Outline of Presentation

1. DISTRICT LEVEL MALARIA ADVOCACYScaling up & Sustaining Malaria Control through PartnershipsEmmanuel FiagbeyCountry DirectorJHU/CCPVoices for a Malaria-free FutureGlobal Health Conf. 14 June 2010

2. Outline of Presentation • Brief update- Current malaria situation and the African scene • Need for new partnerships and district level advocacy • The DMAT Model- Rationale and the Process • Status of DMAT Implementation and benefits so far • Challenges in implementing the district model • Key Lessons Learned.

3. Malaria – Brief Update Malaria still the most effective and persevering killer in many developing countries, particularly Sub Saharan Africa. A significant contributor to; • anaemia in pregnant women and children • adverse birth outcomes such as spontaneous abortion, stillbirths, preterm labour and maternal mortality from severe malaria. • disastrous effects on the foetus such as Intra Uterine Growth Retardation, Intra Uterine Foetal Death and high pre natal mortality. In fact every one of the estimated 30.3 million pregnancies that take place in Africa annually stands the risk of malaria.

4. Malaria - Brief Update • In some countries, malaria consumes about 40% of total government spending on public health and accounts for up to half of all hospital admissions and outpatient visits. • Malaria is a major source of school absenteeism reaching up to 28% in some countries. (4 learning days per episode in Ghana) • It is a major source of workdays lost to ill health (9 workdays per episode) and a loss of about 40% of farmers’ harvests in Ghana.

5. Current Progress World Malaria Day 2010 RBM partnership key message: This message is based on the fact that through international partnership and support and the efforts of various endemic countries, an appreciable level of progress is being achieved in controlling the disease. The statistics is interesting to note. “Investment in malaria control is saving lives and has far reaching benefits.”

6. Current Progress • Malaria deaths in all endemic countries throughout the world have reduced from the estimated 1 million to approximately 850,000 per year. • Overall malaria cases have dropped from at least 350 million cases per year to 250 million a year. • Among African children under 5 years, malaria associated deaths have dropped from an estimated 3000 per day to 2000 per day.

7. Current Progress • In Africa, approximately one child died every 30 seconds from malaria at the beginning of the decade. Countries saving an estimated one life every three minutes today with current control scale up efforts. (RBM 2010) • Ghana, moved from 8 million reported cases in 2006 to 3.2 million in 2008 and in the case of under five deaths from almost 9000 deaths in 2000 to about 4000 in 2008. • Tanzania 11.5 million in 2005 to 8.5 million in 2007. (WMR 2009) These significant results achieved through partnership and support - African countries and institutions such as the Global Fund, the PMI/USAID, CDC, the World Bank, DFID, WHO and others.

8. Malaria in Africa

9. Improving Control Measures Malaria as a development Issue The advent of dedicated advocacy to Malaria by the RBM partnership (from health to development). Calls for harmonization of activities, mobilization of resources and implementation of partners coordinated actions to achieve joint malaria control targets. Strengthening the Health System Building capacity in critical components of the system to achieve more equitable and sustained improvements across all intervention areas and the support structures required to achieve the desired outcomes and targets.

10. The New Partnership An important component of a strengthened health system is an active partnership between non-health public, private and civil society and the health sector, supporting health provision and not simply receiving health services Mobilization and organisation of the non health sector to support the health sector in implementing the approved interventions. The heart of district level advocacy for malaria control

11. Voices Goal & Objectives Goal: To sustain resources and expand political commitment for malaria control, contributing to a decrease in malaria mortality. • Mobilizing Leadership in Government and Civil Society. (equipping national leaders with credible information to speak out on malaria, mobilize funds, coordinate activities and address bottlenecks.) • Increasing District Level Advocacy. (engage local leaders as malaria champions to increase visibility and awareness, prioritize and facilitate the flow of malaria information to the national level NGOs and the NMCP and maintain district and national level funding.) • Policy dissemination & reducing barriers to policy implementation • Advocating for increased funding in Public & Private Sectors

12. Why Foster District Level Partnership Most NMCPs operate in a centralised national health structure. Linked to • District Health Management Teams • Expected to interact with district political and civil society leadership. For example, in Ghana, the NMCP under the Ghana Health Service of the MOH has a structure that sets it up as a central point coordinating three broad zonal levels of managing the malaria control program. Each zone covers multiples of regions comprising many districts and led by a Program Team/Officer based at the NMCP in Accra with monitoring and other activity visits to the regions and districts when necessary.

13. Why District Level Partnership ctd. This structure provides no framework or prescribed ways in which the over 166 DHMTs could each on its own actively interact with the NMCP and the non health sector to generate resources for malaria control and ensure effective implementation of programs. In recognition of this weakness an RBM Country Assessment carried out in 2008 recommended, “A more formal role for regional and district health teams needs to be worked out so that the NMCP can expect with confidence, that interventions will be carried out down to the local level in a competent and thorough manner.” (RBM Ghana Country Needs Survey, 2008)

14. District level Partnership for Focused Malaria Advocacy District level advocacy provides the opportunity for the achievement of a focused, thorough and competent malaria programs delivery; • It ensures that government and nongovernment leadership, district political and financial support becomes available. • Provides grounds for acceptance and sustainability of community structures required to facilitate service delivery.

15. Rationale for District Advocacy The basis for recognition of the district as an important unit for promoting increased advocacy for malaria control lies in; • Decentralized system of local government enshrined in the constitutions; and • Local Government Laws of the various African countries including Ghana, Tanzania and Uganda.

16. The Decentralized Local Government System Article 240. 1992 Constitution of Ghana • Parliament shall enact appropriate laws to ensure that functions, powers, responsibilities and resources are at all times transferred from the central govt. to local units… • That local government authorities plan, initiate, coordinate, manage and execute policies in respect of all matters affecting people in their areas… • ACT 445 (1993) District Assemblies Common Fund Law. 1% to Malaria Control Initiatives.

17. The Decentralized Local Government System Article 146; Constitution of the United Republic Tanzania Local Govt. Laws ACT 1999 Two of the three basic functions of the local government system prescribe: • Promotion of economic and social welfare of the people within their areas of jurisdiction • Ensuring effective and equitable delivery of qualitative and quantitative services to the people within their areas of jurisdiction

18. The District Malaria Advocacy Process Involves constructively engaging district leaders from all sectors of the district’s development in planning, delivering and monitoring of advocacy activities directed at improving malaria control interventions. Leaders – From politicians, government officials and heads of Decentralized Departments, private sector business leaders, NGOs, to traditional chiefs and religious leaders etc.

19. Objectives of the District Malaria Advocacy Process • Increased involvement of all stakeholders in mobilizing support for malaria control programs. • Increased community participation in malaria prevention and treatment decisions. • Increased mobilization of resources including funds to ensure constant supply of commodities and training and motivation of health workers including volunteers. • Judicious and transparent distribution and use of resources and commodities. • Increased participatory monitoring of activities to ensure timely resolution of bottlenecks and improved programming.

20. The Nine Steps Process

21. Step 3: Formation and Orientation of DMAT Central to the operation of the District Malaria Advocacy 9 Steps Model. It is a team of interested advocates from recognized institutions and organizations- public and private, committed to influencing decisions affecting malaria programming. Membership: Selected/elected members of District Assembly/Council, DHMT, reps of relevant decentralized departments, Councils of Chiefs & religious bodies, reps of Private Sector, NGOs etc.

22. Objectives of DMAT • Promote sharing of information on current developments in malaria control among leaders and community members. • Promote involvement of policy makers and decision makers in improving resource generation and allocation for malaria programming, • Motivate all stakeholders in the district to be actively involved in malaria control activities.

23. Objectives of DMAT • Support the DHMT and the District Assembly to strengthen existing systems and structures and or create new ones when necessary for sustaining malaria control programs and activities. • Promote effective implementation of national malaria control policies in the district.

24. District Malaria Advocacy Team Soroti District Malaria Advocacy Team - Uganda SaveluguNantom District Malaria Advocacy Team - Ghana

25. Step 5 & 6: Advocacy Needs Survey and Action Plan • Gather evidence and promote fact-based advocacy in the key intervention areas. • Background of health provision • Status of malaria programs and activities • Partners and their roles • Key Issues, Challenges and Successes • Develop Action Plan detailing activities, responsible persons and groups with required budgets.

26. Issues: IPT and ITN Uptake

27. DMAT Actions Members of a School Malaria-free Club demonstrate ITN Use and its importance: Keta Municipality Chairman of the DMAT , a traditional ruler (Chief) addresses a Mothers’ Support Group: Asuogyaman District.

28. Step 7: Special Session of District Assembly/Council on Malaria • Needs survey report and Action Plan presented to District Assembly/Council • Participation: All members of assembly or council, MPs from district, heads of decentralized depts. Private sector, Chiefs & religious leaders, NGOs in malaria. Milestones: • District Assembly and other sectors motivated to provide greater support to malaria programming. • Agreement reached on allocation of government designated funds for malaria programs. • Other sources of support for malaria control eg. individual and organizational donations identified.

29. Special Session of District Assembly on Malaria MP & Minister of Youth and Sports presents funds to DMAT Chairman at Special Session of the Kpandu District

30. Step 8: Implementation of Action Plan • All responsible institutions and individuals – the District Assembly/Council and its relevant committees, the DMAT, the DHMT, heads of the decentralized departments, private sector leadership, chiefs, religious leaders and NGOs and community members • The Executive Committee of the DMAT and the DHMT Supervises & Monitors. Milestones: • Increased collaboration between the DHMT and the District Assembly/Council in the implementation of malaria control programs. • Increased commitment of resources to malaria control programs by the District Assembly and other sectors.

31. Step 9: Monitoring & Evaluation • Identification, affirmation and celebration of successes, identification of challenges and failures, reviewing strategies and programs and planning for improvement. • The DMAT develops a plan for monitoring all malaria control programs and activities in the district. Milestones: • Monthly /quarterly monitoring plan for malaria control programs developed and implemented by all stakeholders & partners. • Quarterly malaria program review meetings instituted. • Annual evaluation of malaria control programs carried out and results disseminated to the district assembly/council and other stakeholders.

32. DMAT Quarterly Monitoring Form Region…………………… Year……………. District………………….. Period: From …………to ………… Supporting Organizations:…………………………………………………………………….. Key Challenges: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Name/Signature of DMAT Chairman:…………………………………… …………………………………………………..

33. Monitoring ITN Use DMAT Members discus ITN use with Community leaders after Peer Monitors had presented reports Mother demonstrates how she uses her net to DMAT Members during a Monitoring Visit. Yilo Krobo District.

34. District Malaria Advocacy • The DMAT • Advocate for resources and effective programming • Raise malaria as priority within District Assembly/Council • Influence allocations of government designated funds and other resources • Monitor use of funds/resources & distribution of commodities- ITNs, ACTs etc. • Promote fundraising with local & other partners • Monitor NGO programs in malaria • Request M&E info from DHMT on key malaria indicators - ITN distribution, Access to ACTs & IPT, Diagnostics • Support community events - Durbars etc. Partnership • DHMT • Implement DMAT non-advocacy activities: • - Training health workers, SHEP Officers, CBAs, etc. • - Providing appropriate malaria prevention and treatment information & services • NGOs • Implementation and support for DMAT activities: • - Mobilization of communities • - Formation and supervision of community groups • - Promoting acceptance of ACTs & ITN distribution, re-treatment and promoting use Other Partners Private sector – Transport Unions, Community groups, Schools, Community Radio stations etc. implement DMAT activities. - Disseminating malaria information/ IEC materials - Supporting commodities distribution ie. ITNs Improving Malaria Prevention and Treatment in the Communities

35. Status of DMAT Implementation • 8 Districts in Ghana and One in Tanzania on the 9th Step - actively implementing advocacy action plans & monitoring activities. • 4 Districts in Ghana at the 7th Step – just initiated implementation of advocacy action plans • Three Districts in Ghana & 1 each in Tanzania and Uganda at the 6th Step – completed advocacy needs survey and developing action plans.

36. Benefits of the District Malaria Advocacy Process Transparency: • District Malaria Advocacy program formally brings on board other stakeholders who under normal circumstances would have been left out. • Strengthens partnership between District Assembly (Political authorities) and DHMT– reduced suspicion between the two institutions.

37. Benefits of the District Malaria Advocacy Process Transparency: • Monitoring of application of donor, govt. and locally generated resources being applied by all stakeholders including NGOs is enhanced leading to increased confidence in partners in resource provision. (Eg. GCNM to receive $350,000 5 year grant from NMCP) • DHMT and District Assembly assume greater transparency in the application of resources meant for malaria control activities.

38. Benefits of the District Malaria Advocacy Process System Strengthening: • Enhanced knowledge level of leaders on the actual causes of malaria and its burden on the family and the district/country as well as its prevention & correct treatment through the advocacy training and information sharing sessions. • Improved capacity of health workers as DMAT supports DHMT in reorienting staff and volunteers in developments in - ITN use, acceptance & use of new anti-malarials etc.

39. Benefits of the District Malaria Advocacy Process System Strengthening • Enhanced image & improved performance of CBAs. • Eg. 105 trained in Keta, • 44 in Suhum Kraboa Coalta, • Peer monitoring in several communities inYilo Krobo

40. Benefits of the District Malaria Advocacy Process System Strengthening • GCNM: Over 100 NGOs from the 10 regions form a coalition to support programs delivery • GMAAN: a network of media practitioners trained in malaria reporting to keep malaria in the news. • Ghana Malaria Action Alert: Periodic bulletin providing information to DMAT members and other advocates on prevailing malaria control issues.

41. The Ghana Malaria Action Alert

42. Benefits of the District Malaria Advocacy Process Supply Chain Management: Effective management of the supply chain is facilitated • DMAT prevents diversion of supplies eg. ITNs • DMAT monitors stock out of drugs and other commodities and alerts DHMT • Strengthening logistics for improved services; eg DMATs include supply of microscopes, weighing scales etc. in action plans – Keta DA provided 1 more microscope to the DHMT in 2008

43. Benefits of the District Malaria Advocacy Process Resource Generation: • Opening of specific accounts for malaria by the DMATs creates opportunities to halt misapplication of DA funds meant for malaria eg. the 1% District Assemblies Common Fund, thus increasing funds for malaria programs in the district. • Keta: had almost $2,550 this year for ITNs • Asuogyaman: Training of SHEP Cords; ITNS for all hospital beds Akosombo hospital • Suhum Kraboa Coalta: 1200 ITNS • Yilo Krobo: Set up Lab services through Korean support • Savelugu Nantom: Almost $9,000 for net use promotion, and RDTs

44. Benefits of the District Malaria Advocacy Process Summary Summary The District Malaria Advocacy program provides common grounds on which the health sector, local government, public and the private sector speak with one voice in; • Reviewing the district malaria situation • Identifying critical issues • Developing appropriate response programs • Coordinating stakeholders activities • Generating local resources and facilitating proper • use of all resources • Ensuring equitable distribution and proper use of • commodities. • Fast and effective response to emmergencies; eg the Kilosa Floods in Tanzania

45. The Challenges Ownership and sustainability Who owns the DMAT? • The DHMT and therefore the Ghana Health Service, Ministry of Health • The District Assembly and therefore Ministry of Local Government • Civil Society eg. an NGO

46. The Challenges DMAT Stability & Sustainability • Political activism of members of the District Assembly/Council- National and Local elections and campaigns disrupting activities. • Change in leadership at national and district levels – govt. officials, District Assembly members/ Councilors

47. The Challenges Fear of loss of power • Fear of loss of political and administrative authority over govt. funds which holders of such authority sometimes misapply for personal gains. Motivation for Voluntarism • Volunteerism versus paid service – Where are the funds to pay local leaders for enabling them to do what they are expected to do more effectively for their people?

48. Five Key Lessons Learned • Lack of knowledge & inactivity Inadequate knowledge among leaders of the causes of malaria and its socio-economic burden on society have been responsible for failure of many leaders to get actively involved in supporting malaria control activities. “I know malaria can kill but not sure to what extent. Participating in DMAT activities has widened my understanding of the problems malaria brings to us and the safety of the new drug. I will ensure the 1% DACF is provided to help fight the disease.” (Presiding Member, Yilo Krobo District Assembly , Eastern Region )

49. Lessons Learned ctd. 2. Malaria as a development issue District level social, economic and political institutions would consider malaria control as equally important as their core business if they recognize the fight against the disease as an important development activity. 3. Local government responsibility Local governments will not relegate malaria control to the background when faced with competing priorities regarding allocation of resources for developmental issues if they understand health provision is part of their core mandate.

50. Lessons Learned ctd. 4. Guidance for all sectors engagement When clear directions are provided to local government leadership on how to engage other sectors apart from health in malaria control, ownership of programs and the roots for sustainability of activities are firmed up. 5. Effective use of commodities such as ITNs When local leadership is involved, monitoring of actual use of ITNS is strongly facilitated.