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Key Observations and Action Points from
Alliance for Malaria Prevention Annual Meeting
Geneva, IFRC Headquarters, 3-6 February 2009
***Final Version, 17 February 2009***
KEY OBSERVATIONS:
Universal coverage: There is growing interest in transitioning from mass campaigns targeting children under 5 years of age and pregnant women to those providing universal coverage. WHO/GMP data suggest that LLIN campaigns targeting children under 5 years of age have less impact than universal coverage, especially in areas of high malaria transmission. Most countries receiving Global Fund Round 8 grants were funded to provide universal coverage and AMP must provide technical and programmatic leadership to assist with this transition.
Last year, only one-quarter of the 33.7 million LLINs planned for free distribution through campaigns in Africa were actually delivered. Countries postponed campaign activities due to administrative bottlenecks, changes in strategies (e.g., from national to sub-national coverage), and funding delays. About 39m nets were delivered through routine services. To meet the 2010 universal coverage targets, efforts must be dramatically accelerated to increase campaign delivery, while maintaining momentum in routine systems.. Currently, technical and logistic capacity to scale up to universal coverage through stand-alone campaigns is inadequate. EPI management capacity still drives current integrated campaigns. In addition, an RBM survey on existing procurement bottlenecks found significant stakeholder concern particularly about procurement lead time and disbursement of funds, which have important implications for scale-up.
Lessons learned from universal coverage campaigns in Equatorial Guinea and Burkina Faso will be important to document. Countries with a universal coverage policy can consider phasing in these campaigns, as in Zambia. Certain countries such as Madagascar that have recently adopted universal coverage may have to conduct campaigns on top of those that recently targeted children under 5 years of age, as well as emphasize routine distribution channels, in order to meet universal coverage targets.
Integration: Where vaccination or other child health campaign timetables permit, continued integration of campaigns may still be advisable in countries with limited resources, weak managerial and logistics capacity, and unclear policies and strategies in place. As malaria program funding exceeds that of EPI, partners supporting malaria components of campaigns will be asked to furnish a larger share of campaign operational and social mobilization costs than in the past. In 2009, three countries--Rwanda, DRC (in selected provinces) and Sierra Leone--have indicated their interest in distributing LLINs during measles follow-up campaigns. Early joint planning at every level will be critical for the success of these integrated campaigns. A pilot project in Kenya, integrating interventions for adults such as HIV counseling and testing and condom distribution, was shown to be operationally feasible but with significant policy issues to address before expansion.
LLIN distribution versus ownership. Countries report a significant discrepancy between the number of LLINs distributed and those reported owned in surveys. In Malawi, there is concern that household members surveyed may underestimate ownership post-campaign to increase the likelihood of receiving more LLINs.
Mapping of LLIN distribution: The AMP LLIN Mapping Project developed a methodology to help establish a knowledge base on net distribution trends in Africa, including the quantities, locations, dates of delivery, and the needs for replacement. Manufacturers may provide the most reliable information to make projections, but concerns were raised about access to proprietary information. The Project needs to be housed in an institution that national malaria control programs and partners can access easily. AMP needs to clarify who will oversee implementation of this system in the long-term.
Engaging WHO-AFRO: AMP wishes to look to WHO-AFRO for stronger leadership to help drive the LLIN scale-up activities that it supports. Partners want to work with AFRO to help identify ways to orient and fund its staff’s full participation in the campaign planning and implementation process, including the technical review of country plans.
Engaging the Sub-Regional networks of RBM: The RBM Sub-Regional Networks, particularly WARN, provide a partnership forum for supporting bottleneck alleviation and implementation at country level. AMP hopes to continue working with functional SRNs, and needs clarity from RBM on the roles, funding levels, and opportunities for coordination. AMP already works closely with WARN, but the interest or capacity of the other 3 networks to engage at the same level is unclear.
Net durability “check-up”: On-going monitoring of net durability must be an integral part of follow-up to campaigns. A study conducted 3 years after the 2004 campaign in Togo found that only 14-20% of LLINs retained adequate concentrations of insecticide and did not have holes or torn seams. Check-up activities should start no later than one year after a campaign, and should become part of routine programs rather than tied to special studies. Entomologic and epidemiologic data should determine net “failure points” and drive policies on net monitoring and replacement.
Community-level activities can help implement “check up.” Red Cross and other volunteers could be trained to collect information on LLIN condition, perhaps through a 2-year post campaign follow-up as planned in Madagascar. The quality of data collection by volunteers must be monitored carefully. In addition, community-level training and sensitization can emphasize the need to check for and repair holes in nets regularly.
LLIN pull-back, recycling, disposal: AMP looks urgently to WHO leadership for developing guidelines on LLIN pull-back, recycling and disposal. Since large amounts of insecticide could remain in the net fibers for some time, the presence of older nets and packaging could accelerate insecticide resistance. Families may resist giving up their old nets, as seen in Burkina Faso; this poses a huge challenge from both the public health and environmental perspectives. It may be easier to convince families to replace the old nets with new ones than to actually give up their only net, but both are critical. Organizing and funding proper disposal in mass campaigns is a huge challenge. EPI programs can provide important lessons on waste disposal, especially on problems with incineration.
Countries also seek guidance on disposal of LLIN bags. It would be useful to have instructions from WHO by June 2009 to allow countries to plan waste disposal components of their campaigns this year.
A coordination mechanism must be identified to address these issues. Several options are to use existing RBM working groups such as the Procurement and Supply Chain Management (PSM) Working Group, or to establish a proposed new entity: the Initiative for the Recycling of Nets (IRON).
District-level focus: Partners expressed increased interest in district-level service delivery, tracking and evaluation. As current scale up activities use a centralized, top-down approach for implementing activities and sharing information, partners should also consider efforts for sustained control through decentralized approaches that respond to local needs. For example, countries should consider new approaches for monitoring and evaluating universal coverage campaigns that are conducted district by district (as in Zambia and Tanzania), rather than through national surveys.
AMP as scale-up focal point: RBM/HWG proposes that AMP serve as a “focal point” for scale up to universal coverage by 2010, given the substantial LLIN resources available to countries since the Global Fund Round 8. AMP can establish a 23-month game plan for assisting countries in scale up, including a calendar of country activities, mapping of technical assistance, leveraging partner expertise, tracking of progress and monitoring quality, and using AMP partners to help countries cut through “red tape.” In-country partner focal points for each country could provide AMP and RBM with updated information on campaign status, troubleshoot for solutions to funding or logistics problems, and help the NMCP advocate for additional support as needed.
To adopt this ambitious role, AMP would require dedicated operational and logistical technical assistance to help track and support countries’ activities. Functioning with volunteers alone will not allow AMP to lead this drive.
Tracking ownership and use: Longer-term tracking of net ownership and use is critical to designing programs with sustained coverage and high impact. A survey conducted three years following Togo’s 2004 campaign indicated a drop of 8 percentage points in ITN use in children under 5 years of age. Qualitative research is needed to monitor behavior patterns of LLIN owners to design IEC/BCC strategies for increasing use one to two years after distribution. Clear guidelines from the malaria prevention community for countries, implementers, and donor agencies will be needed to reinforce support for post campaign Hang Up and BCC efforts.
Information repository: The RBM information “toolbox” could serve as a repository of information accumulated to assist with LLIN campaign planning. In addition, AMP can create a simple Web link that is easily accessible to countries and partners.
“Keep-up” support: Further integration of malaria prevention and control with routine service delivery can improve the prospects for sustaining campaign achievements. Opportunities exist for providing LLINs through EPI and ANC services, child health days and child nutrition services as well as integration with on-going community based health interventions. Such integration can increase demand for services and strengthen national systems. For emergencies and complex settings, campaigns will remain the primary option.
Communicators working group: The group’s achievements in 2008 included an AMP one-pager, production of the Toolkit, a press list, press releases for campaigns in DR Congo, Mali, Nigeria and Togo, and in-country coordination mechanisms. Lack of funding for disseminating stories, staffing constraints and unclear linkages with RBM have hampered the group’s ability to disseminate stories. In 2009, the group will support two priority events and develop additional country or theme releases, pending budgetary support to do so. The group will work more closely with the RBM Malaria Advocacy Working Group (MAWG) and will focus more on coordinating with key AMP partners, to reduce focus on press, and increase focus on key stakeholders. Having a full-time communications officer would allow the group to plan more sustained story development and dissemination. The group needs a new chair or co-chairs to organize partner calls and coordinate inputs into the two priority events, plus other initiatives as funding and partner support allow.
Operations research and monitoring and evaluation working group: Following the AMP meeting on LLIN use, October 2008, the group’s first task was to create a list of priority operations research critical to current and future LLIN programs. A number of questions from AMP partners and the RBM WIN were reduced to 18 key questions, based on criteria such as country priority, existing opportunities (campaigns already planned that require the data) and strategic needs (research to help develop the technologies and strategies for future LLIN distribution). The group will now assess the methodologies, distinguish research from evaluation activities, and develop a strategy to identify technical support and funding.
The group also formed a sub-group to develop standard indicators for behavior change and communication related to LLINs. The sub-group will eventually present this list of indicators to the RBM MERG for review and dissemination. Finally, a monitoring and evaluation toolkit section was developed, though gaining consensus on the approaches and methodologies to offer as options delayed its completion. The group will now explore ways to identify technical and financial assistance for evaluating campaigns and their follow up.
Toolkit training working group: The toolkit for LLIN integrated campaigns was completed and disseminated in English, and will soon be produced in French. The monitoring and evaluation section was delayed and will be distributed separately in early 2009. While the toolkit still focuses on integration, an updated version will need to incorporate experiences specific to stand-alone universal coverage campaigns. A group of facilitators will conduct a series of regional training workshops on the Toolkit, geared mainly to Ministry of Health campaign staff. Funding will be provided by Malaria No More, Malaria Consortium (SuNMaP- Nigeria), World Bank, UNICEF (HWG, USAID), MACEPA, IFRC, and PMI. There is strong interest from NGOs and other supporting campaign implementers in the training, though this will require additional funding and facilitators. The schedule for 2009 is currently:
– Burundi, Madagascar, Congo, CAR, Senegal, Burkina Faso, CIV, Niger, Comoros, Guinea, Mali
– Ethiopia, Zambia, Mozambique, Malawi, Tanzania, Uganda
– Kenya, Sierra Leone, Somalia, Sudan, Rwanda, Cameroon, Zimbabwe, Angola, Guinea Bissau, Liberia
ACTIONS FOR AMP IN 2009:
General:
Communicators working group:
Operational research, monitoring and evaluation working group:
Toolkit training working group: