLOBAL PARTNERSHIP
6
3.1 REASON FOR THE PARTNERSHIP.
6
3.2 EXISTING PARTNERSHIPS
7
ISSUES IN ESTABLISHING THE RBM PARTNERSHIP: SUMMARY OF
DISCUSSIONS......................................................................................
10
ROUND-UP SESSION
13
4.
5
ANNEX 1 PLANNED OUTCOMES OF THE MEETING
14
ANNEX 2 LIST OF PARTICIPANTS
15
ANNEX 3 AGENDA
23
The meeting was planned and managed by Dr Pene Key, Short Term Consultant
to the Roll Back malaria Project, together with the rest of the RBM team, under
the supervision of Dr Tore Godal, Acting Project Manager. This report was
prepared by Jenny Hill of the Malaria Consortium, in conjunction with David
Nabarro, the current Project Manager (who takes responsibility for its contents).
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
1.
PRELIMINARY PLAN FOR THE GLOBAL PARTNERSHIP
TO ROLL BACK MALARIA: MEETING CONCLUSIONS
1.1
A global partnership was formally established on 9 December 1998
to intensify the international effort to reduce the malaria burden - to
Roll Back Malaria.
1.2
Participants at this first Partners’ Meeting represented national
governments, UN systems agencies, development banks, non
governmental organisations, private sector and bilateral donors.
1.3
Within the limits of their authority, they committed themselves and
their organisations to the establishment of country-level partnerships
to Roll Back Malaria. Where possible they would work within the
context of these partnerships
1.4
The principles of a country Roll Back Malaria partnership are that:
i. National governments determine the goals, strategy, organisation
and operating procedures for Rolling Back Malaria;
ii. A country partnership to Roll Back Malaria is usually set up at
the invitation of a country’s Head of State;
iii. It involves a situation assessment and strategy development
process led by the National Authorities and involving potential
partners;
iv. Partners’ support for Rolling Back Malaria is provided, where
possible, within the context of the sector-wide approach to
health development'.
v. Partners work to common objectives, using agreed strategies, in a
transparent manner;
vi. Within the context of these principles, attempts are made to
ensure that partners have sufficient flexibility and autonomy to
make the fullest possible contribution to Rolling Back
Malaria.
1.5
At the country level, WHO will help to ensure that the partnership is
a success through providing a range of focussed inputs. These are
offered through the WHO Roll Back Malaria (RBM) Cabinet
Project. This involves personnel within WHO headquarters (from
all nine clusters), WHO regional offices, and WHO country offices.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
1.6
The WHO RBM project will contribute to country partnerships by
offering help in several areas, including:
i. possible agreements and means of working
ii. materials for advocacy
hi. help with developing a consensus on strategy- ensuring that
options considered are based on best available evidence
iv. capacity building
v. lesson learning from other countries and from other
programmes
vi. support for monitoring progress, and
vii. brokering resources [looking for new channels as well as
existing ones].
1.7
WHO regions are key elements of the RBM project, contributing to
country partnerships. They may offer other support for national and
local-level action within countries.
1.8
At global level, WHO will set up a small ‘partners’ group' to help the
Global RBM Partnership evolve, and to provide guidance to the
WHO Roll Back Malaria Project, which supports the partnership.
The project will develop strong linkages between partners through
the use of advanced communication technology.
1.9
To reduce malaria suffering and death rates substantially, funding
mechanisms are needed:
• to enable countries to implement new malaria and health
sector development activities
• to ensure that key components of RBM - such as the
Medicines for Malaria Venture, the Tropical Disease
Research Programme, and the Multilateral Research
Initiative on Malaria deliver the desired products
• to build WHO's ability to support partnerships - through in
country action, technical resource networks, international
monitoring and global advocacy
1.10 WHO's role is to support the partnership and make it effective,
ensuring that it has the greatest likelihood of mobilising cash,
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
information and other vital resources within the context of what is
needed. Current plans for the partnership do not envisage a long
term dedicated financing mechanism unless this is demanded by all.
Funding is urgently required for short term needs.
1.11
The RBM partnership will need to mobilise substantial additional
resources - approximately $200 million per annum for country level
action, together with resources for the WHO Roll Back Malaria
Project.
1.12 Political support for partnerships will need to be sustained via:
• information and technical agreements
• reviews of work, with quick reports of results
• high level advocacy
• continued championing and marketing of the idea
In summing up, Dr Brundtland, WHO Director General:
1.13 Expressed her gratitude for the groundswell of support for the basic
concept, objectives and approaches to be taken, in Rolling Back
Malaria.
1.14 Emphasized the importance of capitalising on the current momentum
to get Roll Back Malaria implemented on the ground.
1.15 Underlined the importance of Roll Back Malaria as a pathfinder in
identifying new ways for partners in International Health to work
together effectively.
1.16
Stressed that Roll Back Malaria - as a pathfinder within the
organization, and as a cabinet project - is expected to develop new
ways of working between WHO clusters, regions and country
activities.
1.17 Pointed out that Roll Back Malaria presented a broad institutional
challenge, going far beyond those concerned with malaria at HQ,
regional, and country offices.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
2.
INTRODUCTION
The meeting of partners to ‘Roll Back Malaria’ (RBM) was opened by Dr David
Heymann, Executive Director of the Communicable Diseases cluster, on behalf of the
Director General. Dr Heymann described the positioning of the Roll Back Malaria
project, initiated by the Director General to facilitate intensified efforts and look at new
ways of controlling malaria, within WHO. RBM is a project of Cabinet, has a house in
the Communicable Diseases programme, and draws on expertise in other WHO clusters
such as Emergency and Humanitarian Action, Health Systems Development and Health
Technology and Pharmaceuticals.
Ambassador Store described WHO’s renewal process, a result of the Director General’s
pledge to reform the organisation following her election at the WHA in May 1998. Led
by a senior management team, regrouping of programmes and activities began on 21st
July 1998, the day the Director General took office: 50 programmes have been
regrouped into 9 clusters, then reduced to 35 departments, and the organisation is in the
process of appointing new directors. Other fundamental changes are the introduction of
staff mobility and rotation, so that Headquarters is more inspired by countries and the
organisation becomes ‘one WHO’; transparency of budgets at all levels of the
organisation; and bringing management support closer to technical programmes and
actions to improve efficiency and consistency. As a Cabinet project, RBM is defined as
a pathfinder, teaching WHO how to work across programmes, across the house, and
how to develop co-ownership among partner agencies and among countries.
Dr David Heymaim nominated the Chair - David Nabarro, Head of Health and
Population Division, UK Department for International Development; the Vice Chair Dr Z Maiga, Secretary General of the Ministry of Health, Mali; and the Rapporteur - Dr
Madeleine Leloup, Ministry of Foreign Affairs, France.
The meeting was attended by 41 representatives of national and government agencies,
19 representatives of regional and international organisations, 8 representatives of WHO
regional offices and 8 members of the RBM Secretariat (see list of participants in
Annex 2).
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
3.
ESTABLISHING A GLOBAL PARTNERSHIP
3.1
Reasons for the Partnership
The Malaria Burden: problems and issues - Dr Fred Binka
Malaria affects 100 countries world wide, causing 300-500 million clinical cases per
year, over 80% of which are in Africa, and one million deaths per year, over 95% of
which are in children under five years in Africa. Severe forms of the disease result in
neurological sequelae and disability, the extent of which is probably underestimated but
which no doubt has a significant impact on cognitive learning especially among
children. The malaria situation is worsening: malaria has been reintroduced to areas
where eradication was achieved in the 1950s and 60s; malaria is now found in areas
previously free of the disease; and the number of epidemics in Africa, Southeast Asia
and South America are increasing.
Perhaps the major threat to the control of malaria is the development of drug resistance to sulphadoxine-primethamine and mefloquine in South East Asia and to chloroquine
and, more recently, to sulphadoxine-pyrimethamine in Africa. Other major problems in
the control of malaria are poor access to health care and issues associated with delivery,
including: under utilisation of public health facilities and high use of the formal and
non-formal private sector, poor availability of antimalarials in public health facilities
and high costs.
Contributions to help countries tackle the malaria burden, from external sources,
totalled US$287.5 million in 19971. Sources included Development Banks (US$172
million). Bilateral agencies (US$32 million), Multilateral agencies (US$15 million),
research institutions (US$4 million), NGOs (US$16 million) and the private sector
(US$6 million).
Background to RBM and Preparatory Phase - Dr Tore Godal and David Nabarro
Political and financial commitments to malaria have seen a significant increase in recent
years, and particularly in the last two years, as illustrated by the number of new malaria
initiatives. These include the Africa Initiative on Malaria (AIM), the Multilateral
Initiative on Malaria, the Director General’s special fund for accelerated action in
Africa and new co-operation with the private sector, such as the Medicines for Malaria
Venture. There have been a number of significant political statements by political
bodies including the G8 countries, four UN agencies, the OAU and most recently by
WHO’s newly elected Director General.
The basic concept of RBM is to address a priority problem within the context of health
sector development, intersectoral collaboration and community action. WHO will
1 Martinez J, Hill J and Meek S (1998) Global Coordination of Malaria Control Efforts - issues and options
for supporting country strategies. A study commissioned by WHO/CTD
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
provide strategic direction to a global partnership to make the best use of available
resources through the RBM project.
Objectives of the RBM partnership are to:
• Significantly reduce the global malaria burden through improving people’s
access to interventions adapted to local needs
• Achieve results through effective support to health sector development
• National goals to be set by countries based on situation analysis and
feasibility assessment
• Global targets will be set from aggregated national goals at the end of the
RBM preparatory phase (end 1999)
Expected results at the end of the RBM project period are:
• Significant reductions in poor people’s burdens due to malaria: ideally
halving of malaria mortality by 2010
• Improvements in people’s access to effective anti-malaria interventions
adapted to local needs and contexts
• National health sectors, and other sectors associated with human
development, respond better to requirements of poor people in relation to
malaria
• The RBM approach contributes to the effectiveness of actions by other
groups within and outside WHO
Intermediate objectives for 2001 for:
1) country level action,
2) the Global RBM Partnership,
3) synergy within WHO and associated bodies,
4) monitoring, review and reporting,
5) development and deployment of new tools,
6) advocacy, resource mobilisation and the provision of assistance for RBM.
The RBM approach will be to build on current efforts, with the Africa Initiative on
Malaria as the spearhead, and the Global Malaria Control Strategy, based on regional,
epidemiological and health systems needs and focus on community and district level
action. The first priority will be areas of high transmission in Africa, followed by
countries experiencing epidemic malaria and malaria endemic countries in other
regions. Investment will also be made in research and development of new tools that
can help short term gains.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
3.2
Existing Partnerships
Analysis of country-level partnerships for health
Country level experiences of coordinating international assistance for better health were
presented for Uganda (Dr P Byaruhanga), Zambia (Dr JJ Banda), India (Dr Shiv Lal),
Vietnam (Prof Pham Manh Hung), the Democratic Republic of Congo (Dr Mathey Boo)
and Mali (Dr Maiga).
Uganda is attempting to consolidate their health services after years of political turmoil
in the 1970s and early 1980s. A resource flow map for inputs to the health sector in
Uganda highlights the problem which results with multiple inputs of several different
donors, each with different objectives, leading to uncoordinated, duplicated efforts
realising limited impact. Steps are now being taken to improve and simplify resource
co-ordination through a single clearing house in the Ministry of Finance, from where
eanuarked benefici aides can access resources, i.e. through Sector Wide Approaches
(SWAps). However, there are many challenges that have yet to be addressed to advance
this approach.
Zambia has introduced a partnership of cosponsors for district health services, where
funds from central donor accounts are managed by a Central Board of Health (CBOH)
district account. Districts then receive funds from the CBOH account as well as from
central MOH on a quarterly basis. Cooperating partners also adhere to joint planning
and monitoring missions and operate according to jointly agreed standards of financial
and administrative management systems. The system is well planned and locally
driven, allowing districts a large degree of freedom. Funding delays are however a
problem.
India spends more than one third of the government health budget on malaria. Initial
experiences following the revision of the national malaria control strategy in line with
the Global Malaria Control Strategy have been encouraging - the disease is largely
contained. However, more than 70% of malaria cases go to the private sector for
treatment of variable quality and there is need to educate the community combined with
effective multisectoral coordination at the community level and continuing updating of
private medical practitioners.
In Vietnam, in the period between 1991 and 1997, the number of malaria deaths has
been reduced by 97%, the number of malaria outbreaks by 92%, and the number of
malaria cases by 59%. The success of the National Malaria Control Programme is due
to strong leadership and organisation of the programme by government, realistic
objectives and appropriate technical measures. The National Health Programme is
directed and implemented by MOH with the coordination of the Ministry of Planning,
Investment and Finance. Administration and management of resources are
decentralised to local levels. International donors undergo a process of acceptance and
then work with the Steering Committee of the Malaria Control Programme to undertake
needs assessments, strategy development and planning of malaria activities.
Differences in the fiscal years and financial management regulations between the
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
government and its partners causes delays in addition to which there is limited
management capacity of MOH staff.
DRC has undergone a number of much needed changes with regard to donor
coordination. Currently health sector inputs are coordinated by an interagency
committee, with subcommittees for malaria and other programmes. The committee is
currently changing its method of working.
Analysis of global and regional Partnerships for Health - Dr Penelope Key
An analysis of existing global and regional partnerships which have had varying degrees
of success was undertaken in order to identify key characteristics of successful
programmes of relevance to establishing the RBM partnership mechanism. Some of
these have a public health mandate (polio eradication, UNAIDS) while others address
other sectors such as agriculture or the environment. There is a wide spectrum of
existing partnership structures and governance, ranging from the tightly governed,
legally binding group at one end to the loose stakeholder coalitions at the other end. In
the middle sit a large group with a degree of governance and structure, but having a
flexible operating modality. The degree of ownership by, or involvement of, countries
as equal partners varies from virtual exclusion to full, such as the Intergovernmental
Forum on Chemical Safety.
Partnerships whose prime purpose or mandate is for raising and managing financial
resources, usually centrally operated, tend to be tightly governed, with strict
membership rules, legal agreements, management staff and tight criteria for allocation
of funds. Partnerships whose primary mandate is co-ordination of strategies and
activities, with action taking place at country level, tend (though not always) to be
looser, informal coalitions of stakeholders, where secretariat functions are undertaken
by programme staff. Partnerships with secretariats that are autonomous or independent
of programme management tend to demonstrate better ownership by the partners, but
they have sustainability problems.
Where resource mobilisation and management functions are integral to programmes, as
in WHO TDR and HRP and WHO GPVI, this has a real cost in terms of staff time and
detracts from programme achievements. It appears that there is value in out-placing this
function to an independent Partnership Structure; Resource mobilisation must be
planned and continuous. Involvement of private (commercial) sector agencies as full
members of partnerships may dictate the partnership structure. WHO, for instance, has
regulations which exclude their full (voting) membership of certain official committees.
A high-profile Civil Society Champion is invaluable for continued advocacy and
resource mobilisation. The roles of each Partner organisation should be defined clearly
from the start. Building the partnerships requires time and effort. Continued, consistent
information and updating of partners about programme progress is essential. Personal
rapport is needed between partners at a high level. Political commitment in endemic
countries must be maintained. Inter-sectoral support in countries is vital to public health
programmes and requires involvement of the Head of State to succeed.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Regional Partnerships have shown considerable success. The West Africa OCP is the
outstanding example. This is firmly sited in the tight governance group. One
longstanding collaboration in Asia (SEMEO-TROPMED) is institution-based but has
proved its worth, the second (ACTMalaria) has started well but long term funding is a
problem. Regional partnerships will be challenged by agencies’ differing regional
definitions. In the case of malaria, boundaries based on epidemiological types are more
logical. Cross-regional representation is invaluable.
Proposals are made for possible structure of the RBM partnerships based on past
experiences and lessons learned.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
4.
ISSUES IN ESTABLISHING THE RBM PARTNERSHIP:
Summary of Discussions
The presentations summarised above provoked active discussion among participants
concerning the important issues in establishing the RBM partnership mechanism. There
was excellent participation by all participants and particularly by country
representatives - ministers, malaria programme managers and representatives of non
government agencies - who were alert in responding to what the donors were saying.
This lively interaction was one of the highlights of the meeting. This section attempts to
summarise the issues raised during this discussion.
The RBM project of WHO has been initiated for a five year period in order to establish
and consolidate WHO structure, leadership and partnerships to ‘roll back malaria’.
During the lifespan of the WHO project, the RBM partnership must become highly
effective to ensure continuity of intensified efforts at the end of the WHO project. The
success of the RBM partnership in terms of its impact on malaria will be dependent on
its ability to sustain intensified action in Malaria Endemic Countries over a 20 to 30
year period. Within WHO, the RBM project will become integrated into ongouing
activity within five years.
RBM will address malaria in the context of health sector development. The RBM
partnership must therefore find ways to address the different status of health sector
development and reform in different countries. It must also ensure that Health Sector
Development and malaria technical issues are brought together, for example, to ensure
that pharmaceutical policy, and drug resistance issues, are properly handled within the
health sector context, and that malaria related action takes account of the low salaries of
health workers. Partners will therefore have to become immersed in significant health
sector issues. Results of the RBM partnership will be assessed in terms of health sector
development-related outcomes as well as malaria outcomes.
However, action through the health system is only a part of controlling malaria. The
RBM partnership needs to find viable entry points for malaria control especially to
engage households and to mobilise whole societies. As a first step, the partnership must
involve the poor and the rest of civil society in dialogue about Rolling Back Malaria by
involving those NGOs which articulate demands and interests of civil society. The
challenge is to ensure effective communications between all groups interested in
Rolling Back malaria: several of these do not communicate effectively with each other
at present. The partnership needs to combine focused thinking with a sophisticated,
response - which goes beyond health care systems. This response must also engage the
private sector at all levels - from multinational entities to local shopkeepers.
In addition to a broad response to tackling malaria, RBM needs to take account of other
issues besides malaria. Malaria is only part of the burden carried by poor people,
particularly by women. The RBM partnership needs a proper understanding of the
causal relationship between poverty and malaria and of other social and economic issues
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
which affect the poor. This will require the development of appropriate gender and
poverty strategies for RBM.
Financial contributions to national malaria control activities have often been poorly
aligned to the burden posed by malaria, and the related needs of poor people. The RBM
partnership must develop a rational approach to ensure that resource flows within
countries, and through partners, are aligned with the burden of malaria. Funding
contributions as well as strategies need to be based on regional, epidemiological and
health systems needs. Focus must be on community and district level action; and this
will require simplified, timely and transparent funding channels which allow districts
the freedom to manage their own funds. The challenge for the partnership will be how
to intensify action for malaria through a common pot/basket to avoid the complex
situation found in Uganda and other countries. It is however recognised that not all
partners will be able to channel funds through SWAps, and flexibility of funding
mechanisms will be needed. The RBM partnership will also have to find effective
means to garner untapped resources in both the public sector and the private sector.
Clarity of roles within the partnership is essential from the outset. Countries should be
central to the partnerships at all levels and especially at country level; this will be
government or indeed other recognised institutions responsible for States or parts of
States. Co-ordination at country level will be critical to the success of RBM: the
organisational issues on malaria work at country level within MOH and between MOH
and other service providers need to be clearly understood and addressed by the
partnership. Partnerships need to be sensitive to local conditions and draw on existing
country experiences.
While WHO has a core role to play in the partnership at global level, other partners may
have comparative advantages at country and regional levels and this needs further
discussion. The partnership will need to learn lessons from other programmes both
within and beyond the sector, and from region to region. The role of the WHO project at Headquarters, Regions and Country level - to support the Global RBM partnership is
therefore likely to be different depending on context. A partner will be a partner at
every level: once a partner at global level, this applies at country and regional level, and
partners must speak with one voice at every level. The ways in which partnerships
operate at different levels will differ, and they must not be too complicated, rigid or
time consuming. The objectives of the partnerships at each level need to be realistic.
Criteria for success in the short, as well as the long, term are required so that the
partnership can demonstrate progress.
Advocacy for RBM must go beyond malaria and address other causes of mortality,
inequity and poverty. Furthermore, justification for support must always combine
human rights with hard economics. This broad approach will be central to the
partnership’s advocacy role. Advocacy at community level is also needed in order to
mobilise the people affected by malaria, who have become refractory to the disease.
There needs to be a clear link between local and international advocacy, with messages
originating at the grassroots. A northern champion for the RBM partnership in needed.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Once political will is mobilised, challenges for the RBM partnership are how to
translate political will, both of the international community and from malaria endemic
countries, into precise and concrete action and how to gamer regional and country
perspectives on how the RBM partnership should work.
- 13 -
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
5
5.1
ROUND UP SESSION
During the round-up session with Dr Brundtland, very strong and broad support
was expressed for the Roll Back Malaria initiative, and the underlying approach,
including;
•
•
•
the strong linkage to health sector development
the need to engage various partners, NGO’s, Civil Society and various types
of health providers at the local level
adding value and investment to research efforts for the development of new
and better tools through MMV, MIM and TDR
5.2
There was strong support for the leadership role of WHO in taking the global
RBM partnership forward.
5.3
WHO was requested to take a leadership role on Roll Back Malaria and to take
the partnership forward in a flexible way, building on current structures, rather
than building new ones.
5.4
Partners were satisfied with the way Roll Back Malaria had been taken forward
during 1998, and noted the commitment already expressed by Governments in
affected countries, Civil Society Institutions, Donor countries, the private sector,
the UN system’s Agencies and Development Banks.
5.5
Some partners proposed a follow-up meeting of the full group towards the end
of 1999.
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Annex 1
Planned outcomes of the meeting (prepared November 1998)
1. Agreement on purpose, operation and possible structure of the partnership
2. Frameworks for country-level agreement on:
•
•
•
synchronising partners’ strategies
resource mobilisation, flow and provision in a transparent and coherent
manner
Monitoring and review of partnership action, financial accounting,
communications and maintenance of partnerships
3. Agreement on approaches to international advocacy, public relations and political
action in relation to RBM
4. An understanding or the roles and responsibilities of different partners, and an
examination of the need for governance and/or legal instruments
5. A shared understanding of the role of the WHO-RBM project in relation to the
global partnership
6. Plans for taking forward the partnership
- 15 -
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Annex 2
List of Participants
Countries
Australia
Ms Leonie D’Cruz, Executive Assistant, Australian Agency for International
Development, c/o Australian Permanent Mission, 56 rue du Moillebeau, 1211 Geneva
Tel: 918 2907
Fax: 918 2990
Belgium
Mrs Sonja Gerlo, Mission permanente de la Belgique aupres de 1’Office des Nations
Unies et des Institutions specialisees a Geneve, Case postale 473, 1211 Geneve 19
Tel: 730 40 00
Fax: 734 50 79
Canada
Mr R. Lavoie, Manager, Pan Africa Programme, Africa and Middle East Branch,
Canadian International Development Agency, 200 Promenade du Portage, Hull, Quebec
K14 OG4, Canada
Tel: 1 819 - 994 4297;
Fax: 1 819 - 997 5453
Mr Yves Bergevin, Senior Health Specialist, Canadian International Development
Agency (CIDA), 200 Promenade du Portage, Hull, Quebec K14 OG4, Canada
Tel: 1 819 - 997 7870;
Fax:1 819-997 904 email: Yves Bergevin@acdi-cida.gc.ca
Denmark
Mr D. E. Frederiksen, Deputy Head of Department, S.4, DANIDA, Royal Danish
Ministry of Foreign Affairs, 2, Asiatisk Plads, DK-1448 Copenhagen, Demnark
Tel: 45 33 92 1405
Fax: 45 32 54 0533
Mr Ole Torpegaard Hansen, Counsellor, Permanent Mission of Denmark to the United
Nations Nations Office and other International Organizations at Geneva, Case postale
435, 1211 Geneve 19
France
Dr M. Leloup, Ministere des Affaires etrangeres, Cooperation et Francophone, Ibis, 20
rue Monsieur, 75700 Paris 07 SP, France
Tel: 01 53 69 31 87
Fax: 01 53 69 37 19
Germany
Dr Herbert Krumbein, Chief, Sector Division, Education Health and Population Policy,
Federal Ministry for Economic Cooperation & Development (BMZ), Referat 221,
Friedrich-Ebert-Allee 40, 53113 Bonn, Germany
Tel: 49- 228 3690
Fax: 49- 228 535 3500
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Dr Bergis Schmidt-Ehry, Senior Technical Advisor, German Technical Agency,
Deutsche Gesellschaft fur Technische Zusammenarbeit, Dag-Hammaskjold WEG 1-5,
65726 Eschborn, Germany
Tel: 49 6196 791215
Fax: 49 6196 797104
Professor Bernhard Fleischer, Bernhard-Nocht-Institut fur Tropenmedizin, D-20359
, Hamburg, Germany
Tel: (49)40 311 82401
Fax: (49) 40-31182 400
Professor Rolf Horstmann, Deputy Director, Bernhard-Nocht-Institut ftir
Tropenmedizin, Hamburg, Germany
Mr Holger Eberle, Minister, Deputy Permanent Representative, Permanent Mission of
Germany, Geneva
Ms. Heike Jirari, Third Secretary, Permanent Mission of Germany, 28c Ch. Du PetitSaconnex, 1211 Geneva
Tel: 730 1111
Fax: 730 1245
India
Dr Shiv Lal, Director, National Malaria Eradication Programme, Ministry of Health
and Family Welfare, Government of India, 22 Sham Nath Marg, Delhi 110057
Tel: 91 11 2918576
Fax: 91 11 2518329
Ireland
Dr Vincent O’Neill, Lead Adviser, Health Specialist Support Unit, Irish Aid,
Department of Foreign Affairs, 76-78 Harcourt Street, Dublin 2, Ireland
Tel: 353 1 408 2488
Fax: 353 1 408 2626
Italy
Dr G. Masala, Health Adviser, Focal Point for Malaria, Directorate-General for
Development Cooperation, Ministry of Foreign Affairs, Via Contarinia 25, 00194
Rome, Italy
Fax: 39- 06 32 40 585
Dr G. Majori, Director, Department of Parasitology, Istituto Superiore di Sanita, Viale
Regina Elena, 299 , Roma 1-00161
Tel: 39 06 49387066
Fax: 39 06 49387065
email: majori@iss.it
Japan
Dr O. Utsunomiya, Deputy Director, International Affairs Division, Minister’s
Secretariat, Ministry of Health and Welfare, Government of Japan, 1-2-2Kasumigaseki, Chiyoda-Ku, Tokyo 100-45, Japan
Fax: 81- 3 3501 2532
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Dr Ichiro Okubo, Medical Chief Advisor of Intelligent Service, Infectious Disease
Control Division, Ministry of Health and Welfare, Government of Japan, 3-2-3 Kowada
Chigasaki, Japan
Tel: 81 467 54 5957
Mr Masaharu Yoshida, Director, Research and Programming Division, Economic
Cooperation Bureau, Ministry of Foreign Affairs, 3-612, 2-15 Higashiyama Meguro,
Tokyo
Mr Ken-ichi Kimiya, Deputy Director, Research and Planning Division, Economic
Cooperation Bureau, Ministry of Foreign Affairs.
Dr Yoichi Yamagata, Development Specialist, Institute for International Cooperation,
Japan International Cooperation Agency, 10-5 Ichigaya Honmura-cho, Shinjuku-ku,
Tokyo, 162 Japan
Tel: 81 42249 6167
Fax: 81 3 3269 6992
Mr Akito Yokomaku, Second Secretary, Permanent Mission of Japan, Geneva
Luxembourg
Mr A. Weber, Mission permanent du Grand-Duche de Luxembourg aupres de 1’office
des Nations Unies a Geneve, Chemin du Petit-Sacconex 28A, 1209 Geneve
Mali
Monsieur le Docteur Z. Maiga, Secretaire general, Ministere de la Sante, des Personnes
agees et de la Solidarite, Koulouba, Bamako, Mali
Tel: 223 225301
Fax: 223 230203
Netherlands
Dr Harry van Schooten, Health Adviser, Ministry of Foreign Affairs, P.O. Box 20061,
NL-2500, EB The Hague, The Netherlands
Tel: 31 70 348 4467
Fax: 31 79 348 5366
Mr Jan-Peter Mout, Policy Officer, Ministry of Foreign Affairs, P.O. Box 20061, NL2500, EB, The Hague, The Netherlands
Mr J. Waslander, First Secretary, Permanent Mission of the Kingdom of the
Netherlands to the UN Office & other International Organizations, BP 276, 1219
Chatelaine, Geneva
Fax:41-22-795 1515
Fax:41-22-795 1511
Norway
Dr Rune Lea, Health Adviser, NORAD, (Norwegian Agency for Development
Cooperation), P.O. Box 8034 DEP, 0030 Oslo
Tel: 47 22 314502
Fax: 47 22 314402
- 18 -
email: ruiie.Iea@norad.no
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Spain
Mr Jose Consarnau, Counsellor, Permanent Mission of Spain to the United Nations
Office and other International Organizations at Geneva, Avenue Blanc 53, 1202 Geneva
Tel: 731 2230
Sweden
Mr Anders Molin, Senior Programme Officer, Swedish International Development
Cooperation Agency, Birger Jarlsgatan 61, S-105 25 Stockholm, Sweden
Tel: 46 8 698 5239
Fax: 46 8 698 5649 email: anders.mo 1 in@sida.se
Professor Anders Bjorkman, Karolinska Hospital, Karolinska Institute, Stockholm,
Sweden
Tel: 46 8 517 7000
Fax: 46 8 622 5833
Uganda
Dr Philip Byaruhanga, Minister of State for Health, Ministry of Health, PO Box 8,
Entebbe, Uganda
Tel: 256-41 232170
Fax: 256 42 20622
Dr Betty Mpeka, Principal Medical Officer, Malaria Control Unit, Ministry of Health,
PO Box 8, Entebbe, Uganda
Tel: 256-41 321395
Fax: 256 41 345597
United Kingdom
Dr David Nabarro, Chief Health and Population Advisor, DFID, 94 Victoria Street,
London SW1E 5JL, United Kingdom
Fax: 44 171 917 0174
Ms Mary Keefe, DFID, 94 Victoria Street, London SW1E 5JL, United Kingdom
Tel: 44 171 917 0130
email: e-taylor@dfid.gtnet.gov.uk
Dr Elizabeth Tayler, DFID, 94 Victoria Street, London SW1E 5JL, United Kingdom
Tel: 44 171 917 0104
email: m-keefe@dfid.gtnet.gov.uk
Mr Guy M. Warrington, Permanent Mission of the United Kingdom of Great Britain
and Northern Ireland to the United Nations Office and other International Organizations
at Geneva, Rue de Vermont 37-39, 1211 Geneva 20
Tel: 918 2300
Fax: 918 2333
United States ofAmerica
Dr Dennis Carroll, Senior Health Advisor, USAID, G/PHN/HN, 1300 Pennsylvania
Ave, NW, Washington, D.C. 20523
Tel: (202) 712 5009
Fax: 1-202 216 3404
email: dcarroll@usaid.gov
Dr John Paul Clark, Senior Public Health Advisor, USAID, Bureau for Africa, L325 ‘G’
Street, N.W. 4th Floor, Washington D.C. 20523
Email: jclark@usaid..gov
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Viet Nam
Professor Pham Manh Hung, The First Vice-Minister of Health, Professor of
Immunology, Ministry of Health, 138A Giang Vo Street, Hanoi City, Viet Nam
Tel: 84 4 8462433
Organizations
African Development Bank
Ms Patience Kuruneri, Principal Social Sector Specialist (Health), African Development
Bank, 01 B.P. 1387, Abidjan, Cote D’Ivoire
Tel: (225) 20 45 69
Fax: (225) 20 59 91 Email: P.KURUNERI@AFDB.ORG
European Commission
Dr Li eve Fransen, Principal Administrator, DG VIII/G/1, European Commission,
Gearlestreet 12 1049 Brussels, Belgium
Tel: 32 2 2963697
Fax: 32 2 2963698
IFPMA
Dr Harvey Bale, Director-General, International Federation of Pharmaceutical
Manufacturers Association, 30, rue de St. Jean, 1211 Geneva 18
Tel: 41-22-340 1200;
Fax: 41-22- 340 1380
MIM — Wellcome Trust
Dr Melanie Renshaw, Scientific Assistant, MIM, The Wellcome Trust, 183 Euston
Road, London NW1 2BE, United Kingdom
Tel: 44-171 611 7260;
Fax: 44-171 611 7288
Dr Catherine Davies, Scientific Officer, Tropical Medicine, Multilateral Initiative on
Malaria, Wellcome Trust, 183 Euston Road, London NW1 2BE, United Kingdom
Tel: 44-171 611 8692;
Fax:44-171 611 7288
NIH
Dr John R. La Montagne, Deputy Director, National Institute of Allergy & Infectious
Diseases, National Institute of Health (NIH), Rm 7A03, Building 31, 31 Center Drive,
Bethesda, Maryland 20892, USA
Tel: Fax: 301 496 9677
Fax: 301 496 4409 email: JM79Q@NIH.GOV
UNDP
Mr Charles Desmond Cohen, Senior Advisor, Health, HIV and Development
Programme, UNDP, 304 East 45th Street, NY, New York 10017
Tel: 1-212 906 6976
Fax: 1-212 906 6336 email: desmond.cohen@undp.org
Mr Kevin McGrath, Consultant, UNDP, 1 United Nations Plaza, New York N.Y.
10017, USA
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
UNICEF
Dr Sadig Rasheed, Director, Programme Division, UNICEF, 3 United Nations Plaza,
(TA-25A) New York, N.Y. 10017, USA
Tel: 1-212 824 6566
Fax: 1-212 824 6470
Mr David Alnwick, Chief of Health Section
Dr Kopano Mukelabai, Senior Health Adviser, UNICEF, 3 United Nations Plaza, New
York, N.Y. 10017, USA
Tel: 1-212 824 6318
Fax: 1-212 824 6460
The World Bank
Dr Richard Feachem, Senior Health Advisor, Health, Nutrition and Population, The
World Bank, 1818 H. Street N.W., Washington, D.C. 20043, USA
Tel: (510) 521 7358
Fax:(510) 521 9805 Email: kfeachem@worldbank.org
Dr Ok Pannenborg, Sector Leader for Health Nutrition & Population, Africa Region,
The World Bank, 1818 H. Street N.W., Washington, D.C. 20043, USA
Tel: 1-202-473 4415
Fax: 1-202-473 8107 Email: oDannenborg@worldbank.org
Dr Maureen Law, The World Bank, 1818 H. Street N.W., Washington, D.C. 20043,
USA
Malayah Harper, Health Specialist, AFTH4, The World Bank, 1818 H. Street N.W.,
Washington, D.C. 20043, USA
Tel: (202) 473-0069
email: Mharper@worldbank.org
Civil Society & Non-Governmental Organizations
Dr John B. Tomaro, Director, Health Programmes, Aga Khan Foundation, P.O. Box
2369, Avenue de la Paix 1-3, 1211 Geneve 2
Tel: (41 22)909 72 00
Fax: (41 22)909 72 91
Dr Vinand M. Nantulya, Senior Technical Advisor, African Medical and Research
Foundation (AMREF), P.O. Box 30125, Wilson Airport, Nairobi, Kenya
Tel: (254 2) 602494 Fax: (254 2) 609518 email: nannilya@afncaonline.co.ke
Ms Francisca Issaka, Centre for Sustainable Development Initiatives, CENSUDI,
Commercial Street, TUC Building, P.O. Box 134, Bolgatanga, Upper-East Region,
Ghana
Tel: 233 71 23036 & 233 72 2249 Fax:233 71 23036 email: censudi@africaonline.com.gh
Dr Fidel Font Sierra, Senior Officer, Community Health and Social Welfare
Department, International Federation of Red Cross and Red Crescent Societies, Geneva
(representing NGO Forum for Health
- 21 -
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Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
WHO - Regional Offices
AFRO
Dr A. Kabore, Acting Director, Division of Communicable Diseases
Dr Akpa Raphael Gbary, Public Health Specialist, RBM/AIM Secretariat
Tel: 263 707 493
Fax: 1 407 733 9090
Dr M.H. Mathey-Boo, Chief Inter-agency Resource Management (IRM/AFRO)
Tel: 1-407 733 9214
Fax: 1-407 733 9090
AMRO
Dr Renato Gusmao, Regional Advisor, Communicable Diseases Control Programme
Tel: (202) 974 3259
Fax: (202) 974 3688
email: giismaore@paho.org
EMRO
Dr Bijan Sadrizadeh, Director, Integrated Control of Diseases
Tel: 20 3 4830090
Fax: 20 3 4838916
EURO
Dr S.K. Litvinov, Director, Infectious Diseases (DCD)
Tel: 45 39 17 1352
Fax: 45 39 17 18 51
SEARO
Dr Vijay Kumar, Director, Integrated Control of Diseases
WPRO
Dr Kevin Palmer, Acting Regional Adviser in Malaria
Secretariat
Dr Tore Godal, Acting Project Manager
Dr James J. Banda, RBM
Dr Fred Binka, RBM
Dr M. K. Cham, RBM
Ms Jenny Hill, Malaria Consortium
Dr Pene Key, RBM
Dr Kamini Mendis, RBM
Dr Hans Remme, RBM
- 22-
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
Annex 3
Agenda
Tuesday, 8 December
0830 - 0900
Registration
0900 - 0915
Opening and Introductions
- Dr David L. Heymann, Executive Director,
Communicable Diseases
0915-1000
WHO Renewal: progress and challenges
- Ambassador J.G. Store, EXD, DGO
Appointment of Chair / Rapporteur
Meeting Objectives
1000 - 1045 The Malaria Challenge
1.
The malaria burden world-wide; problems and issues
Present Contributions to Malaria Control
- Dr F. Binka, WHO/RBM Team
2.
Roll Back Malaria: The preparatory phase
- Dr Tore Godal, Acting Project Manager, WHO/RBM
Discussion
1045-1100 Coffee Break
1100- 1300
3.
•
Global Partnerships for national and local action
Existing mechanisms for coordinating international assistance for
better health
Country perspectives; experiences and lessons learned
Zambia
Dr J.J. Banda
Uganda
Dr Philip Byaruhanga, Minister of State for Health
UNDP, India, Mali & Vietnam as discussants
•
Existing Global and Regional Partnerships
- 23 -
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
- Dr P.J. Key, WHO/RBM Team and
Dr Ok Pannenborg, The World Bank
Discussion
1300-1430 Lunch Break
Poster Session commences in Foyer:
1300
Represented Agency’s Work Plans for support to RBM / Malaria
Control for 1998/99 and beyond
Technical posters
1430 - 1600
Establishing the RBM partnership
The purpose, operation and possible structure of the partnership
- Dr P. J. Key, WHO/RBM Team
4.
Possible organization for the RBM-African Initiative for Malaria
- Dr A. Kabore, Director of Communicable Diseases,
WHO/AFRO
5.
An understanding of the roles and responsibilities of different partners
- Mrs M.-H. Mathey-Boo, WHO/AFRO
6.
How the bi-lateral agencies can best participate
- Dr Dennis Carroll, USAID
7.
The Role of Local Government and Civil Society
- Ms F. Issaka, Ghana
Discussion
r-
1600-1615
Tea Break
1615-1745
continue discussion
1800-2000
Reception in French Restaurant
-24-
Establishing a Global Partnership to Roll Back Malaria: December 1998: Draft report
t
Wednesday, 9 December
0900 — 0945
Advocacy and Public Relations
Approaches to international advocacy, public relations and political
action in relation to RBM - Dr David Alnwick, UNICEF
8.
Discussion
0945 - 1030
RBM Funding
Funding and financial arrangements for long term support for RBM
Country programmes - Dr Ok Pannenborg, The World Bank
9.
1030-1100
Coffee Break
1100 - 1230
Potential for Frameworks at country, regional and global levels:
•
•
•
synchronising partners’ strategies and plans
resource mobilisation, flow and provision in a transparent and coherent
manner
monitoring and review of partnership action, financial accounting,
communications and maintenance of partnerships
1230 -1400
Lunch Break
1400 - 1530
Plans for taking forward the partnership
10.
Institutional Structure
•
•
•
•
1530 -1545
An RBM partnership secretariat
A standing committee
Governance and/or legal instruments
Global/regional/block/National stakeholder meetings
Tea Break
1545-1700
Conclusions and Recommendations
1700
Closure
- 25 -
World Health Organization
Organisation mondiale de la Sante
DISTR:LIMITED
DISTR: LIMITEE
t
WHO Roll Back Malaria (RBM)
Emergency and Humanitarian Action (EHA)
OUTLINE STRATEGY FOR MALARIA CONTROL
IN COMPLEX EMERGENCIES
<?
Dr S. Meek, Malaria Consortium
Dr M. Rowland, HealthNet International/Malaria Consortium
Dr M. Connolly, WHO
TABLE OF CONTENTS
1. RATIONALE
1
2. DEFINITIONS
2
3. STRATEGY
3
3.1 Development of a plan
3
3.2 Situation analysis and assessment
3
3.3 Site Planning
4
3.4 Disease management
4
3.5 Prevention
6
3.6 Malaria Surveillance
9
3.7 Epidemic Response
11
3.8 Disease awareness education
12
3.9 Training
12
3.10 Coordination
13
3.11 Monitoring and evaluation
14
3.12 Operational research
14
2
1.
Rationale
Malaria is a major communicable disease of the tropics and subtropics, killing more than
one million people each year. Roll Back Malaria (RBM) is a new global partnership that
will address this priority health issue at the country and local level. The objective of RBM
is to significantly reduce the global malaria burden through interventions adapted to
local needs and by reinforcement of the health sector. RBM was launched in October
1998 by WHO, World Bank, UNICEF and UNDP. WHO will provide strategic leadership
to the global partnership which is drawn from malaria affected countries, UN
organisations, bilateral development agencies, non-governmental organisations and the
private sector. RBM will build on all current malaria efforts to achieve targeted levels of
coverage in the affected population.
Malaria is a disease of the poor, especially of those in remote areas with no easy access
to health services. Malaria is also associated with conflict or the aftermath of conflict, as it
is a disease that flourishes in conditions of crisis and population displacement. Complex
emergencies have been defined as “situations affecting large civilian populations, involving
war or civil strife, food shortages and population displacement, resulting in excess
mortality and morbidity”. In complex emergencies, the factors that contribute to the malaria
burden include:
• breakdown of health services and of malaria control programmes
• movements of non-immune people or concentration of people in high risk areas
for malaria
• weakened nutritional state of the displaced population
• environmental deterioration that encourages vector breeding
• problems of supply of food and medicine and difficulty of access
Conflict results in instability and lack of governance. UN organisations and NGOs
(international and local) often take responsibility for providing health services in
collaboration with the host country. The insecurity makes long-term planning impossible
and the breakdown in systems can cause major difficulties for health care delivery. RBM
has identified malaria control in complex emergencies as an important initiative to
reduce the global burden of malaria. It also recognises that the problem of malaria in
such situations deserve special attention, and that strategies used in stable situations
must be adapted for complex emergencies.
An important component of RBM is the establishment of networks composed of experts
who can provide technical support to interventions in endemic countries. One of these
networks will be on Malaria Control in Complex Emergencies. This RBM Network
represents a opportunity to bring together malaria experts that specialise in providing
health services in complex emergencies, to share and learn from their experiences and
from that to develop and assist implement a strategy for effective malaria control in
complex emergencies. The challenge is to implement malaria control programmes that
are scientifically optimal and operationally feasible for each situation. The strategy will
guide coordinating and implementing agencies - UN, NGOs and national authorities - on
how to plan malaria control in complex emergencies, on how to select the most
appropriate interventions, on case management, on surveillance and response, prevention
and personal protection, resource and training needs, coordination, and what should be
monitored and evaluated. Gaps in knowledge needing further research will be identified.
Roll Back Malaria
Objective
The malaria burden in participating countries is significantly reduced through
- interventions adapted to local needs
- reinforcement of the health sector with first priority being given to high transmission areas of Africa
RBM project helps through
- creating a global partnership for advocacy, financial support, co-ordination, monitoring
- creating country level partnerships to ensure harmonised strategies
- providing consistent technical guidance through technical support networks
- endorsing technical content of strategies based on WHO strategies/intemational best practices
- ensuring that partners adopt appropriate strategies and implement in a harmonised manner
2. Definitions
Complex emergencies evolve from the acute to the post-emergency phase. The acute
phase may be defined as the period where the crude mortality rate is above one death per
10,000 per day. The acute phase is characterised by a number of events: population
displacement internally (internally displaced persons -1 DP) or cross border (refugee) but
may affect a static population or an ethnic group, a change in authority at local or
national level, a breakdown in infrastructure (health, logistics), impaired access to food,
and higher mortality. The acute phase may last only a few months.
The post-emergency phase begins when mortality rates return to the level of the
surrounding population and basic needs are met. During the post-emergency phase
there is reasonable confidence in security, the health situation is under control, longer
term approaches can be initiated, and more input can be made into capacity building
and reconstruction. However, the post-emergency phase can transit rapidly backwards if
the conflict resumes or slowly forwards if stability is maintained.
In chronic emergency countries, usually characterised by political deadlock of some
kind, some areas of the country may stay in an acute phase while others move towards
the post-emergency phase.
Different levels of health service are achievable in the acute and post-emergency
phases, and different operational strategies or approaches may be required. Some
operational agencies specialise in helping in the acute phase, others in the post
emergency phase. The malaria control strategy outlined in this paper summarizes what
can be attempted at the different phases of the emergency.
2
3.
Strategy
3.1
Development of a plan
In order to implement appropriate and effective malaria control, it is essential to develop
a plan. The elements of a good plan are:
1. Situation analysis
2. Define objectives for malaria control based on the severity of the problem,
human/material resources available, level of control in the host country and the
expected future movements of refugees
3. Select strategies - the following sections give details of these strategies
4. Decide on activities
5. Develop a workplan with responsible officer, objectives and targets
6. Agree with all interested parties on organisational framework
7. Develop indicators for monitoring and evaluation, and plan how they will be measured
8. Plan operational research, if gaps in necessary information are identified
9. Develop a budget
3.2
Situation analysis and assessment
An initial assessment of the situation is essential in order to plan the appropriate response,
to decide upon the most effective interventions, and to avoid costly or life-threatening
mistakes. An assessment team of experienced and qualified people with a mix of
complementary skills in disease control and operations should be mobilized to assess the
underlying causes and establish objectives and priorities. It is also important to assess the
displaced community itself, to determine human resources available and methods to
ensure their involvement in interventions. Information should be collected on:
Environment
geographical factors, water, agriculture
seasonal variation in rainfall and temperature
site selection
• Population
density, age & sex
ethnic structure
displaced & host, settlement patterns
• Epidemiology
disease endemicity
vectors and breeding sites
identifying at risk communities or areas
• Security
military & other authorities
access to vulnerables
• Available resources and logistics
human
health facilities
drugs, etc
funds
logistics, import practices
legal, registration policy
•
3
Assessment guidelines exist already and should be used, but specific malaria information
must be added such as local drug resistance, government health policy, and pre
emergency national malaria control guidelines. Team members should be drawn from
local health professionals, operational NGOs and from other agencies that can provide
skills in epidemiology, vector control, medicine and organisation. Presence of a donor
representative may ensure project funding.
The situation may have to re-assessed when the acute phase is over since different
strategies will be needed.
3.3
Site Planning
If camps are unavoidable, good site selection may reduce or prevent malaria. It is vital
that the assessment is made as early as possible to lobby against potentially malarious
sites that might support vector breeding.
3.4
Disease management
3.4.1 Diagnosis
Diagnosis is essential. Microscopic diagnosis may not be possible in the acute phase of
an emergency or where there is a very weak health system. Where no microscopy is
possible diagnosis must depend on clinical symptoms and knowledge of the risk of
malaria, recognising that this is not very accurate. In much of Africa, even under stable
political and economic conditions, clinical diagnosis is used in areas of high
transmission, as presence of parasitaemia does not correlate well with disease. Slide
confirmation is particularly important in areas where drug resistance necessitates use of
expensive drugs or where treatment failure due to resistance can progress rapidly to
severe malaria. It is also important in limiting unnecessary use of drugs.
The recently developed rapid diagnostic tests are very useful for screening large
numbers of patients, but are currently too expensive for individual diagnosis in most
places, and also remain positive after treatment and do not accurately measure parasite
density. In Cambodia where antimalarial treatment is becoming extremely expensive,
there is consideration of use of rapid tests for routine diagnosis.
3.4.2 Treatment
The treatment provided should be based on knowledge of drug resistance patterns in
the area. This is particularly important as displaced populations are especially vulnerable
due to low immunity (from malnutrition or lack of previous exposure to malaria) and to
risk of being unable to seek retreatment if treatment fails.
Local up to date information on drug resistance is essential for developing appropriate
treatment policy. Local health authorities who may have the information already and
operational agencies should collaborate on obtaining the information. Other causes of
treatment failure, such as non-compliance, vomiting and poor quality drugs should
always be monitored. Drug efficacy monitoring should follow standard procedures as
developed by WHO. As drug resistance is rapidly developing it is also important to
evaluate second line or future treatments prospectively.
4
Combinations of artemisinin derivatives and various other antimalarials are currently
being used in South East Asia due to the spread of drug resistance. These
combinations are under evaluation in Africa at present, and information on safety and
efficacy is expected in 1999. Depending on the results there may be a change in
approach to chemotherapy in Africa aimed at protecting the few remaining effective
antimalarials from rapid development of resistance of Plasmodium falciparum whilst
providing the patient with an acceptable treatment. There is a major concern about
what to do when sulfadoxine-pyrimethamine resistance becomes more widespread, as it
already has in Southeast Asia.
Management of severe malaria should be according to the national treatment protocols/
WHO recommendations and guidelines. Training manuals will be developed by WHO.
Treatment of Plasmodium falciparum gametocytes with primaquine is not
recommended, as evidence of its effectiveness is inadequate, and it can be dangerous
in glucose 6 phosphate dehydrogenase (G6PD) deficient individuals. Artemisinin
derivatives have been shown to have a gametocytocidal effect, and combinations
including them may lead to a reduction in transmission in some areas.
WHO will maintain a database of national treatment protocols of emergency affected
countries where these protocols exist. If protocols need to be adapted in the event of a
complex emergency, this should be developed and endorsed by WHO. The database
should also include information on drug sensitivity, simple protocols for sensitivity testing
and mapping of malaria and malaria risk (epidemiological, climatic, land use, etc) in
complex emergency countries. The WHO/HINAP project will hold malaria data on
complex emergency countries on its website.
3.4.3 Chemoprophylaxis and preventive treatment
In complex emergencies, chemoprophylaxis for malaria should be limited to pregnant
women, expatriate staff, and special groups such as the army. The drugs available for
chemoprophylaxis in these situations are chloroquine, proguanil,
pyremethanine/dapsone, mefloquine and doxycycline.
In highly endemic P.falciparum areas, where malaria in pregnancy is associated with
high maternal and infant morbidity and mortality, semi-immune primi- and
secundigravidae should receive intermittent preventive treatment with an effective,
preferably one-dose antimalarial drug delivered in the context of antenatal care. Such
intermittent treatment should be started from the second trimester onwards and not be
given at intervals less than one month apart. Studies indicate that HIV-positive pregnant
women may need such intermittent treatment on a monthly basis during all pregnancies.
The ratio of low birth weight (LBW) in primigravidae versus multigravidae in a population
in a malaria endemic area may be used to identify the endemic areas where malaria
control in pregnancy is inadequate and where intermittent treatment should be beneficial
to pregnant women.
Non-immune pregnant women exposed to falciparum malaria transmission are at high
risk of severe disease, death, and high rates of pregnancy failure. They should have
access to prompt and adequate medical care. In addition, in exceptional circumstance it
5
may be suitable to offer weekly chemoprophylaxis, if compliance with an effective and
safe antimalarial drug can be assured. Where weekly chemoprophylaxis is not possible,
non-immune pregnant women exposed to malaria transmission should at least be
offered directly-observed intermittent treatment.
Recent studies from Thailand show LBW associated with maternal vivax malaria
infection during pregnancy. This may be an indication for weekly chloroquine
prophylaxis in some situations where compliance can be assured.
3.4.4 Service delivery
A clear, understandable, implementable treatment regimen should be established and
communicated to all involved in health service delivery.
First line treatment may need to be changed if drug resistance studies show that the
national policy is ineffective.
On-site training of health workers is needed to improve case management: the cost of
drugs, the consequence of non-compliance and potential side effects should be clearly
spelled out to avoid confusion.
Accessibility of the population to the health structures is important, and may determine
the most appropriate type of health systems, including mobile clinics and community
health workers where indicated.
Ongoing rigorous evaluation of the case management strategy is essential to identify
needs to improve it.
Quality control of the laboratory should be given high priority.
In the acute phase, cash incentives may be needed to carry out control interventions,
but food-for-work is an option. Delivery of services should be integrated with primary
health structures or networks (e.g. using local NGOs or community based organisations)
as soon as possible. Delivery systems should be diversified and community participation
encouraged to reduce costs and to improve efficiency and coverage. In the post
emergency phase the commercial sector may provide sustainable supply of nets and
insecticide (sachets or tablets for home-treatment).
3.5
Prevention
(
3.5.1 Acute phase
The choice of intervention for disease prevention in the acute phase is not prescriptive and
will vary according to effectiveness, feasibility, cost and speed of supply. The key local
factors influencing choice are:
1. Type of shelter available
- permanent housing, tents, plastic sheeting
2. Human behavior
- culture, sleeping practices, mobility
3. Vector behavior
- biting cycle, indoor or outdoor resting
Some promising new methods of prevention (insecticide treated tents, clothing) have
been implemented to good effect in emergencies in Asia and Africa. These are still
under development and are not necessarily transferable to other regions owing to
differences in culture, dress, malaria endemicity or vector habits.
6
9
• Insecticide treated mosquito nets (ITN) are suitable if nets were previously used by
the population, and if living in structures that allow mosquito nets to be supported or
hung. ITN may be appropriate for those who regularly travel cross-border to insecure
areas. Not precluded in other situations but
- if people are new to nets, they may be less likely to use the nets appropriately (good
IEC essential)
- consider human or environmental factors that may lead to loss or damage of nets,
or hasten insecticide decay
- procurement of nets means higher initial costs than for other methods (see cost
analysis estimates below).
• Permethrin sprayed blankets and other materials are a promising initial option for
those under temporary shelters made of standard UNHCR plastic sheeting or where
correct use of ITNs is in doubt
- treated bedding has not been tested outside Asia or in highly endemic conditions
• Permethrin treated outer clothing worn in the evening or in bed is effective in south
Asia but needs testing in highly endemic African conditions Insecticide sprayed tents
for “transit” buildings, temporary treatment facilities, and family shelters
- not tested outside Asia
- use of plastic sheeting more common in complex emergencies in Africa and
conventional sheeting is not suitable for insecticide treatment
• Indoor spraying of residual insecticide (“house spraying”) has been the method of
control most often used in chronic refugee situations. It is suitable for refugee
populations who have built or are occupying mud huts or houses. To be effective the
local mosquito vector must be indoor resting (seek expert advice) and the
programme must treat all the houses.
- effective in West and South Asia when sprayed at the beginning of the transmission
season but less effective in SE Asia
- limited effectiveness in highly endemic parts of Africa
- has to be repeated annually in Asia and at 3-6 month intervals in stable endemic
areas; repeated application becomes expensive in chronic emergencies
• Environmental control may be difficult during the acute phase except on a local scale,
and impact is often limited. To reduce the number of vector breeding sites:
- drain clean water around water tap stands & rain water drains
- larvicide vector breeding sites if these are limited in number (seek expert advice)
- drain ponds, but may not be acceptable if used for washing
Local epidemics justify additional resources for spraying operations. In areas where
malaria is seasonal, by the time these become fully operational epidemic conditions may
have declined.
Relative efficacy and cost effectiveness
The alpha-cyano pyrethroids, such as deltamethrin and lambdacyhalothrin, are the most
effective insecticides for indoor spraying or treatment of nets. Permethrin is preferred for
topsheets or blankets since it has a very low human toxicity.
Among Afghan refugees in Pakistan, insecticide treated nets, tents, and housing appear
to be equally effective against malaria (giving about 60% protection against falciparum
malaria). Treated bedding and clothing are 10-20% less effective than treated nets. In
endemic Africa, treated bednets are the most effective intervention (reducing malaria
7
death by 42% and morbidity by 45% in the Gambian trials).
Treated bedding and clothing are cheaper than nets in camps since only insecticide has
to be provided. House spraying is cheaper than nets if done only once or twice. If
people are willing to pay for nets, nets become more cost-effective than house spraying
(see below: post-emergency phase).
Cost analysis is a useful substitute for cost-effectiveness analysis when local
effectiveness is not known. When the effects of the interventions being compared are
broadly similar (see above), then cost analysis on its own may be sufficient to make a
choice.
In West Asia (Afghanistan/Pakistan), the cost per person protected* per year is:
Treated nets
Treated blankets
House spraying
Tent spraying
$1.5 (in first year, $0.25 thereafter)
$0.25 (cost of blankets/sheets excluded)
$0.5
$0.25
* Includes cost of insecticide and nets but not of operations. Assumes that house is occupied by
10 people and a net by 3-4 people.
3.5.2 Post-emergency phase
Agencies need to carry out regular strategic reviews of the control programme and re
evaluate interventions as:
emergency needs change and mortality is brought under control
beneficiary involvement and skills improve
displaced people living in plastic shelter or tents construct local style huts; this
will allow increased use of mosquito nets or indoor spraying
this phase allows a longer term approach and provides opportunities for
establishing wider use of self protection methods
As malaria is a focal and controllable disease it may be necessary to redeploy resources
to where they are more needed.
• Treated materials and nets
Some cost recovery should be introduced for new nets as people’s livelihoods
improve
Retreatment process needs to be established on a cost recovery basis
Free or reduced cost distribution is essential for some vulnerables (widows with
young children, orphans etc.)
• Environmental control may be possible during rehabilitation of irrigation and water
supply sources; collaboration needed with agencies responsible for agricultural and
rural development.
• House spraying should become increasingly focal; prioritization of camps for spraying
should be based on sound indicators such as malaria incidence rates to ensure cost
effectiveness.
• Funds saved from house spraying might be allocated for nets and more sustainable
interventions instead.
8
Net treatment process
• Ideally recipients should impregnate the materials themselves as this reinforces
awareness of the insecticide, its importance in protection, and encourages proper
net care. However, in the acute phase, this might cause additional delay to initial
implementation, so pre-treatment is acceptable in this phase.
• Re-treatment should always be done by recipients, with training in safety.
3.5.3
•
•
•
3.6
Inappropriate interventions at any stage of the emergency
Aerial spraying; too dangerous in acute phase, too expensive in post-emergency
phase.
Scrub clearance (there is no evidence that this reduces man-vector contact).
Outdoor spraying with residual insecticide; expensive, environmentally
contaminating, usually fails to reach the targeted vector, limited impact
Malaria Surveillance
3.6.1 Surveillance indicators
Malaria surveillance is essential to assess the impact of the disease on the displaced
population in a complex emergency. It is also necessary to plan and implement an
appropriate control programme and to monitor progress. Malaria surveillance should be
done in the context of integrated disease surveillance.
The information sources or indicators available will depend on whether the region
cannot, could, or does support malaria transmission. Historical epidemiological
information and recent climatic records (seasonal rainfall and temperature patterns) may
provide evidence of a potential malaria problem. These data may be held by health
authorities or meteorological services. Mapping of malaria and malaria risk is presently
an active area of research in Africa, and this might be extended to complex emergency
countries as part of the preparation for dealing with any future epidemic. In addition to
key climatic variables, indicators reflecting population movement and breakdown of
health services may predict outbreaks or epidemics. Demographic changes to watch out
for, known to trigger epidemics in complex emergencies, are:
• migration of non-immune groups into areas with current malaria transmission
• migration of infected groups into malaria-free areas which are capable of supporting
renewed transmission
• movement of infected groups into an area with established malaria transmission but
of a different strain
These may be exacerbated by environmental changes that favour vector breeding or
increased man-vector contact.
Despite its limitation, a clinically defined case definition must suffice during the acute
phase of an emergency since microscopic confirmation is unlikely to be available
particularly in high transmission areas. In unstable endemic areas, even the best clinical
algorithms may wrongly classify a disease episode as being malaria and may also fail to
identify many true cases of malaria; microscopy diagnosis should be provided as soon
as possible to improve case management and surveillance. In stable endemic areas,
microscopy may not be so useful for defining cases; anaemia in children and pregnant
women, low birth weight, and high rates of splenomegaly, may serve as supporting
indicators.
9
Epidemiological information systems are essential in all malaria control programmes to
assess the country’s malaria situation, allow the forecasting of epidemics, define risk
groups, and monitor programme progress. Although data collection is difficult in the
acute phase of an emergency, minimal information is required in order to assess the
impact of malaria and to prepare a response:
Species of Plasmodium
which species are present, in what ratio, and in which seasons?
Mortality
what evidence is there for excess mortality or for malaria being the cause?
Morbidity
what is the incidence of fever and incidence of malaria?
what is the evidence for an increase in incidence of malaria?
which age groups are affected (<5, 5-14, >14y)?
pregnancy outcomes (low birthweight, stillbirth, prematurity)
These indices are only meaningful in relation to population as the denominator. During
an emergency population size may be difficult to estimate.
•
Slide positivity rate as a measure of parasite prevalence is a very useful malariometric index
in unstable malaria areas, since it is independent of population size and may show a sudden
increase during an epidemic. Its interpretation depends, however, on the criteria used for
taking slides. In such areas Plasmodium parasitaemia is equivalent to a malaria episode. In
areas with stable malaria, asymptomatic malaria is common, slide positivity may not reflect
disease so accurately, and rates must be interpreted cautiously.
Entomological inoculation rate may be discounted during the acute phase since the
components of this index (human biting rates and sporozoite rates of vectors) are difficult to
obtain and the index has little immediate value for programme management. During the post
emergency phase, if expertise is present to interpret the data, such information collected over
the course of a year may aid evaluation and re-planning.
(
3.6.2 Surveillance and epidemic investigation
Where malaria is potentially a problem, the resources and expertise needed to
investigate any outbreak should be prepared in advance. Epidemic preparedness
measures for malaria should taken jointly with other disease of epidemic potential in the
area e.g. identification of laboratory for sensitivity testing, stockpiles of drugs/equipment.
In the event of a suspected outbreak, the investigation should ideally be conducted by
epidemiologists or others skilled in outbreak investigation with local health workers so
that knowledge and skills developed can be used again in future outbreaks.
To ensure that data are of the required quality, an excess of information should not be
requested from the health care system. But to respond appropriately to the outbreak,
the following minimal information is required:
Population
Who is affected?
Where are they from?
How are they living?
Disease
Number with acute febrile illness
Number with confirmed uncomplicated malaria
10
Number with microscopically confirmed severe malaria
Number of malaria deaths
Number of maternal deaths due to malaria
Proportion of children with anaemia
Proportion of pregnant women with anaemia
Drug resistance; the proportion of treatment failures
Management
Number of health facilities
Available staff and expertise
Access of population to the health facilities
Availability of drugs and supplies
Malaria policy and treatment guidelines
Exceptional circumstances justify an exceptional response, and in an epidemic there
may be a need to deviate from national treatment protocols. WHO should have an
advisory role in such instances.
3.7 Epidemic response
Deciding on the intervention to adopt will depend upon available resources, state of the
health system, and other health priorities. The main aim of the response must be to
reduce mortality and disease burden. Three strategies for intervention might be feasible
according to the situation:
1. Mass treatment of fever cases
2. Case detection by outreach services
3. Passive case detection
In a severe outbreak the majority of fever cases may be due to malaria. Even if
microscopy was available there may not be time to confirm the diagnosis of every
suspected case. Mass treatment of febrile cases is then justified. If, exceptionally, an
expensive treatment is required because the malaria is multi-drug resistant, use of
microscopy or the more expensive rapid diagnostic kits might be justified. Microscopy is,
however, very useful for monitoring epidemic trends through the monitoring of slide
positivity rates (i.e. malaria as a proportion of all febrile illness) in samples of slides
taken from fever cases at regular intervals.
Health services should reach as deeply into the community as possible and make full
use of community health workers if available. Active case detection is fully justified
during an outbreak when there is mortality due to malaria and referral systems are
unavailable.
Ideally, treatments should be short and simple (preferably one-day) to avoid the
necessity for follow up or the chances of severe malaria developing.
Passive case detection is not a sufficient response in the acute phase if excess mortality
is documented and the population is dispersed. It is more suited for chronic refugee
situations when mortality is under control. Then, laboratory services with quality control
are essential not just for routine case management but also for surveillance of disease
trends. Such data may be used to justify implementing vector control or personal
11
05702
protection. Consolidated microscopy data trends are also useful for assessing the
impact of control interventions. When refugees are settled in numerous camps,
consolidated microscopy data and population data from each camp may be used to
estimate malaria incidence rates which may be used in turn as an indicator to prioritize
camps for targeting of prevention. The monitoring of field laboratories from a central
reference laboratory and imposition of quality control forms the basis for a health
information system.
3.8
Disease awareness education
Simple messages are needed that:
• improve understanding of disease
• encourage appropriate treatment-seeking behavior
• make the connection between protection against mosquitoes and prevention of
disease
• improve mosquito net retention and correct use
• emphasise who needs protection most (usually children and pregnant women)
(
Health messages may be delivered through community health workers (CHWs),
posters, leaflets, and the mass media.
3.9
Training
Who to train?
• Policy makers
• Health co-ordinators: National/local/expatriate NGO staff
• Clinical workers
(,
Content
The epidemiology of malaria and appropriate control measures may differ greatly
between Asia and Africa, so region-specific material may be needed. Control measures
may differ between the acute and post-emergency phase. There should be information
on how to organise malaria control, basic features of malaria control, diagnosis and
treatment using WHO training manuals and methods of prevention and surveillance.
Active supervision of health staff and regular updating of materials are important.
Issues
• The RBM technical support network has an important role to play.
• With the high turnover of NGOs there is an ongoing need for training.
• Evaluation and follow-up are important looking at change in practice.
• Malaria control should not be taught in isolation but as part of a broader training.
• A training programme should be planned to lead to the greatest possible degree of
self-sufficiency of displaced health workers, so that they can continue to work when
the emergency is over.
• In chronic refugee situations the training needs will change and in some cases may
need to take into consideration the refugees’ repatriation.
12
3.10 Coordination
3.10.1 Organisational framework among agencies
Coordination and information sharing may
•
•
•
•
•
reduce security risk
improve efficiency
prevent duplication of activities
provide common logistic systems
mediate or improve agency negotiating power with authorities or factions
Coordination might be provided under a UN umbrella agency or by a special
coordination body which agencies subscribe to. Within such fora it is possible to
establish sector committees to address specific health issues.
3.10.2 Division of responsibility
During a complex emergency, a health agency may take responsibility for a specific
geographical area and run general health care services within it, or may specialise and
take responsibility for a particular health service role (e.g. CHW training, laboratory
quality control, EPI) over a wider area. Either way coordination is essential; in the former
case, to ensure standardised protocols, in the latter case, so that general health
agencies can benefit from specialised services. Malaria is a specialist activity that
should be implemented through the general health services. That is as true for a
complex emergency as it is for stable conditions. General health agencies (MOH, UN or
NGOs) might, for example, coordinate with an agency specialising in laboratory training
services who has taken on the responsibility for ensuring the quality of diagnosis and
treatment in NGO clinics. Another agency specialising in disease control might take
responsibility for malaria prevention, and provide technical advice, commodities, or
training to agencies that want to implement personal protection or vector control in their
specific area of operation.
3.10.3 External expertise
Several agencies can provide specialist assistance on malaria:
RBM resource networks
WHO
CDC
Tropical Medicine Institutes
Malaria Consortium
Specialist NGOs
National Malaria Control Programmes and ministries of health
There is no single formula for enlisting assistance, and this will depend on coordination
arrangements within each complex emergency.
3.11
Monitoring and evaluation
Management and disease indicators should be set from the outset and monitored
throughout to ensure programme quality, progress, coverage, and to guide strategic
direction.
13
The number of indicators needs to be rationalized. The disease indicators selected will
depend on the state of development of the surveillance system (see section 3.5) while
the operational indicators will depend on intervention selected.
New indicators (e.g. stocks and accounting) need to be established in the post-acute
phase if cost-recovery or revolving funds are introduced.
Periodic, systematic evaluation of the programme (needs, plans, implementation, and
impact) provides evidence of progress or need for change.
(
Evaluation of epidemiological impact may be impossible during the acute phase but
should be considered during the post-acute phase when the population settles and
laboratory diagnosis becomes available. Confirmation of disease control will justify
continued implementation and helps secure further financial support. Suitable evaluation
methods include cross sectional prevalence surveys (i.e. mass blood surveys) and
simple case control studies at clinics (e.g. comparison of slide positivity rates between
personal protection users and non-users). Technical advice on design should be sought.
3.12 Operational research
The following is a list of areas where further operational research is needed.
3.12.1 Protection from malaria in pregnancy
Strategies to protect pregnant women are available but more research needed in
complex emergencies. Research on various interventions would be valuable.
(
3.12.2 Insecticide treated materials
Treated blankets and outer clothing: Preliminary research in Asia indicates these could
be useful in the acute phase as they get around some of the constraints inherent with
bednets, namely the need for appropriate behaviour, logistics and supply problems,
expense). Further work is needed on:
• suitability of alpha-cyano pyrethroids over permethrin (especially irritancy and
other side-effects)
• suitability of different materials and treatment methods (spraying, immersion)
• efficacy under highly endemic conditions or by other cultures (especially in
Africa)
Insecticide treated mosquito nets: Use and impact in acute phase. There is scepticism
that ITN would be used appropriately or have an impact. To define policy, need further
case studies and evaluation making use of rapid immuno-diagnostics and case-control
methods. Washing practices, and use of low-dose treatments to accommodate frequent
washings.
Treated (layered) plastic sheeting: Treated tents have been shown to work but plastic
sheeting is favoured increasingly by relief agencies. Sheeting cannot be treated using
conventional methods. Treatment of laminated polyethylene sheeting, analogous to the
'olysef slow release treated nets, may substitute.
14
3.12.3 Vector control
Impact and acceptability of ULV aerosoling of camps and buildings: Aerosoling is
normally only done under special circumstances:
- during an acute epidemic
- newly established camp or mobile population
- when no other method will work
- to control fly borne disease (e.g. shigella) or dengue
Because evaluation is difficult in the acute phase, effectiveness would be better
demonstrated in post-acute conditions in paired intervention/control camps (even though
the camps selected would not normally be aerosoled except in an epidemic).
3.12.4 ITN operational strategies
Mosquito net distribution strategy effectiveness in acute and post acute phases: the
range of delivery strategies possible (e.g. clinics, CHWs, mobile teams, private sector)
needs to be further developed and evaluated with respect to costs and cost
effectiveness; uptake, coverage and equity achievable; best I EC methods for stimulating
demand creation and appropriate use; “essential protection kits”, single dose sachets.
And how to achieve a transition from free provision in the acute phase to cost recovery
in the post-emergency phase
3.12.5 Case management
The Private Sector: In the post-emergency phase aid declines but the government may
not be able to fully resume a provider role. The private sector may take over this
function but with little sense of accountability or responsibility. Accreditation or
certification systems, with monitoring of quality control, regulated by government or
WHO, may stimulate improved prescribing practices, improve case management, and
reduce user costs.
Better understanding of different communities’ beliefs and treatment-seeking behaviors
is essential for developing appropriate treatment policy.
Monitoring drug efficacy and assessing the efficacy and practicality of newer treatment
regimes continues to be necessary
3.12.6 Service delivery
Comparison of different health delivery systems for malaria control in complex
emergencies may provide useful information for future emergencies.
15
Press Release
United Nations Development Programme • United Nations Children’s Fund • World Bank • World Health Organization
EMBARGO:
1000 a.m., New York
time, Friday, 30 Oct
1998
Press Release WHO/77
30 October 1998
FOUR INTERNATIONAL ORGANIZATIONS UNITE TO ROLL
BACK MALARIA
The United Nations Children’s Fund (UNICEF), the United Nations Development
Programme (UNDP), the World Bank and the World Health Organization (WHO) have
joined forces to launch a new campaign to fight malaria, which kills more than one million
people a year.
The programme, “Roll Back Malaria”, seeks to reduce substantially the human
suffering and economic losses due one of to the worlds most costly diseases. Malaria
causes an estimated 300 to 500 million acute cases per year, with most deaths occurring
among children in Africa - nearly 3,000 die each day. It has been estimated that malaria
accounts for about 10% of the disease burden in Africa.
“Malaria is the number one health priority of people and leaders in affected
communities and countries, but their voices have not been heard,” says Dr Gro Harlem
Brundtland, WHO Director General. Roll Back Malaria was initiated when Dr Brundtland
was elected WHO Director-General in May. "The human suffering is unacceptable and so
is the economic burden and impediment to progress. Africa and other regions with malaria
are responding and we must answer their call," she says.
Roll Back Malaria (RBM) is different from previous efforts to fight malaria. RBM will
work not only through new tools for controlling malaria but also by strengthening the health
services to affected populations. RBM will implement its activities through partnerships
with international organizations, governments in endemic and non-endemic countries,
academic institutions, the private sector and nongovernmental organizations. Above all, it
will be a united effort by the four international agencies concerned with malaria and its
effects on health and economic development.
Malaria is, above all, a disease of the young and of the poor, many of them children
who live in remote areas with no easy access to health services. But the use of simple
prevention and control methods has shown startling results: in trials conducted in The
Gambia, Burkina Faso, Kenya and Ghana, the use of bednets - which are treated with
biodegradable pyrethyroid insecticide was shown to effectively protect sleeping children
from malarial mosquitoes, resulting in dramatic reductions in deaths among children under
five years of age. Deaths were reduced by average of one fourth in these mega trials.
W
Press Release WHO/77
Page 2
Roll Back Malaria will seek to:
•
•
•
•
•
strengthen health systems to ensure better delivery of health care, especially at district
and community levels;
ensure the proper and expanded use of insecticide-treated mosquito nets;
ensure adequate access to basic healthcare and training of healthcare workers;
encourage the development of simpler and more effective means of administering
medicines; such as training of village health workers, mothers and drug peddlers on
early and appropriate treatment of malaria, especially for children;
encourage the development of more effective and new anti-malaria drugs and
vaccines.
"While strengthening the health sector is essential to Roll Back Malaria," says
UNICEF Executive Director Carol Bellamy, "the new strategy will be most effective when
families, communities, local leaders and other groups, such as shopkeepers and
schoolteachers, become fully committed and involved in the effort. In all of the countries
seriously affected by malaria, communities have already demonstrated that rapid
improvements in child health are possible when they are given the right kind of support
and encouragement. We are confident that this new initiative will be able to provide this."
Unlike most other major diseases in the world, malaria is spreading. As roads are
built, forests cut down, new mining areas opened up, habitats which favour the breeding of
mosquitoes expand, and what starts out as economic development often unintentionally
leads to an underperforming and sick workforce.
“The poor suffer the most from malaria,” says James Gustave Speth, Administrator
of the UNDP. “The international community must firmly commit itself to this new
partnership and to developing integrated actions that take aim at both malaria and at its
greatest breeding ground which is poverty. UNDP looks forward to working with its UN
and other partners in this worldwide campaign against malaria.”
"Making significant, sustained inroads in the battle against malaria urgently requires
a coordinated, focused initiative. Governments, international organizations, the research
community and the pharmaceutical industry must all play a major role. The World Bank is
committed to playing its part in the mobilization of resources needed to spur such a
coordinated response," says James D Wolfensohn, President of the World Bank Group.
For further information, journalists can contact Gregory Hartl, Health Communications and Public Relations,
WHO, Geneva. Telephone (41 22) 791 4458. Fax (41 22) 791 4858. Email: hartlg@who.ch .
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
Press Release WHO/77
Page 3
Malaria and economic development
Roll Back Malaria is being launched at a time of growing scientific interest and
investment in malaria, which still remains grossly underfunded.
"We and other groups of economist researchers are trying to determine the
consequences of malaria on economic development," says Jeffrey Sachs, Professor at
Harvard. "Our findings are striking. They point to Malaria as a major impediment to
economic development."
Poor health via disability from diseases such as malaria reduces incomes by as
much as 12 percent in some studies, a particularly important factor in developing countries
where a significant proportion of the workforce is involved in agriculture and other forms of
manual labour.
The evidence also suggests that the effects of improved health are likely greatest
for the most vulnerable -- the poorest and those with the least amount of education.
New tools
Bednets: Large-scale field trials have conclusively demonstrated that the use of
bednets treated with biodegradable pyrethroid insecticide can protect children from dying
from malaria. Do-it-yourself approaches to insecticide treatment of nets are now available.
Mapping: Based on satellite mapping and climatic information, the distribution of
malaria can now be determined at the community level.
For countries participating in RBM, national malaria information will be integrated
with regional information to produce a comprehensive national malaria control map, as
part of the international mapping of the disease.
The information will allow a better estimation of the burden of malaria and the
population at risk, and hence a better assessment for RBM. It will also provide more
reliable and area-specific information for national and international advocacy for malaria
control. Where RBM operations have started, information on the availability and quality of
health services and the results of monitoring and evaluation will be added to the data
base.
Bringing treatments to the people: In Africa, the RBM will create a network of teams
to go into villages and analyze treatment and prevention practices at the household and
community level, the availability and quality of health care by the public and private sector,
and potential local partners. The RBM will provide technical and financial support for each
analysis through this network at the district level.
Treatment at home can be greatly facilitated by simple packaging of drugs; fast
acting rectal caps can rescue life-threatening disease in children.
Most victims of malaria die simply because they do not have access to health care,
or their cases are not diagnosed as malaria. In addition, life saving drugs are often not
available.
Press Release WHO/77
Page 4
"These tools will greatly help in bringing the attack where it matters, says Dr. David
Nabarro, newly appointed leader of the central team for Roll Back Malaria, headquartered
at WHO in Geneva.
Research breakthroughs
Researchers are investigating a wide range of activities in malaria are severely
underfunded, but investment is increasing thanks to a new Multilateral Initiative for Malaria
research (MIM). The new techniques being investigated include ways of preventing the
mosquito parasite from infecting the mosquito.
“A number of scientists are trying to make the mosquito resistant to the parasite,"
says Fotis Kafatos, Director-General of the European Molecular Biology Laboratories in
Heidelberg, Germany. "Using the most sophisticated techniques in molecular genetics we
are discovering an array of novel possibilities."
Several vaccine candidates using the latest breakthroughs in vaccine technology
are undergoing field testing in Asia and Africa and in US volunteers, while the whole
genome (a complete set of hereditary factors) of the malaria parasite is being sequenced.
"This will create completely new opportunities," says Dr. Harold Varmus, Director of
United States National Institutes of Health (NIH), which is one of the leading drivers in the
MIM. "Malaria is a global concern. We are gearing up our support for research both here
and abroad.”
New discoveries have led to many different approaches to a malaria vaccine, with
many of the possibilities already undergoing human trials. However, scientists estimate
that it will take 7-15 years before an effective malaria vaccine is ready.
Vaccines taking advantage of DNA research may provide one of the best hopes.
One possibility is being developed by the US. Naval Medical Research Institute, the US
Agency for International Development and partners in Ghana, Australia, France and the
US private sector.
“Our work in relationship to WHO objectives is focused on producing multi-gene
DNA vaccines designed to reduce morbidity and mortality of malaria in young children in
sub-Saharan Africa,” says Dr. Stephen Hoffman, of the Naval Medical Research Institute.
The major project is entitled MuStDO 15.1 (multi-Stage DNA vaccine operation), which is a
15-gene malaria DNA vaccine.
Researchers hope to initiate clinical trials of this new vaccine within 18 months. Dr.
Hoffman has just published the first proof of the principle that DNA vaccines are
immunogenic in normal, healthy humans.
Another promising vaccine candidate has just begun field trials in the African nation
of the Gambia. This new recombinant protein vaccine, RTS,S, developed by SmithKline
Biologicals, would prevent the malaria parasite infectious stage from entering or
developing within liver cells of human beings. Such vaccines would prevent the severe and
life-threatening consequences of malaria in non-immune individuals.
Press Release WHO/77
Page 5
Another approach is to develop a vaccine that prevents transmission of the malaria
parasite from one infected person to another person. This type of vaccine would block the
development of the parasite in the mosquito, thus preventing the parasite from infecting
someone else. This transmission blocking vaccine is under development by scientists at
the US NIK, in collaboration with WHO/TDR. The NIH has recently initiated a major
Malaria Vaccine Development Programme aimed at ensuring the production of clinical
grade materials for use in clinical trials.
A different asexual blood stage vaccine type is based on a cocktail of antigens. One
such synthetic peptide vaccine, SPf66, developed by Manuel Pattaroyo working at the
Institute de Inmunologia in Bogota, Colombia, has been tested in field trials in South
America, Africa and Southeast Asia. It has only been partially effective to date. Dr.
Pattaroyo is using sophisticated biochemical methods to improve its potency.
The leading scientific journal Nature published this week research from Kenya,
Thailand and Malawi which shows that pregnant women living in malarious areas develop
a unique immunity which protects them from malarial infection. Professor Bernard Brabin
of the Liverpool School of Tropical medicine, who is a co-author of the paper, and has
worked for 20 years on the subject of malaria in pregnancy, says that it is the most exciting
scientific development in this field for decades and could open the way for developing a
vaccine to protect pregnant women from malaria.
Public private sector collaboration
Because malaria is largely found among poor people in poor countries, the private
sector can not engage fully in research and development. A public-private sector initiative
is being set up to circumvent the problem. The New Medicines for Malaria Venture will be
financed by public sector and philanthropic bodies. The private sector will primarily provide
facilities and staff. Industry is committed to making this work, says Harvey Bale, Executive
Director of the International Federation of Pharmaceutical Manufacturers Associations.
The four UN-System organizations contribute unique expertise
UNDP has committed to the following actions.
At country level, UNDP will:
1. Create capacity for integration of malaria-related action into national poverty
eradication policies, strategies and programs.
2. Strengthen, through Sustainable Human Development activities, the balance of action
among state, private sector, civil society and communities themselves, to ensure that
people have access to basic social services and productive assets.
3. Work through the UN Resident Coordinator system to encourage collaborative
programming in support of intersectoral action and resource mobilization.
At regional/sub-regional levels, UNDP will:
1. Support links between Sub-regional Resource Facilities (SURFs), providing technical
referral services to country offices and the Roll Back Malaria resource support
networks.
2. Collaborate with WHO Regional Offices to strengthen capacity of relevant regional
inter-governmental organizations (ISO) in support of Roll Back Malaria.
At global level, UNDP is providing continuing support for the UNDP/World Bank/WHO
Special Programme for Research & Training in Tropical Diseases (TDR), which has as a
Press Release WHO/77
Page 6
major focus the development of drugs and tools for malaria control and adapting research
in local settings.
UNICEF will:
1. Provide support to intensified malaria control efforts via its country programs.
2. Work with Government & NGO partners to:
• give special attention to reducing the terrible toll of malaria on young children and
pregnant women;
• further strengthen support for community-based and local action to improve health
and nutrition;
• focus on making insecticide treated mosquito nets available to all families that need
them and on ensuring that every child with malaria has access to early and effective
treatment;
• mobilize leaders (community, district and national) to make effective malaria control
a priority.
3. At international level, raise additional funds for country activities, and focus support on
10 of the most severely affected countries in the next two years.
4. Take lead responsibility for developing an impregnated bednet resource network.
The World Bank Group strongly supports the Roll Back Malaria global partnership.
Malaria has a major impact on social and economic development. Consequently, the Bank
has committed to:
1. Increase World Bank investments in malaria control and research;
2. Facilitate resource mobilization to support RBM;
3. Enhance a more effective involvement of Departments of Finance, Economics,
Infrastructure, Agriculture and others to become full partners in reducing malaria as an
economic factor;
4. Explore innovative finance mechanisms to deliver support;
5. Support research on the economic aspects of malaria;
6. Help establish private-public partnerships with industry on new malaria products.
Together with Roll Back Malaria partners, the Bank will actively pursue these activities
through its country programs and research agendas. Malaria must be reduced as a
negative factor on macro-economic growth.
WHO will be coordinating the Roll Back Malaria project. Project Countries and affected
populations have identified malaria as a priority health issue. Activities will cut across
WHO programs & regions to:
1. Support governments & partners:
• strengthen the health sector to better tackle malaria;
• monitor the geographic spread of malaria;
• measure results and outcomes of action;
2. Improve technical efficiency & capacity:
• build & support technical support networks, regional and local;
• invest in the development of new methods, tools and capacity strengthening
through research networks and programs;
3. To improve resource allocation, utilization and mobilization:
• local/national: promote concerted action by stakeholders
• regional: establish resource networks;
Press Release WHO/77
Page 7
•
global: supporting partners for common action and sharing information on malaria,
programs and resources.
Global Malaria Rates*
REGION
CLINICAL CASES
AFRICA (South of the Sahara)
270-480 million estimated**
AMERICAS
(Including Brazil)
(Brazil alone)
2.2-5.6 million estimated
1.1-2.8 million reported
MIDDLE SOUTH ASIA
(Including India)
(India alone)
2.6 million reported
2.1 million reported
ASIA WEST OF INDIA
(Including Afghanistan)
(Afghanistan alone)
0.5 million reported
0.3 million reported
EASTERN ASIA & OCEANIA
(Including Thailand, Vietnam
and The Solomon Islands)
(Thailand, Vietnam and
The Solomon Islands alone)
0.5 million reported
EUROPE
(Including Turkey and
the former USSR)
12 000 reported
1.0 million reported
* Estimates of global malaria mortality are 1 million deaths a year, and occur primarily in
African children under five years of age.
** Included in this total, there are 140-280 million estimated cases of malaria
in children under the age of five.
Source: WHO, 1998
For further information, journalists can contact Gregory Hartl, Health Communications and Public Relations,
WHO, Geneva. Telephone (41 22) 791 4458. Fax (41 22) 791 4858. Email: hartlg@who.ch .
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can be
obtained on Internet on the WHO home page http://www.who.ch/
Presentation Structure
Roll Back
Malaria
■ Global Malaria Burden
■ Background to Roll Back Malaria
■ RBM Partnership Principles
■ RBM Partnership Strategy
■ Process for Rolling Back Malaria
A Global Partnership
■ Criteria for success of the RBM partnership
■ Proposed Values for RBM
March 15th 1999
■ Challenges
■ Plans, Progress and Issues to be addressed 2
M1MDurban March 1999 DN
Malaria affects poor people the most
Global Malaria Burden
GNP
■ Disease Burden
per capita
(1995)
• 300-500 million clinical cases per year
■ A global problem
■ 80% of cases In Africa
• 1 million deaths per year
■ confirmed by recent analysis
■ > 95% of deaths among under-fives in Africa
• Disability from severe form of the disease
• Health sectors find it hard to cope
——
■
.1
r
'-4-
Malaria
Index
3
Background to Roll Back Malaria
Background: the RBM concept
■ Despite partial success of eradication efforts in the
1960s, malaria causes increased levels of suffering
particularly among children
■ New initiative proposed by Organisation for African
Unity and World Health Assembly since 1994
■ Accelerated efforts in Africa 1995 - present
■ WHO Africa Region proposed Africa Malaria Initiative
in 1997
■ Global effort to Roll Back Malaria proposed by Dr
Brundtland when standing as DG a year ago
■ Roll Back malaria announced in January 1998
■ Preparatory work from February 1998;
■ World Health Assembly and G8 backing May 1998;
■ Inception July 1998;
■ Launching October 1998 by WHO, UNDP, World Bank
and UNICEF;
■ Global Roll Back Malaria Partnership established
December 1998;
■ WHO Roll Back Malaria Project supports the
Partnership: Preparatory Phase till December 1999
1
RBM Principles: their evolution
RBM Principles: where are we now?
■ Malaria Burden is a Challenge to Human Development
• (significant cause of poverty and suffering)
■ Present response characterised by fragmented effort and
lack of synergy among "development partners"
■ Favours the parasite and mosquito, not people at risk
■ Primary focus of response must be with people at risk
• (not just the parasite or mosquito)
■ If people know more they are in a better position to make
beneficial choices
■ Choices influenced by knowledge, understanding,
resources and services, opportunities to act, supportive
environment
7
Strategy: informed response to a
complex disease
• People focus
• Partnerships at the country level
• Prioritising malaria - appropriately - within
health sector development
• Packaging the response to malaria - agreed
strategy, clear deliverables
• Project in WHO, supporting global partnership
• Private sector involvement
• Professional "technical support networks"
• Pathfinder for work on communicable disease
Strategy: Determined search for new tools
■ Malaria situations vary: need to assess and respond to
the pattern in each case
■ Existing efforts could yield so much more
• Early detection
• Rapid assistance
• Multiple prevention
• Well-coordinated strategies
• Dynamic coalition of stakeholders
• incorporated fully into Health Sector
■ However, in some situations, significant gains
will depend on cost-effective new products
and tools
9
10
• a vaccine is needed, and there are
promising candidates
• new drugs - such as rectal artesunate - are
vital to reduce mortality and combat drug
resistance
Strategy: Clear communications
/
Clear explanations of
what is involved
in
Rolling Back Malaria
adjusted to the interests of
the recipient
For example ....
/
/
Roll Back Malaria
Multiple strategies
targeted to local needs
\
\
\
/ Roll Back Malaria is a co-ordinated and Intensified response to \
local malaria control needs. It mobilizes effective and appropriate |
action based on a careful assessment of the unique local situation.
'i
A global movement
focused on local initiatives
/
\ Roll Back Malaria seeks to Increase the political commitment /
\pf influential institutions to control the disease. It channels /
\ this commitment In support of local partnerships and
/
\ national Initiatives working toward common goals.
/
2
1. EARLY^
DETECTION
Six Elements of X
Roll Back Malaria \
Community Awareness
Grassroots education and training programmes
can prepare families and community members to Identify
malaria symptoms.more quickly
A Dynamic
Cut
Malaria
Deaths
In Half
Surveillance
and climate studies
to detect areas and populations most at risk.
Resistance Alert By carefully following
Determined’^^
/
Research
/
\
Well-Coordinated /
X.
Strategy -X
2. RAPID
ASSISTANCE
/
/
Home is the First Hospital \
/
A simple packet of fast-acting drugs made widely
available for use by parents can rescue
the spread of drug resistance,
/
prescriptions can be changed
/
to ensure patients are treated with /
effective drugs.
y'
\
\
3. MULTIPLE
PREVENTION
X
\
Bednets treated with Insecticides - in Africa/
Asia and the Pacific region - have reduced
childhood malaria deaths t>y an average of 25%
Personal protection in the home, with
People with fever often seek help from frlends'or local healers.
Communities will become knowledgeable in
,
\
recognising new malaria cases and treat them quickly.
/
\ Providing care for the very sick/
\
Accessible health services and quality treatments /
x.
are Important for curing people
/
with severe malaria Illness
/
insecticides and other deterrents, can further
reduce the likelihood of bdng bitten
Community action, when well planned,
\& Environmental Management/
done properly/iifhjt?''
mosquito breeding
s'
4x.
ELL-COORDINATE
STRATEGY
^5. DYNAMIC^
AND EFFECTIVE
MOVEMENT
Social Mobilisation: enabling households
to respond better to the malaria threat
A Coalition of Stakeholders
Theprivate sector, foutBWriSa'rid trusts
NGOs,:§^odety, assodatio^;iOTje;nnedia
Better Health Care: ensuring that health
services, private practitioners and local healers
can respond to.problems posed by malaria
Involvement of many sectors:/
\schools, community groups, local business
k
and government departments /
X.
all have a part to play/X
K
\
■assass'
,
Partnershl|MStet®3"ai%i sustained by /
natfonaTgbvprnment
X.
X.
Backed by who-sponsored
technical networks
/
/
3
Process for Rolling Back Malaria (RBM)
6.
DETERMINED
RESEARCH
■ Objective
• The malaria burden in participating countries
is halved through
- interventions adapted to local needs
- reinforcement of the health sector
■ Approach
■ Global response tailored to local situation with
spearhead in Africa
■ Countries in the lead
■ Emphasis on partnerships which lead to effective
action: avoid missed opportunities
■ Drawing on the full range of interests in WHCP
Drive to discover new tools
A new medicine needs to be discovered every five years.
Existing medicines can be made more user-friendly
through repackaging.
An effective vaccine would be a powerful weapon.
Eight vaccines are currently being tested.
\
\
New, ecologically safe insecticides are needed /
to protect homes and bednets.
/
Components of the RBM process
la: Intensified National Action through
country-level partnerships
1 Intensified National Action, through Country
level Partnerships to Roll Back Malaria
■ National Authorities
• committed to RBM
2 Political and Institutional backing through the
Global partnership
• seek a wide range of partners
■ (including civil society, private sector, donors, media)
• encourage partners to agree to work together
in a flexible manner
■ towards common goals
■ using agreed strategies and procedures
■ within context of Health Sector Development
■ Institutionalise partnership procedures as soon as
possible
22
3 Harmonised strategies and consistent technical
guidance through promotion (and sponsorship)
of technical support networks
4 Strategic investments in better tools through
focused support for research and public-private
initiatives
21
lb: WHO support to country-level
partnerships
2: Political and institutional backing
through global RBM partnership
■ WHO Roll Back Malaria project helps through
■ Brokering technical/fmancial assistance for
situation analysis and strategy implementation
■ Endorsing technical content of strategies based
on WHO standards / international best practices
■ Encouraging partners to stick to agreement
■ Monitoring progress within context of health
sector development
■ Project includes headquarters and regional
resources
23
■ An opportunity for all partners to
• focus on the needs of Country
Partnerships
• ensure sustained commitment by partners
at headquarters and regional levels
• monitor effectiveness of efforts to Roll
Back Malaria within context of health
sector development; report on progress to
partners
• link with other global partnerships for
development
■ Support from WHO project
• a slimline secretariat for the partnership
24
4
3a: Harmonised strategies; consistent technical
guidance
3b: RBM Project draws on capacity
throughout WHO to
■ WHO-RBM project will seek ways
• to sustain a common approach to Rolling Back Malaria
throughout the organisation and beyond
• to ensure that partners adopt appropriate strategies and
implement in a harmonised manner
• to help countries access consistent technical guidance
• to encourage operational research in country to develop
the best strategies
■ through sponsoring
• work to develop common concepts and strategies
• structured "technical support networks"
• advocate the new concept
• set standards, promote best practices,
endorse proposed actions
• establish links with national authorities,
help them sustain partnerships
• support development and implementation
of strategies
• broker financial and technical assistance
• track progress
• sponsor research and development
25
26
3c: RBM project promotes Consistent
Technical Support: Issues and Networks
4: Strategic investments in better tools
through the Global Partnership
• 9 critical issues for
effective RBM identified
• Networks offer access to
Experts, mainly from within
the region
♦ Review and inform on
State of the Art
• Provide technical support
to countries upon request
■ Needs assessment
■ Implementation of bednets
■ Home-management
■ Sector-wide approaches
■ Drug resistance
■ Access/quallty of drugs
■ Mapping malaria/health care
■ Prevention of epidemics
■ Complex emergencies
27
>■ Advocacy of focused research to identify new
approaches for prevention and treatment
• TDR, Multilateral Initiative on Malaria
■ Support for public-private efforts to discover
new products (medicines, vaccines, insecticides)
• Medicines for Malaria Venture Capital Fund
• Malaria Vaccine Initiative?
■ Partnership with commercial entities to support
development and marketing of products to
make them accessible to those who need them
28
Criteria for overall RBM Partnership Success
Criteria for overall Partnership Success (2)
■ Country Partnerships
• Are they being developed? Are they owned by national
authorities, with inclusive membership?
• Are strategies harmonised? Are good opportunities being
taken? Are outcomes being monitored?
• Is technical guidance consistent and useful?
■ Health Sector Development (public-*-private)
• Is good quality care provided for those with malaria?
• Do they access - and benefit from - this care?
• Does health sector development result in greater
benefits for more people?
■ Strategic Investments
• New products discovered?
• Distribution approaches reach poorer people?
■ Prevention and treatment of malaria
• Are more people (children and pregnant women)
receiving timely and appropriate treatment?
• Are more people protected with
30
Insecticide-Treated Nets?
■ Global partnership
• Is there evidence of political commitment? Are partners
contributing? Is there a multidisciplinary approach?
• Is there transparency on objectives, resources, strategies?
• Are global strategies harmonised - within the health sector
context? Does WHO have a consistent approach?
29
5
Criteria for overall Partnership Success (3)
■ Malaria burden
10 Values for Roll Back Malaria (1)
■ RBM is a social movement supported by
many partners
• Is there a decline in malaria-related mortality and
morbidity in areas of continuous infection?
■ RBM is owned by all the partners
• Is there a reduction in malaria suffering (incidence
and severity) due to epidemics?
■ Decisions are made by consensus
• Are poor people better able to attend school, earn a
living, find new opportunities, have children safely
and become better off?
■ Country priorities drive Roll Back Malaria
• Are there more opportunities for sustained
economic and human development in the locality?
■ Partners contribute where they have a
comparative advantage - or interest
■ Partners function independently, but in
concert
31
10 Values for Roll Back Malaria (2)
■ Action plans are clear, evidence-based,
prioritised and adapted to local realities
■ RBM is about broadening and strengthening
the capacity of health sectors to fight all
diseases
■ RBM is not a new agency or funding
institution
■ The ultimate objective is to reduce poverty
and promote development
33
Challenges for Rolling Back Malaria:
1999
• Encourage conduct of, and investment in,
good quality strategic research and
product discovery [NUM]
• Promote interest in development of new
tools and investment in selected public
private partnerships [MMV]
35
32
Challenges for Rolling Back Malaria:
1999
• A consistent WHO-wide approach for Rolling
Back Malaria: maintain involvement of all
clusters
■ Ensure that National Authorities are in the lead
in country partnerships
• Encourage partners to respond to local
situations in ways that yield maximum benefit
from existing control tools and strengthen the
health sector
• Mobilise additional resources to help countries
Roll Back Malaria without encouraging inter
disease competition or vertical programmed
Plans and Progress: Developing the RBM
approach in WHO
1 Develop the concept, make sure it is
widely known, get key groups to join in
2 Build the global partnership, keep it going
3 Activate country-level progress through
Supporting critical actions
Backing strategy development and country
partnerships
4 Promote consistency of technical guidance
5 Strategic support for research and
development
6 Monitor progress
36
6
Issues - the concept
Issues - implementation
■ Is the proposed concept and approach
feasible?
■ Can it be put into practice given the
resources available to national governments?
■ Does WHO's capacity to support RBM depend
on additional capacity in Ministries of Health
or in WRs' offices?
■ How - at country level - to take account of
• ongoing or planned action against malaria?
• Ongoing plans and progress with Health
Sector Development?
■ How to ensure the most effective action to
Roll Back malaria within this context?
38
37
Issues - partnerships
Issues - funding
■ How to ensure that the WHO RBM project
• has access to up-to-date information on
what is happening,
• is plugged in to partnerships even when
these are being taken forward by others,
• offers flexible support in a responsive
manner,
• takes full account of Health Sector,
decentralisation, and other development
initiatives,
39
■ How to establish effective procedures for
ensuring that countries have access to
additional funds to enable them to Roll Back
malaria, while
■ Supporting the existing sector-wide approach
to health, and
■ Ensuring that the WHO has sufficient
resources - at the country level - to add value
to ways in which these funds are used?
The Prize
Summary
Much reduced malaria burden
Human development
Poverty
reduction
41
J
40
■ Malaria: Health Sector responds to Human Development issue
■ New approach builds on previous experience
■ People focus, strategic synergy, partnership
■ Yet disease is complex and needs sophisticated response
■ RBM: Ambitious goal, process approach, health sector context
■ Global and country partnerships led by national authorities
■ Partners work together in flexible but disciplined manner
■ WHO supports partnerships: brokering, endorsing, monitoring
■ WHO encourages harmonised strategies, consistent guidance
■ Focused research and public/private efforts for new tools
■ Evaluation: Clear criteria for partnership success
■ Challenges: technical consistency, countries in lead, resources
7
Global Malaria Burden
■ Disease Burden
The Roll Back Malaria
Movement: Progress Report
David Nabarro: WHO Roll Back Malaria
Cabinet Project
Geneva: April 1999
• 300-500 million clinical cases per year
■ A global problem
■ 80% of cases in Africa
• 1 million deaths per year
■ confirmed by recent analysis
■ > 95% of deaths in Africa
• Disability from severe form of the disease
• Health sectors find It hard to cope
2
Malaria affects poor people the most
GNP
per capita
(1995)
Malaria
Index
RBM Principles: their evolution
■ Malaria Burden is a Challenge to Human Development
• (significant cause of poverty and suffering)
■ Present response characterised by fragmented effort and
lack of synergy among "development partners"
■ Favours the parasite and mosquito, not people at risk
■ Primary focus of response must be with people at risk
• (not just the parasite or mosquito)
■ If people know more they are in a better position to make
beneficial choices
■ Choices Influenced by knowledge, understanding,
resources and services, opportunities to act, supportive
environment
5
Background: the RBM concept
■ Roll Back malaria announced in January 1998
■ Preparatory work from February 1998;
■ World Health Assembly and G8 backing May 1998;
■ Inception July 1998;
■ Launching October 1998 by WHO, UNDP, World Bank
and UNICEF;
■ Globa) Roll Back Malaria Partnership established
December 1998;
■ WHO Roll Back Malaria Project supports the
Partnership: Preparatory Phase till December 1999
■ Roll Back Malaria movement in Africa
Roll Back Malaria: progress 1999
■ High level political backing
■ Robust International Partnerships
■ Strong advocacy for community level action
■ Critical contribution from WHO
■ Intense action at country level
■ Long-term investment in better tools
6
1
s
IS
1
High level political backing
Robust international
Partnerships
International development organisations
committed to working together
-4 Economic and social impact of illness
recognised
•4 Global partnership established with strong
regional alliances
■4 29 Heads of State committed to Rolling Back
Malaria
Joint working to an agreed plan
-4 Malaria a national development priority in
many nations - beyond the Ministries of Health
Private sector, NGOs, research community and
foundations all engaged
Full support from G8 leaders
s
®gl Strong advocacy for communitylevel action
Critical contribution from
WHO
■4 Goals articulated
■4 Global movement supporting local initiatives
■4 New and effective strategies identified
-♦personal protection, home-based treatment,
prediction and response to epidemics,
evidence-based responses
■4 Co-ordinated approach to strengthen public
and private health care
Multiple strategies focused on local malaria
needs
■4 Promoting the movement, Sustaining
partnerships, Brokering resources
•4 Diverse partnership acting in concert
■4 Unified WHO response: HQ, Regions, Countries
-4 Clear messages why, what, how and when
Bl
’
Country-level process
underway
-4 in-country consultations
-4sub-regional consensus meetings
-4 building momentum at country level
-♦■developing RBM partnerships, fostering the
movement
-♦using technical instruments (situation analysis
and strategy development)
-♦accessing technical support networks
-♦agreeing national plans for RBM
11
-4mobilising additional resources
New and better products
■ Help ensure that existing tools are used
wisely
■ Identify new diagnostic tools, and
standardised case definition
■ Develop new treatments, introduce
them with care to preserve their utility
■ A vaccine - in 10 years?
■ Useful instruments for economic and
behavioural analysis
12
2
it
Promising progress
■ Ethiopia
■ Guinea
■ Cote d'Ivoire
■ Mozambique
■ Complex Emergencies
■ Mekong delta
■ Mali
■ Phillipines
■ Armenia
The Challenge
■ Build and strengthen country level
partnerships
■ Establish Technical Support Networks
■ Sustain the partnership
■ Mobilise a further $10 m in 1999, $60m
in 2000
13
B 10 Values for Roll Back Malaria (i;
■ RBM Is a social movement supported by
many partners
■ RBM is owned by all the partners
■ Decisions are made by consensus
■ Country priorities drive Roll Back Malaria
■ Partners function independently, but in
concert
■ Partners contribute where they have a
comparative advantage - or interest
14
■
10 Values for Roll Back Malaria (2
■ Action plans are clear, evidence-based,
prioritised and adapted to local realities
■ RBM is about broadening and strengthening
the capacity of health sectors to fight all
diseases
■ RBM is notnew agency or funding
institution
■ The ultimate objective is to reduce poverty
and promote development
1$
16
3
Roll Back Malaria
RBM/World Bank
The World Bank Group strongly supports the
Roll Back Malaria global partnership. Malaria
has a major impact on social and economic
development. Consequently, the Bank has
committed to:
► Increase World Bank investments in malaria
control and research
► Facilitate resource mobilization to support RBM
► Enhance a more effective involvement
of Departments of Finance, Economics,
Infrastructure, Agriculture and others to become
full partners in reducing malaria as an economic
factor
► Explore innovative finance mechanisms to
deliver support
► Support research on the economic aspects
of malaria
► Help establish private-public partnerships
with industry on new malaria products.
Together with Roll Back Malaria partners, the Bank
will actively pursue these activities through its
country programmes and research agendas.
Malaria must be reduced as a negative factor
on macro-economic growth.
RBM/WHO Project
GLOBAL
INITIATIVE
Countries and affected populations have
identified malaria as a priority health issue.
Activities will cut across WHO programmes
and regions to:
7. Support governments & partners
► Strengthen the health sector to better
tackle malaria
► Monitor the geographic spread of malaria
► Measure results and outcomes of action
A worldwide partnership
to fight malaria, one of
the world's most
devastating diseases
2. Improve technical efficiency & capacity
► Build & support technical networks in
affected countries
► Invest in the development of new methods,
tools and capacity strengthening through
research networks and programmes.
3. Collaborate and coordinate in order to improve
resource allocation and utilization
► Local/national: promote concerted action by
stakeholders
► Regional: establish resource networks
► Global: support partners for common action
► Share information on malaria, programmes
and resources.
Roll
Bock
Malaria
A network of national
governments, international
organizations, private sector
| OKPANNENBORG
| World Bank, 1818, H Street N.W.,
' Washington DC 20433, USA
Tel: (+1)202-477-1234
Fax: (+1)263-470-0146
E-mail: opannenborg@worldbank.org
TORE GODAL
World Health Organization, 20 Avenue Appia
1211 Geneva 27, SWITZERLAND
Tel: (+41)22-791-2660
Fax: (+41)22-791-4198
E-mail: godalt@who.int
and others, contributing
their skills and resources to
maximize the impact
against malaria
j
RBM/UNDP
Malaria has important implications for health and
RBM/UNICEF
UNICEF will:
poverty. Effective responses will require broad
based support across sectors and the involvement
of a range of development partners.
1. Provide support to intensified malaria
control efforts via its country programmes.
UNDP has committed to the following actions:
At country level
1. Create capacity for integration of malaria-related
action into national poverty eradication policies,
strategies and programmes.
2. Strengthen, through Sustainable Human
Development activities, the balance of action among
state, private sector, civil society and communties
themselves, to ensure that people have access to
basic social services and productive assets.
3. Work through the UN Resident Coordinator system
to encourage collaborative programming in support
of intersectoral action and resource mobilization.
Roll
Bock
Malaria
At regional/sub-regional levels
1. Support links between Sub-regional Resource
Facilities (SURFs), providing technical referral services to
country offices and the Roll Back Malaria resource
support networks.
2. Collaborate with WHO Regional Offices to strengthen
capacity of relevant regional inter-governmental
organisations (ISO) in support of Roll Back Malaria.
At global level
UNDP is providing continuing support for the UNDP/
World Bank/WHO Special Programme for Research &
Training in Tropical Diseases (TDR), which has as a major
focus the development of drugs and tools for malaria
control and adapting research in local settings.
MINA MAUERSTEIN-BAIL
UNDP, 1 UN Plaza, New York,
New York 10017, USA
Tel: (+1)212-906-6349
Fax: (+1)212-906-6350
E-mail: mina.mauerstein-bail@undp.org
2. Work with Government & NGO partners to:
► Give special attention to reducing the terrible
toll of malaria on young children and pregnant
women
► Further strengthen support for community
based and local action to improve health
and nutrition
► Focus on making insecticide treated mosquito
nets available to all families that need them and
on ensuring that every child with malaria has
access to early and effective treatment
► Mobilize leaders (community, district and
national) to make effective malaria control
a priority.
3. At international level, raise additional
funds for country activities, and focus support
on 10 of the most severely affected countries
in the next two years.
4. Take lead responsibility for developing an
impregnated bednet resource network.
DAVID ALNWICK
UNICEF, 3 UN Plaza, New York,
NewYork 10017, USA
Tel: (+1)212-824-6369
Fax: (+1)212-824-6460
E-mail dalnwick@unicef.org
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