Equipping FBOs for Malaria Programming activities:

1. Equipping FBOs for Malaria Programming activities: Some Technical Facts and Key Organizational/Management Issues Presentation at CCIH Annual Meeting on May 26,2007 Larry Casazza, MD MPH Director, ACAM-African Communities Against Malaria

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

3. Suggested Objectives • To increase knowledge of SOTA for current Malaria interventions • To be able to prepare future malaria curriculum materials to train trainers and field staff in malaria programming implementation • To improve skills on malaria interventions for inclusion in grant proposals

4. Suggested Objectives (continued) • To understand and participate in strategies for improved funding of FBOs through PMI, Global Fund, private sector partners, and other malaria program granting mechanisms • To appreciate and leverage the main strength of FBOs as partners in malaria programming at Regional and national levels • These objectives cannot be fully answered in this presentation alone, but hopefully it serves to encourage you to discover what more there is to learn

5. Impact in Africa • Inhibits economic growth in SSA by estimated $12 billion GDP per year • SSA excluding Southern tier is 28% of 0-4 yr mortality 57% of 5-14 yr mortality 6% of 14+ mortality • 40%+ of household and health system effort

6. Why is the malaria problem growing? • Climate changes • Development of drug resistance • Complex emergencies (Geopolitical Issues) • Development of insecticide resistance • Weak health infrastructure to deal with the problem of malaria • Limited local resources • Human and behavioral factors • ALL Key Factors to be considered in your programming!

7. Malaria: Africa's major parasitic disease • Yet Malaria is a curable disease if promptly diagnosed and adequately treated, while prevention methods are relatively cheap and simple. • Malaria is a disease of the poor and the world’s poorest people living in rural communities are particularly affected • Children suffer an average of five bouts of malaria/year • Rural and urban populations affected in new areas where malaria was not a threat previously

8. #1Why epidemiology is important • To understand the disease and its vector better • Malaria epidemiology differs by place • Malaria epidemiology is not static over time • Malaria control is context-specific • Malaria is a challenging disease in all respects

9. What FBOs need to know about the Vectors • Where do they breed? • When do they bite? • Who/what do they bite? • How ubiquitous are they? • How resistant to insecticide are they?

10. #2 Classification of malaria transmission intensity • The term endemicity is used to describe the degree of malaria transmission intensity in an area • Endemic areas : where the incidence of malaria has been constant for many years (i.e. stable malaria transmission intensity but may still have seasonal variations) • Epidemic areas: where increases in malaria are occasional and sharp (i.e. unstable malaria transmission intensity)

11. Classification criterion for endemicity of malaria Source: adapted from (Eds) Gilles and Warrell. Essential Malariology, Oxford University Press

12. Prevention The most effective way to prevent malaria is through the selective and safe use ofinsecticides that kill the malaria transmitting mosquito. There are two options for getting these insecticides into the homes of those most at risk: indoor residual spraying (IRS) and insecticide-treated nets (ITNs).

13. #3When is IRS the Best Option? IRS is best suited for areas of unstable malaria, epidemic prone malaria, in urban settings when local transmission of malaria is well documented, and in refugee camps. In each of these settings IRS has important advantages: it has rapid and reliable short-term impact and can be targeted to communities at highest risk. IRS is, however, relatively demanding in terms of the logistics, infrastructure, skills, planning systems and coverage levels.

14. #4 When are ITNs the Best Option? The consensus is that in endemic Africa (south of the Sahel and north of the Zambezi River) ITNs are the most practical and effective means for protecting the population ITNs have been shown to be highly deployable in rural Africa using the existing NGOs, commercial sector, community groups and public sector infrastructure.

15. When are ITNs the Best Option? ITNs provide significant protection to those sleeping under them, and can reduce all cause mortality in children by one-fifth and episodes of malaria by half. Maintaining supply chains and behavioral promotion activities to keep ITNs widely available, insecticidally-active and effectively used is a challenge

16. Technical Challenges for large scale Prevention Implementation • Sustained insecticide treatment of nets (not a problem with LLINs) • Disparity between demand and supply of prevention interventions –but much improved now due to private sector responsiveness • Limited number of insecticides for public health use • Pyrethroids for ITNs/LLINs • Efficacy of insecticides on different surfaces (IRS) • Short list of insecticides –check with your NMCP • Short residual efficacy of larvicides

17. FBOs/NGOs Public Sector Expanding ITN Coverage Through Market Segmentation A Rich Commercial Sector B C Relative Wealth D E Poor ITM Coverage

18. Threats for large scale prevention implementation • Vector resistance • No immediate threat to ITNs • Impact on mass effect • Immediate threat to IRS • Malaria vectors • Nuisance mosquitoes–confuse the clients But what about access and sustainability of prevention interventions for those millions at the “Bottom of the Pyramid” not targeted by current program efforts?(4/5

19. #5 Use of DDT for IRS • DDT can be used for IRS, provided that stringent measures are taken to avoid its misuse and leakage outside the public health system • DDT is used only/strictly for Indoor Residual Spraying • A country that decides to use DDT for disease control is required to notify WHO (Secretariat of the Stockholm Convention) & UNEP • Every 3 years, each country that uses DDT will be required to provide detailed information on amount of DDT used, the conditions under which it is being used, and how such use relates to the country’s disease control strategy etc • Countries need to develop and establish regulatory mechanisms ( where will the FBOs be in this process?)

20. Current status of IRS in AFRO, 2006 • 22 countries have included or consider to include IRS in their malaria control strategy • 14 are applying IRS routinely • 5 spray to control endemic malaria • 9 spray to control epidemic malaria • 4 have piloted • 4 planning to pilot • A total of about 4 million unit structures are sprayed • About 230 000 kg of insecticide is used • DDT, pyrethroids, malathion, carbamate Where are the FBOs and CBOs in the national programs? (They do implement IRS in CHEs.)

21. Chronic Disease Acute Disease Infection During Pregnancy Chronic or Recurrent Asymptomatic Infection Placental Malaria & Anemia Anemia Low Birth weight Developmental Disorders Transfusions Death Increased Infant Mortality #6 MALARIA 101 – clinical syndromes Non-severe Acute Febrile disease Cerebral Malaria Death

22. Effect of HIV on malaria: • HIV infection increases the incidence and severity of clinical malaria • In non-pregnant adults, HIV infection has been found to roughly • double the risk of malaria parasitemia and clinical malaria. • In East and southern Africa, where HIV prevalence is near 30%, • it is estimated that about one-quarter to one-third of clinical • malaria in adults (including during pregnancy) can be accounted • for by HIV.

23. Effect of Malaria on HIV • Acute malaria infection increases viral load, and one study found that this increased viral load was reversed by effective malaria treatment. • This malaria-associated increase in viral load could lead to increased transmission of HIV and more rapid disease progression • This malaria-associated increase in viral load could lead to increased transmission of HIV and more rapid disease progression, with substantial public health implications • So why do these diseases remained stovepiped programatically ?

24. #7 Treatment of uncomplicated falciparum malaria • Artemisinin-based combination therapies (ACT) are the treatments recommended for all cases of uncomplicated falciparum malaria including: • in infants, • in people living with HIV/AIDS • for home-based management of malaria • pregnant women in the 2nd and 3rd trimesters Exception: • 1st trimester of pregnancy* *only use when there are no alternative effective antimalarials

25. The standards have been raised for drug efficacy Malaria Treatment Guidelines 2006: • Medicines must be discontinued before resistance reaches 10% • New medicines must have an efficacy of > 95% This is because: • Drug resistance has a high morbidity, morbidity and social and economic costs • New medicines are very effective New medicines must be highly effective and efficacious in curing malaria infections, and have a long, useful therapeutic life

26. ACT saves lives RDTs reduce ACT use when the fever is not clinically caused by malaria

27. Past and Future Outlook Expanding parasite-based diagnosis

28. The context in much of Africa • The private sector flourishes especially in areas with limited or no public sector health care facilities (+informal sector, 35-65%) • Public sector HWs are poorly remunerated yet face a heavy workload – attitude and “moonlighting” during working hours • All categories of people use the private sector (age, wealth) • Private sector HW feel marginalised more so now with “free ACT” distribution through the public sector and impending community distribution

29. The challenges • Lack of consistent & high coverage post-qualification training and supervision • Poor prescribing behaviour • Quality and types of medicines prescribed is questionable • ACTs still prescription-only medicines but in reality are over-the-counter medicines

30. The challenges • “Unqualified” people successfully operate in the private sector • Lower cadres of health workers (HW) are often in charge of clinics • Presumptive treatment is widespread • Diagnostic results often not respected • Profit-driven sector with less emphasis on technical quality • FBOs can help to support good treatment practices to curtail emerging drug resistance

31. #8 During Pregnancy, Malaria in Africa causes • Up to 15% of maternal anemia • 35% of preventable low birthweight • Also MTCT in HIV positive mothers

32. Intermittent Presumptive Treatment (IPT) • Two treatment doses of sulfadoxine-Pyrimethamine (SP) given to all pregnant women in areas of high malaria transmission, even without symptoms, can significantly reduce the negative consequences of malaria during pregnancy • For each respective country, consult and abide by the current IPT national policy especially for areas of high HIV prevalence

33. Effective ITM use can reduce: • Rates of severe malaria by an average of 45% • All-cause child mortality by 17% to 63% (roughly 25% reduction) • Pre-term births by 40%

34. Shifting Roles and Responsibilities to achieve impact at scale Private, Commercial Public Clinical/ANC Services Schools Policy/Standards Regulatory Training M&E Consumer Information Clinical Services Drug Sellers Marketing Demand Creation Distribution Equity & Vulnerable Groups Distribution Sustainability Clinical and ANC Services Household and Community Demand Creation Development of new Services FBOs, CBOs, NGOs

35. What are FBOs to do now? • When preparing a malaria proposal or engaging in a project, get the facts: • Data on the burden of disease due to malaria locally and nationally • Data on epidemiology of malaria • Information on the vector involved • National policies on malaria prevention and treatment • Availability/local access to ITN’s and IRS supplies • Monitoring and evaluation requirements and protocols • Think outside the box toward developing new strategies to build up from your existing strengths/programs

36. The Key to Sustainability and Involvement through Collaboration and Organizational Development Coupling Technical Expertise With Management & Implementation Capability

37. Current Condition of NGO/FBO Networks Strong implementation expertise Provide established focal point for technical input Often lack minimal leadership, management, or administrative capabilities Governments have no clear model of how to work with NGO’s (and vise versa) Seven +/Secretariats now under formation

38. Secretariat Toolbox Events Management Tools • National Malaria ‘Fresh Air‘ workshops • Malaria ‘Fresh Air’ local and community workshops • Event methodology and follow-up activities • Strategy & roadmap planning and tracking • Project management fundamentals • Transfer of competency model/ techniques • LQAS Ownership Strategy Secretariat Vision Leadership Accountability Relationship & Governance & Roadmap Marketing & Communication • Governance framework • Relationship and network management framework • Government relations • NGO relations • Community relations • Internal and external communication management framework • Common communication and reporting templates Partnership Creating A Basic “Toolbox” For Networks To Build Capability

39. But How to make it happen? • Where does the Leadership come from? • Where are the resources to do it? • What if we fail? • See: www/acamalaria.org for more details

40. You already have everything that you need to become a great leader! • We simply can explore frameworks and tools that will help us lift our horizons, enliven imagination, and deepen our thinking. • FBOs have done this in the past for centuries

41. What we have learned about leadership • Leadership development is a life-long, non-linear process. • Being a leader is a dynamic condition that changes constantly. • Leadership is not a position or role. It is who we are, what we know, and what we do. • We need to nurture leadership at all levels, not just at the top!

42. Leadership-Management Time Proportion Continuum -- Where are you? Leadership Coping Management

43. Coping is dominant in many NGOs Leadership Management Coping

44. What happens when coping is too dominant? • 1. Panic reactions; depression and burn out • 2. Confusion and chaos • 3. Waste of time, human and other resources • 4. Error chains • 5. Problems continue tomultiply • 6. No strategic thinking takes place—NO CHANGE occurs

45. Leadership concepts • Leadership is about transformational change. • Leaders deal with issues that are “beyond imagination”, “impossible”, “difficult”. • Leaders define problems in terms of why there is a difference between a shared visionand the current situation?

46. The top–down, or “blueprint” intervention strategy disconnects learning from action Interest groups Policymakers, planners Managers, providers MIS Communities, households Evaluations Research, pilot projects Health Learning Action

47. The “Learning Organization” strategy will link knowledge to action Communities, households Health Interest groups Demand Needs Learning Decisions Outputs Managers, providers Policymakers, planners Competencies Tasks

48. But How to make it happen? • Where does the Leadership come from? • Where are the resources to do it? • What if we fail? • See suggestions for Learning Organization approach at: www.jhuccp.org/training/scope/starguide/begin.swf

50. Many Thanks to all my contributors for their valuable reference materials • WHO-AFRO • Malaria Consortium • Global Fund Staff in EARN • PMI staff and USAID Hdqrts. contacts • Johns Hopkins Bloomberg School of Public Health-Gates Summer Institute • Gates Foundation for Leadership training support • THANK YOU