Thursday, May 1, 2008

MERG ... and the lack of accountancy expertise

Dear Colleagues

A few months ago I wrote the following. It was addressed to Dr. Kochi at WHO and was copied to a number of people who have been associated with the WHO MERG initiative (MERG stands for Monitoring and Evaluation Reference Group) over the past several years.
From: "Peter Burgess"
Date: Sun, 16 Dec 2007 02:08:01 -0500
Subject: Performance Metrics in the International Health Malaria Sub-Sector

Dear Dr. Kochi

This is a rather belated follow up to some communication earlier in the year.

We are continuing to push forward a Tr-Ac-Net initiative to be of assistance in the global effort to have an effective integrated mosquito and malaria control program.

We are proud to be associated with the Integrated Malaria Management Consortium (IMMC) in our efforts to get good cost accounting and performance metrics to be an integral part of the malaria management approach that is used everywhere.

However, it is apparent that there are serious problems with the prevailing modus operandi. Notably, the expertise in cost accounting and performance metrics is almost totally absent.

While the Tr-Ac-Net contribution into the malaria sector is our expertise in cost accounting and the metrics of performance, it seems that (1) this functional expertise is being ignored, and worse (2) there is an active effort to ensure that good accounting and accountability is not deployed in this segment of the international relief and development sector

I offer as an an example of the problem the information below. This is a list of people charged with developing the MERG methodology (albeit back in 2004, but what has really changed?) ... but I find there is nobody (that I recognise) as being an expert in either cost accounting or in performance metrics. Tr-Ac-Net would argue that without this, the exercise is doomed to failure. We recognise that scientific and medical professionals do not like to be challenged by mere accountants ... but the fact is that while scientific and medical professionals are good at what they do ... they are not very good at mere accounting, and especially cost accounting and performance analysis.

In due course we will offer critiques of work that is currently going on based on the MERG methodology that totally fails to address the key issues.

With a substantial increase in funding now flowing into the malaria subsector ... it would be great if this translated into a sustainable reduction in the burden of malaria in the beneficiary countries and communities. Up to now, we have been able to locate a lot of information about the "coverage" of various anti-malarial interventions ... but is this really of much importance? Surely we should be looking for the maximum of reduction of the burden of malaria in the society at the least cost BOTH in the reduction phase and in the ongoing sustainable phase. I would refer you to the experience in Darwin, Australia where the last case of local malaria was in 1962, but their surveillance (in 2007) is still ongoing and their interventions are rapid and comprehensive in order to keep malaria out of their society.

Tr-Ac-Net and the IMMC are interested in helping ... the question is simply HOW?

Peter Burgess
Peter Burgess
The Transparency and Accountability Network:
Tr-Ac-Net in New York
IMMC - The Integrated Malaria Management Consortium Inc.
917 432 1191 or 212 772 6918

Washington, USA 8-9 MAY 2003
Dr Bernard NAHLEN, Coordinator, M&E, WHO/HQ - Geneva
Tel: 004 1 22 791 2869; Fax: 004 1 2 791 4824; e-mail:
Dr Claudia STEIN, Edipemiology & Burden of Disease, WHO/HQ - Geneva
Tel: 004 1 22 791 3234; Fax: 004 1 2 791 e-mail:
Dr Magda ROBALO, Regional Malaria Adviser, WHO/AFRO - Harare
Tel: 47 241 38 167; Fax: 47 241 38006; e-mail:
Dr Alisalad ABDIKAMAL; Malaria M& E, WHO/AFRO - Harare
Tel: 47 241 38 167; Fax: 47 241 38006; e-mail:
Dr Thomas TEUSCHER, WHO/HQ - Geneva
Tel: 004 1 22 791 3741; Fax: 004 1 2 791 4824; e-mail:
Dr Tessa WARDLAW, Senior Project Mofficer, Monitorning & Evaluation
Tel:+1 212 824 6727; e-mail:
Dr Mark YOUNG, Senior Health Adviser RBM Health Section Programme Division
Tel: +1 212 303 7966; Fax: +1 212 824 6460; e-mail:
Dr Abdoulaye SADIO, Regional Monitoring & Evaluation Officer, West and Central Africa; e-mail:
Dr Lawrence BARAT, Technical Specialist on Malaria
Tel: +1 202 458 9123; Fax: +1 202 473 8107; e-mail:
Dr Matt LYNCH, Malaria Advisor, USAID, Office of Health, Infectious Diseases and Nutrition, 1300 Pennsylvania Ave, Washington DC 20523-3700.
Tel: +1 202 712 0644; Fax: +1 202 216 3702; e-mail:
Dr Alastair ROBB, Senior Public Health Adviser, Health & Population Department
Tel: +44 207 023 0112/733; Fax: 44 207 023 0428/0174; e-mail:
Dr Vinand NANTULYA, Director, Strategy & Evaluation
Tel: +41 22 791 1700; Fax: 41 22 791 1701; e-mail:
Dr Fred BINKA, School of Public Health, University of Ghana
Tel: +233 21 401 550/27 581 828; Fax: +233 21 254 752;
Dr Graham ROOT, Malaria Consortium East Africa Office, Uganda
Tel: +256 41 344 038; Fax: +256 41 344 059;
e-mail: or
Dr Don de SAVIGNY, IDRC/TEHIP Research Manager, Swiss Tropical Institute
Tel: +41 61 284 8221, Fax: +41 61 271 7951; e-mail:
Dr Bob SNOW, Centre for International Development, Harvard University
Tel: +1 617 495 4112; Fax: +1 617 496 875; e-mail:
Dr Richard STEKETEE, Chief, Malaria epidemiology Branch, Division of
Parasitic Diseases, Centres for Diseases Control (CDC), United States of America
Tel: +1 770 488 7755; Fax: +1 770 488 4206; e-mail:
Dr Erin ECKERT, Principal Investigator, ORC/Macro - Measure Evaluation, USA
Tel: +301 572 0397; Fax: +301 572 0999; e-mail:
The people involved have a lot of expertise, but, I think it is fair to say that none of them have much, if any, experience of cost accounting and the best way to make use of cost and performance information.

Cost accounting and performance metrics are not well served by the use of advanced statistical methods ... cost accounting is different from doing clinical trials.

In most cases it is very easy to get a good idea of costs simply by knowing some of the cost elements and knowing how the operations are carried out ... and by focusing on the "material" items. For example, there is a vast difference in the cost of doing something using local staff paid at local wage rates and doing similar work with expatriate staff at international rates, together with all the other cost adders associated with expatriates (travel, accommodation, per diems, etc.).

Tr-Ac-Net is developing the Community Impact Accountancy (CIA) system as a framework for analysis of program impact. CIA draws on experience with accounting systems and with development activities around the world ... many of which had elements of excellence, and some which were expensive and disastrous. CIA type management information would have helped then, and will soon be available so as to help in some of the much larger programs now being initiated.


Peter Burgess

Friday, April 25, 2008

On malaria metrics ... missing cost effectiveness measures

In a World Malaria Day presentation at Georgetown University today Dr. Bernard Nahlen, the Deputy Coordinator, President's Malaria Initiative made the following observations:
In the first year, PMI reached over 6 million people in the initial 3 countries with malaria prevention and treatment activities. In just its second year of operation, more than 25 million people have benefited from PMI interventions.

To summarize in more detail some of the progress that has been made to-date:
Indoor residual spraying programs have been conducted in ten countries, and they protected over 17 million people.
More than 6 million long-lasting insecticide-treated mosquito nets were bought and around two-thirds have already been distributed;
More than 12 million treatments of the most effective drugs combinations of treatment of malaria -- artemisinin-based combination therapies -- have been purchased;
More 1.3 million preventive treatments for pregnant women have been procured, with more than 500,000 distributed; and
Finally, PMI has supported training for more than 5,000 health workers on preventive treatment for pregnant women and for more than 29,000 health workers on artemisinin-based combination therapies.

In just two years since we started supporting national malaria control programs, we are now starting to see early evidence in several countries that our collective efforts are beginning to have an impact on malaria transmission:
In Zanzibar last year, a survey showed that the percentage of children who tested positive for malaria dropped by over 90% over the course of two years from 22 percent in 2005 to less than 1 percent after the distribution of long-lasting insecticide-treated nets and indoor residual spraying.
Malaria infections are one of the major contributing causes of severe anemia in young children in Africa, and severe anemia is a major cause of deaths in these children. In Malawi, where coverage with insecticide-treated nets has increased rapidly over the past three years, a 2007 household survey in six districts showed a 43% relative decline in severe anemia among children aged 6 to 30 months, when compared with 2005.
In Uganda and Tanzania, where PMI and the national malaria control program supported indoor residual spraying campaigns, 2007 health facility records document reductions in the proportion of blood slides positive for malaria of 58% in Uganda and 37% in Tanzania, when compared to previous years.
It is good to hear reports of progress, but what does the reporting really mean.

There has been a very large increase in the funding for malaria control interventions. Instead of the expenditures being in the range of $100 million a year, the amount is now more like $1 billion a year. There is some progress ... and some of it can be described as excellent progress ... but we don't seem to be able to talk about the costs and the results in an integrated way.

The reporting about Zanzibar is frequent ... and it is clear that the prevalence of malaria in Zanzibar has been reduced ... but at what cost, and what is going to be the cost of keeping the prevalence of malaria low, and where is this funding going to come from?

The reporting about reduction in mortality of young children is positive ... great anecdotes ... but the malaria industry still quotes the fact that 3,000 children die in Africa every year from malaria ... the same fact that was used to justify the surge in spending that is now "maturing".

In fact ... there is still a lot more work that needs to be done to improve the performance metrics so that the various implementing and oversight agencies can be held to account for the resources they are using.

While the growth in fund raising has been impressive ... the related reduction in the burden of malaria in Africa is still a big unknown. Yes there is progress ... but it is not at all clear whether the progress matches the fund flows or not ... the metrics are not good enough yet.

The Integrated Malaria Management Consortium (IMMC) has worked on an effective system of malaria metrics as a component of Tr-Ac-Net's Community Impact Accountancy system. This system has a community focus because of the need to address socio-economic development issue, including malaria intervention performance, in a manner that is location specific.

Hopefully this will be embraced in due course so that leaders of the malaria industry will not have to rely on the rather poor data that is presently available when making their presentations. From an analysis perspective, the data confirms that a lot of money is being used, and confirms that there are some results that are positive ... but hardly anything that links the two so that we can affirm that the resources are being used cost effectively.

Maybe next year at the Second World Malaria Day


Peter Burgess

The First World Malaria Day ... April 25, 2008

Today is World Malaria Day ... the first time this designation has been used. For the past few years it was Africa Malaria Day. The name change is, I am told, to help get improved world awareness about the malaria crisis, which affects Africa the most.

Lance Laifer has been one of the important drivers of building awareness and helping to get funds raised. This morning he sent this message:

"On Fri, Apr 25, 2008 at 9:24 AM, lance laifer wrote:
This is from a message we are sending out on facebook today. If you can't be on Facebook today please email it to friends and ask them to share it with their Facebook friends.


Billions of people have died from malaria and billions of people get it every decade - tens of millions die from it every decade. According to Bill Gates, malaria causes more misery than any disease on the planet. Malaria is a also a circular disease of poverty. It is a cause of poverty and it is caused by poverty. It is impossible to know what comes first, malaria or poverty. To end malaria - we the citizens of Facebook must unite and show our solidarity. To that end we are asking you and everyone you can touch to post a black profile picture.

Post your black profile picture now and be part of the most audacious experiment in Facebook history - One Million Faces Against Malaria - World Malaria Day April 25 Project Blackout.

put your cursor over the black group picture and then right click with your mouse
- then choose save image as black (or choose any name) and save it in "my documents"
- then go to your profile page - click edit (next to your profile).
- choose picture from the menu along the top
- then click browse and choose the black picture that you saved in my documents.
- click that you have permission to use it and it should be uploaded to your profile page
THIS IS A MOST IMPORTANT STEP - After you post a black profile picture please make sure to change your status to: is posting a black profile pic as part of the blackout of facebook on World Malaria Day - April 25.
MAKE SURE TO JOIN THE GROUP ONE MILLION FACES AGAINST MALARIA - PROJECT BLACKOUT - you need to join this group to add your number to the count in the next step.
After you change your status, please add you number to the count here:
After you post a black profile picture and post your number to the count please join the group - My black profile picture is posted as part of World Malaria Day FB Blackout - - This group is comprised only of people who have blacked out their picture and is a great thing to show your friends to help show them what Facebook can look like tomorrow afternoon.
After you take care of yourself please invite your friends to join:

- our event One Million Faces Against Malaria - World Malaria Day April 25 Project Blackout close to 200,000 people are invited - already the largest online malaria event in history;

- and our group
which is already larger than all malaria groups on all social networks combined with more than 20,000 members.

Today the United Nations is going to make a special announcement regarding the UN's leadership in the fight against malaria. Join our group to help support all of the efforts of Ray Chambers, the UN Special Envoy on Malaria.

Take action today - get your black picture up - get your friends to get their black pictures up - together we WILL help save millions of lives.

Be Against Malaria today and make malaria NO MORE!

PS - THIS IS A MOST IMPORTANT STEP IN SPREADING THE WORD - After you post a black profile picture please make sure to change your status to: is posting a black profile pic as part of the blackout of facebook on World Malaria Day - April 25.

PPS - Email and message this message to as many friends as possible. Over 3,000 children will die on world malaria day - stop this madness NOW!
FINALLY - please consider donating to project blackout at Against Malaria - 100% of all funds donated will be used to buy long lasting nets for $5 per net. They will show you where the net went and there are no costs added to the price of the net for distribution, management, marketing etc. -

Today is also the sweet sixteen round of the Madness against malaria competition - see to help decide who wins."
Lance Laifer is doing everything he can to raise awareness and raise money ... and this is good. However, there is a long history of success and of failure in the malaria control area, and important lessons to be learned. Sadly, it is now very predictable that the funds being raised will not produce much sustainable benefit in large part because lessons of history are being ignored and simple interventions are being used without very much performance data being collected and used to inform decision making.

This is what I wrote to Lance Laifer.
Dear Lance

Thank you for your efforts.

I can also report some success in the development and use of Community Impact Accountancy (CIA) for Integrated Malaria Management (IMM).

As you know, there has been a great wave of support for increased funding for malaria and awareness of the burden of malaria is much improved over three years ago. A few years ago annual funding for malaria control interventions were perhaps less than $100 million a year, and now the annual funding is up to as much as $1 billion. This is an amazing accomplishment and everyone concerned should be proud of this.

But raising money and spending money does not assure success. At a World Malaria Day event in Washington this week I listened to prominent leaders in the global malaria health subsector refer to progress in Zanzibar ... including the observation that this is the third time that malaria has been conquered in Zanzibar ... but it has come back. The lesson is that malaria will come back unless there is a comprehensive integrated approach that has built in sustainability. AND THE CURRENT APPROACH TO REDUCING MALARIA SIMPLY USING INSECTICIDE TREATED BEDNETS DOES NOT HAVE THE CHARACTERISTICS TO DELIVER SUSTAINABLE SUCCESS.

My hope is that the wonderful success in fund raising, and the wonderful success in raising awareness of the impact of malaria on human beings, especially children in Africa can be matched with some serious management information about the sustainable results being achieved using these resources. Admiral Ziemer, the PMI coordinator understands very well that it is very important to not only have the funds available, but to use the funds well and to know what works and what does not.

Christian Lengeler at the Swiss Tropical Institute, one of the international experts on bednets and malaria control, has summarized the evidence about effectiveness of bednets in a plain language summary as follows: "Insecticide treated bednets can reduce deaths in children by one fifth and episodes of malaria by half." and "Sleeping under mosquito nets treated with insecticide aims to prevent malaria in areas where the infection is common. They are widely promoted by international agencies and governments to reduce the bad effects of malaria on health. This review showed that good quality studies of impregnated nets markedly reduce child deaths from malaria."

Unless I am totally mistaken ... this is significantly less in terms of effectiveness than the claims being made in the successful fund raising campaigns ... and this is, I believe, a situation that needs to be addressed. I am an old corporate cost accountant and former CFO, and I am used to looking ahead to long term impact of today's strategy ... and my guess is that without really good performance metrics for malaria control interventions there will be a day of reckoning and fund flows will dry up. This would be disastrous.

I applaud your efforts in getting funds raised and getting awareness raised ... are you going to be able to get intervention cost effectiveness raised? When is the 3,000 children dying every day in Africa from malaria going to be not true any more


Peter Burgess
Peter Burgess
The Transparency and Accountability Network
Tr-Ac-Net in New York
IMMC - The Integrated Malaria Management Consortium Inc.
The Tr-Ac-Net blogs ... start at
917 432 1191 or 212 772 6918

Saturday, April 12, 2008

World Malaria Day ... Resurgence of Malaria?

Dear Colleagues

In the last few years there has been a very rapid increase in the amount of funding being allocated to malaria control. Five years ago the annual funding was reported to have been around $100 million a year ... and it is now reported to be more than $1 billion a year.

But I am not convinced that the malaria health subsector is representing the history of malaria entirely fairly. For example, the Global Health Council in announcing the Wold Malaria Day activities used the following preamble:
The resurgence of malaria in sub-Saharan Africa in recent decades has resulted in more than 1 million deaths each year - with young children comprising most of the victims. The 300-500 million infections that occur each year affect people of all ages and have serious economic impact in poor communities.
The use of the word "resurgence" in connection with Africa seems to be quite incorrect ... for almost all of malaria endemic Africa malaria has never been controlled. Major malaria control interventions took place in a lot of places, but not much was done in Africa.

What has happened in Africa is that drugs used to treat malaria have now become ineffective because of the perpetual cycle of reinfection ... and new more effective drugs are much more expensive.

For all practical purposes rather little integrated mosquito and malaria management has been practiced in Africa. The reasons for this are many, including the lack of political will in local governments and a lack of interest on the donor side. There have been some localized success stories ... but the international community is still using the same "3,000 children under five die avery day from malaria in Africa" now as they were doing five years ago. This suggests either the programs are not working, or a set of performance metrics that don't work.
In honor of the first World Malaria Day (formerly "Africa Malaria Day"), please join the Global Health Council, Johns Hopkins University Voices Project and PATH as we address the next frontiers in malaria prevention, control and treatment.

The expert panelists will discuss both innovations and challenges in some of the field's most pivotal areas, including research and development, strengthening health systems, and tackling high-burden countries.
I want to listen to the panelists ... in particular I am interested in how the funds being mobilized because of the malaria health crisis are going to be used and how we are going to know that the money is being used effectively.

The Tr-Ac-Net approach to performance metrics has a role in the disbursement and use of malaria resources ... and hopefully will be adopted in due course by the global malaria community.


Peter Burgess

Sunday, April 6, 2008

Increased funding ... no solid news about results

Dear Colleagues

The good news is that there is a high likelihood that there will be increased funding for malaria in 2008 over prior years ... and a further increase in 2009. That is really very good news.

What is interesting is that while most of the funding is coming from official development assistance sources such as bilateral aid agencies like the US President's Malaria Initiative (PMI) and government funding for organizations like the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), there is also substantial assistance funding from private philanthropies like the Bill and Melinda Gates Foundation, and initiatives like Malaria No More.

But the not so good news is that the experts are not able to show success in ways that are very satisfying to critics of the programs. Some of the major funding agencies seem to be getting feedback that shows that that there has been an improvements in some of the metrics of success ... such as reduced mortality of children under 5 and reduced mortality of pregnant mothers ... but not as to the reduction of morbidity in the population nor a reduction in the paracite prevalence in the area, both mosquito population and human.

What this means is that even though there has been a tremendous increase in the fund flows into the malaria sector ... progress towards a sustainable reduction in the malaria burden is not yet documented.

From a management perspective, this is, of course a formela for almost certain failure ... if not now, in quite a short time.


Peter Burgess

Tuesday, February 19, 2008

$1.2 billion in research ... with what results?

Dear Colleagues

In a recent New York Times article, the following:
The Gates Foundation has poured about $1.2 billion into malaria research since 2000. In the late 1990s, as little as $84 million a year was spent — largely by the United States military and health institutes, along with European governments and foundations. Drug makers had largely abandoned the field. (China was developing a drug, artemisinin, that is now the cornerstone of treatment.)

I was aware that the Gates Foundation was a big source of funding for malaria research, but had no idea that the funding level was in excess of $1 billion.

I was aware that malaria funding was very small prior to 2000, but again, had no idea that it was this small.

Almost anything that scales up this fast is prone to problems in the area of accounting and accountability, and it is likely that such problems abound in the malaria health subsector.

The Tr-Ac-Net Organization routinely seeks to relate resources used with results accomplished and it would be interesting to do this in the area of malaria research. While it is clear that there is more activity in the area of malaria research ... it is far less clear that the results up to now have substantial value. There is more research. There are more studies. But is knowledge moving forward? Is the research making it possible to reduce the burden of malaria more rapidly and at lower cost?

I would have thought that by now there should be measurable results that would give the interested public a good feeling about the use of these resources. Rather, however, I get the impression that the needed performance metrics do not exist. As a former corporate cost accountant and CFO, of course, I am appalled ... but no longer surprised.


Peter Burgess

Monday, February 18, 2008

President Bush is in Tanzania ... which raises questions about malaria performance.

An AP newswire circulated by the UN starts as follows:

ARUSHA, Tanzania (AP) — President Bush handed out hugs and bed nets to battle malaria in Tanzania's rural north on Monday, saying the U.S. is part of an international effort to provide enough mosquito netting to protect every child under five in the east African nation. "The disease keeps sick workers home, schoolyards quiet, communities in mourning," Bush said in an open air pavilion at Meru District Hospital. "The suffering caused by malaria is needless and every death caused by malaria is unacceptable ...

This little paragraph shows the sad inconsistencies between the rhetoric and the reality.

"The disease keeps sick workers home, schoolyards quiet, communities in mourning," is a reasonable definition of the problem.

"the U.S. is part of an international effort to provide enough mosquito netting to protect every child under five in the east African nation" is a description of a strategy that is expensive, insufficient and doomed to failure.

Young children are at risk of dying from malaria ... more so than older children and adults. But it is morbidity ... :"The disease keeps sick workers home, ..." that impacts the economy and nets for young children does not address this part of the problem.

The good news is that the US and others are engaged in serious funding of malaria reduction efforts. The bad news is that there are almost no data that show that the program is cost effective and will be successful in the long run.

Through a collaboration with the Integrated Malaria Management Consortium (IMMC), it is hoped that the lack of performance metrics can be addressed ... and soon.


Peter Burgess

Thursday, February 7, 2008

Does WHO-RBM have the right planning model?

Dear Colleagues

What I know of the WHO-RBM planning model suggests that they do not have the right planning model. It seems to be an approach that tries to improve on an unsatisfactory status quo ... and in so doing makes matters worse.

There are three issues that need to be addressed in the health - malaria sub sector:
  1. Broadly speaking malaria control interventions have been unsuccessful in Africa and the malaria health situation has deteriorated over the past several decades;
  2. The country level health authorities are faced with multiple donor funded initiatives and little or no coordination between the various initiatives; and
  3. A weak local capacity in the health sector caused essentially by lack of government funding for public health activities and poverty in the population at large.

The WHO-RBM planning model incorporates the idea that there should be a single plan for the country. This addresses the issue of multiple initiatives and the lack of coordination ... but it does not address the issue of the past failure (1) and the limited capacity issue (3).

And if the WHO-RBM planning is done poorly, then there will be just another plan and just one more initiative that needs to be coordinated.

The WHO-RBM planning model seems to argue for a "one size fits all" approach ... and while there are some aspects of malaria control that would benefit from a universal approach, in general, it is clear that the cost effectiveness of malaria control is optimized when there is careful attention paid to the specific situation of the location.

The WHO-RBM planning model seems to be very long term in thinking ... with simplifications that do not seem to be justified. Where WHO-RBM is thinking in years, I would argue there is a need to think in terms of months. Where they are thinking in terms of months, I would argue for weeks. Malaria transmission is driven by a mosquito population that lives for perhaps 30 days. The control of this population is a critical dimension of malaria control. Malaria transmission also needs a pool of the malaria parasite ... the infected human host. Reduce the pool of malaria parasite and reduce access to the infected human host and transmission is reduced. These mechanisms are well known and their cost effectiveness depends on the timeliness of all the interventions. This is specific in time and it is geographically specific as well.

Rather than the WHO-RBM planning model, it would seem that a planning model incorporating integrated mosquito and malaria management principles should be developed that can be (1) area specific; and (2) aggregated for country level planning.

Experience suggests that a plan of this type would help to improve cost effectiveness significantly and make it possible to make more progress with the resources available.

Good area specific planning can incorporate capacity improvement in ways that are practical and realistic. Improving capacity can best be done with the cooperation of government and community ... something that will vary from community to community and country to country.

It may be that the WHO-RBM planning exercise is "high level" and serves to help mobilize resources ... and also serves as a framework for area specific planning. If not, I am not optimistic that the exercise serves much of a useful purpose.

Maybe I misunderstand ... but I don't think so.

Peter Burgess

Wednesday, January 30, 2008

$11bn needed for malaria control according to report released at the WEF

Dear Colleagues

It is really very disappointing that every new report calls for more funding ... yet rarely talks about how the funding can be used in the most effective way.

Rajat Gupta, from McKinsey that helped prepare the report is reported to have said: "We have pretty much all the tools to aggressively control the disease and reduce or eliminate mortality, but it has not been done." The sad fact is that it is not going to be done, either.

The report that was released on January 25th is interesting in that it talks about scale up, without much reference to the scale down that should be possible with a successful program. In other words, the model is one of continuing intervention at a high cost rather than a systemic approach where the intervention declines over time because it is being successful.

Maybe I am missing something ... but I don't think so. I will have more comments on the report in the future.

Andrew Jack 24 Jan 2008 Financial Times

A group of government and business leaders will on Friday unveil a plan to sharply reduce the impact of malaria in the developing world. The Malaria Implementation Support Team plans to rapidly boost prevention and treatment measures in the 30 African countries most hard hit by malaria, which causes more than a million deaths and very large numbers of hospital admissions each year.

A report by McKinsey & Company and Malaria No More estimates that such a scale-up of malaria controls would require $11bn in donor funding over five years.

The move marks a fresh effort to reinvigorate the fight to eradicate malaria, using a series of well-tested approaches including the distribution of bed nets, indoor spraying with pesticides and combination drug therapies.

It follows long-standing frustration that malaria continues to cause widespread personal and economic damage, despite frequent political pressure, growing funds and a number of existing organisations working to tackle the parasite.

The new malaria team, to be announced at the World Economic Forum in Davos, will be jointly chaired by the head of the World Health Organisation, Ethiopia's health minister, and Malaria No More, a business-led group.

It will work closely with Roll Back Malaria, the existing multi-lateral coordinating body, as well as the Global Fund to fight Aids, TB and Malaria, the World Bank, Unicef and the Bill & Melinda Gates Foundation.

Rajat Gupta from McKinsey, which drew up the new estimate of costs, and who also chairs the Global Fund, said past efforts had failed because the groups involved "represented the interests and politics of the organisations they came from and were not answerable to the common task in hand."

He said: "We have pretty much all the tools to aggressively control the disease and reduce or eliminate mortality, but it has not been done."

The Gates Foundation last autumn offered fresh funding as part of a long-term objective to eradicate malaria.

Uganda - DDT spraying set for February 5

From Patrick Opio, 28 Jan 2008 in the New Vision newspaper, Kampala.

The Government is to begin indoor residual spraying of the anti-mosquito chemical, DDT, on February 5, the officer in-charge of the process has revealed. Gilbert Ocaya said the countrywide exercise would start from the high malaria endemic districts of Apac, Lira, Kitgum, Amuru, Gulu, Pader, Mbale and Pallisa.

He added this would be done in accordance with the World Health Organisation (WHO) and Stockholm Convention guidelines. Ocaya, who did not disclose the cost of the exercise, last week told participants at a workshop for trainers at Scout Hall in Apac that the Ministry of Health had secured funds to buy the chemical considered the most economical and effective. "Unless constrained by late delivery of the logistics, we shall start as scheduled," he affirmed, "Malaria continues to be life-threatening in Uganda, with Apac being the area most infested with mosquitoes in the world."

Michael Okia, a senior entomologist with the Malaria Control Programme in the health ministry, said indoor residual spraying was one of the effective strategies the Government has adopted to control malaria, now killing an estimated 320 Ugandans daily, mainly children and expectant mothers. "We have already seen impressive results of spraying in Kabale and Kanungu districts where the malaria prevalence has reduced from 30% to less than 4% and 45% to 4.7% respectively," Okia said.

However, some people, including environmentalists and farmers, have opposed the use of DDT, saying it was harmful. But Ocaya allayed the fears. He said DDT has been endorsed by the WHO and it would not have any negative impact on the environment as little amounts of a special type would be sprayed on walls inside houses where the lethal anopheles mosquitoes tend to rest.

The Malaria Control Programme manager, Dr. John Rwakimari, affirmed that by the end of 2010, all areas considered malaria-prone would have been sprayed.

Saturday, January 12, 2008

A need for $38 to $45 billion ... why?

I wrote the following to the correspondent author of a paper titled "Estimated global resources needed to attain international malaria control goals".
I have the paper "Estimated global resources needed to attain international malaria control goals".

I guess I come from a different background. I trained in engineering and economics at Cambridge. I qualified as a Chartered Accountant. I worked as a cost accountant and CFO in the US corporate world for a number of years ... and only then did I start doing consulting work in the international field of relief and development ... and preparing business plans and financial projections.

I am therefore quite concerned about the financial planning dimension of the international development assistance community ... and the remarkable lack of historic cost effectiveness measurement, and therefore a terrible weakness in terms of planning and optimizing interventions.

I define management information as the least amount of data that enables optimum decisions to be made reliably and quickly.

Hardly any of the material available has this characteristic ... and, in my view, without it ... results are going to be less than optimum, or more bluntly, are likely to be unacceptably poor.

What to do? The paper talks about $3.8 billion to $4.5 billion a year! It talks about $38 to $45 billion from 2006 to 2015. These are huge amounts ... but why? In the body of the report ... costs are going up over time ... but why?

In the mosquito and malaria control model I have worked on, costs go down over time ... by working on breaking the transmission cycle ... by having good data to optimize local performance and respecting the tremendous importance of geography ... by doing only what is needed ... by doing sentinal surveillance to ensure that there is rapid intervention to stop re-establishment of the malaria crisis.

In our approach we measure costs and we measure results ... the reduction in mortality in a community ... the reduction in morbidity in the community ... the reduction in work days lost ... the number of cases of malaria ... the prevalence of parasite in the human host ... the prevalence of parasite in the mosquito population.

In our experience cost effectiveness is very variable ... averages are meaningless. Optimization is achieved by good analysis of timely relevant data ... both locally and in a multivariate broad based database. Optimization starts from what has happened, what is happenning and what needs to happen.

We do all of this more in an accounting mode than in a statistical mode ... statistics have their place. There is a professional activity called cost accounting ... I do not know one called cost statistics!

I just don't see this dynamic in what is being circulated ... what is being discussed ... what is being done.

What am I missing? Can you help?

Peter Burgess

It will be interesting to see whether I get a reply. Over the past two years there has been only about a 5% response from my attempts to contact the writers of documents. I have used different approaches to gain attentions ... but in the main none work. In many cases the writers have "moved on" and no longer seem to have a continuing interest in the malaria issue ... but more broadly there seems to be a systemic problem that might be described as the disconnect between the work needed for addressing the malaria crisis on the ground and the research community that is publishing a lot, most of which has rather little practical value.

Maybe I am wrong ... but getting an active dialog about cost effectiveness in any specific situation is almost impossible. Why? What is it going to take to get a serious interest in cost effectiveness?

Peter Burgess
The Tr-Ac-Net Organization

Friday, January 11, 2008

Performance Metrics - Child mortality reduced by 25%

Dear Colleagues

The best performance metrics are easy to understand. Most of the performance metrics in the academic literature about mosquito and malaria control are difficult to understand.

At the present time, the long lasting insecticide treated bednet is the most popular of malaria control interventions. It lends itself to simple comments along the lines of "Bednets save lives" ..."Donate $10 and save a life" ... etc.

But the data that are available are much less convincing.

One report, which I was under the impression was making the case for bednet use, has the conclusion that "With substantial bednet coverage, under 5 child mortality is reduced by 25%".

According to widely quoted WHO data, there are some 3,000 child deaths every day in Africa from malaria.

Does this therefore mean that with substantial bednet coverage there will be 2,250 child deaths every day instead of 3,000? I would have thought that this is a failed idea ... and would be totally unacceptable if the program was being offered in Europe or North America.

What am I missing?

Peter Burgess
The Tr-Ac-Net Organization

WHO-RBM Global Malaria Business Plan

Dear Colleagues

It would be wonderful if 2008 could be the year when very good performance metrics becomes the norm ... this is possible but this is unlikely.

WHO and Roll Back Malaria (RBM) and working on a Global Malaria Business Plan that aims to have the whole world using one approach.

From a management perspective the WHO-RBM approach seems to be the ultimate in "one size fits all" with a maximization of the risk of failure. It seems to be heavy in overhead and academic opinion and weak in data and responsiveness to operational realities. It seems to be building on a timeline that achieves too little over a period that is too long ... using a framework that has little or no management value. It seems to be creating another level of overhead and moving even further from the community where the work of mosquito and malaria control has to be done and the benefits delivered.

The Integrated Malaria Control Group (IMMC) in cooperation with The Tr-Ac-Net Organization has a very different approach. IMMC uses surveillance data and an operational plan for every individual area affected by malaria, with optimization being done for each individual situation. IMMC has developed a comprehensive cost effectiveness analysis system which uses best practice from the corporate world for cost accounting and performance metrics rather than the monitoring and evaluation and statistical methods favored by donors, the research establishment, NGOs and the relief and development organizations.

Using the IMMC approach, a community can move as fast as the situation allows ... and get results rapidly ... get benefits quickly ... and reduce intervention costs as soon as the situation stabilises at an improved level. The IMMC approach is likely to prove more than 10 times more cost effective that the WHO-RBM approach. This is a vast improvement over the prevailing practices.

What is possible is exciting ... but the majority of the fund flows for malaria control are currently committed to programs that have high costs and potentially limited benefits.

Sadly, because of the generally low quality of the data, it is difficult to show how expensive the current approach is going to be.

Peter Burgess
The Tr-Ac-Net Organization

Wednesday, December 26, 2007

Dialog with WHO in early 2007

During the course of 2007 Tr-Ac-Net and IMMC have made many efforts to participate in the establishment of systems of performance metrics for the malaria subsector, and to help with the operation of malaria control performance metrics. In general, there is a willingness on the part of the official relief and development agencies (like WHO) to have a modest amount of dialog ... to do some talk ... but almost no interest in getting down to doing the walk.

The following is dialog with WHO earlier in 2007. It comprises just 4 messages ... with my last message going unanswered.

The Tr-Ac-Net plan is to share our experience with the instititions of the relief and development sector, including that of specific individuals ... good and bad ... with a wider public than has been normal up to now. This is essential if there is going to be any realistic accountability in these organizations. It is not going to be comfortable ... but performance has been so poor in the relief and development sector that some relatively strong initiatives are required.

Message 1 ... Peter Burgess to Dr. Arate Kochi at WHO

Peter Burgess
IMMC and an integrated approach to malaria abatement
Peter Burgess
Thu, Mar 22, 2007 at 11:50 AM

Dear Dr. Kochi

I think one of my colleagues, Paul Driessen, met you when you were in Washington in December at the President's Malaria Summit. He has suggested I should contact you directly to introduce IMMC – The Integrated Malaria Management Consortium.

The potential for more fund flows into the malaria sub-sector is good news, but results depend not only on how much is disbursed, but how it is used.

I have been brought into IMMC to address the issue of data and decisions in the malaria sub-sector and ways to use management information to optimize the use of resources. When smallpox was eradicated there were millions of people involved in surveillance and interventions were totally focused on where intervention was needed.

With malaria ... the mosquito and the environment must be addressed ... and the parasite ... in order to have a sustainable result in terms of reduced malaria burden in society. With appropriate data, interventions can focus on the part of the transmission cycle where results will be maximized ... prevention ... and cure can get used as part of an overall initiative to reduce transmission as much as to reduce the pain of the illness.

Cost is only of analytical interest in relation to the results being achieved ... that is how much malaria is reduced in the society.

A lot is known about malaria, and it is interesting that Dr. Larry Brilliant is bringing back the idea that eradication is possible IF the right approach is used, including using surveillance and data to drive decisions about interventions and the use of resources.

I am attaching a short brief about IMMC ... the experience represented in the IMMC group is substantial, and from multiple disciplines needed to have a successful outcome rather rapidly. I think IMMC is the right idea, in the right place, and at the right time.

Please can you point us to the people in your organization who will be the most interested in the IMMC approach both at headquarters and in the field.


Peter Burgess
Peter Burgess
The Transparency and Accountability Network: Tr-Ac-Net in New York
IMMC - The Integrated Malaria Management Consortium Inc.
212 772 6918
Print on demand books: Search: Peter Burgess
"Hundreds of Issues that Impact Relief and Development Performance"
"Revolutionary Change for Relief and Development"
"Iraq - A New Direction – A Strategy for Peace"
IMMC Brief D 070303k.pdf ... 892K

Message 2 ... Dr. Arate Kochi at WHO to Peter Burgess

Kochi, Arata
Fri, Mar 23, 2007 at 7:49 AM
To: Peter Burgess
Cc: "Aregawi Weldedawit, Maru" , "Cibulskis, Richard" , "Spinaci, Sergio" , "Mendis, Kamini Nirmala" , "Guillet, Pierre" , "Buj, Valentina" , "Crowell, Valerie"

Dear Mr Burgess

Thank you for contacting me.

I am very glad to know that someone start to tackle information management system issues for malaria, which is far far behind that of TB, Immunization, even AIDS.

One of the major thrust for WHO Global Malaria Program is to develop simple , but timely and effective information management system for malaria activates in the world.

We have already made some tangible progress on this field, and very interesting in interacting with agencies like yours.

The focal person in GMP is Mr Maru Aregawi for this.

Maru and others please look at this attachment and ready for interaction with him.
Looking forward to hearing from you .


-----Original Message-----
From: Peter Burgess []
Sent: 22 March 2007 17:52
To: Kochi, Arata
Subject: Fwd: IMMC and an integrated approach to malaria abatement
[Quoted text hidden]
Message 3 ... Dr. Maru Aregawi at WHO to Peter Burgess

Aregawi Weldedawit, Maru
Fri, Mar 23, 2007 at 8:23 AM
To: Peter Burgess
Cc: "Kochi, Arata" , "Cibulskis, Richard" , "Spinaci, Sergio" , "Mendis, Kamini Nirmala" , "Guillet, Pierre" , "Buj, Valentina" , "Crowell, Valerie"

Dear peter,

As per Dr Kochi's brief note, I would like to establish the communications with you and your institution. Let me take this opportunity to give some more highlight on surveillance, M&E, activities of the Global Malaria Programme (GMP) of WHO.

Cognizant of the importance of malaria information and the challenges to regularly track reliable and quality data, WHO has significantly invested and developed relevant tool and strategies that would enable us to channel information regularly from lowest possible Administration level of the countries to build global database. The tool tracks data from the routine HMIS, surveys and sentinel sites. We are in the process of rolling out this database to over 50 countries- where over 30 of them will be in Africa. The database is basically a Management tool for the country programmes that interacts with the overall HMIS and health systems; and enables them to monitor performance and to store retrospective and prospective data dynamically. These data will be the basis for Regional and Global reports on malaria burden, trends and progress of interventions. WHO will share the data systematically and made it available for use by other stake holders.

This investment GMP/WHO is going to continue and sustain in collaboration with interested partners. Therefore, we welcome your interest and collaboration in this endeavor.
As we value your contributions, let us know how concretely you would like to participate in the exercise.

Thank you and look forward to working with you,

Dr Maru Aregawi
Acting Coordinator
Surveillance, Monitoring and Evaluation (SME),
Global Malaria Programme,
HIV/AIDS, TB and Malaria (HTM) Cluster,
World Health Organization, Geneva, Switzerland
Office: L-270
Tel: +41 22 791 3905
Fax:+41 22 791 4824

Message 4 ... Peter Burgess to Dr. Maru Aregawi at WHO

Peter Burgess
Sun, Mar 25, 2007 at 8:55 PM
To: "Aregawi Weldedawit, Maru"
Cc: "Kochi, Arata" , "Cibulskis, Richard" , "Spinaci, Sergio" , "Mendis, Kamini Nirmala" , "Guillet, Pierre" , "Buj, Valentina" , "Crowell, Valerie"

Dear Dr Maru Aregawi

Thank you for very much for your very prompt message.

I was asked to become involved with IMMC (the Intgegrated Malaria Management Consortium) because of my interest in the data and management information dimension of business and the relief and development sector. My belief is that data and analysis can be a very effective driver of decisions ... and if you don't have adequate data ... then get it.

But I also believe that data should be well used ... use the data as many times as possible ... and don't reinvent the wheel. If data already exist, use them across sectors and institutions and, to the extent it serves a good purpose ... across boundaries.

I am delighted with the roll-out of your WHO database information system for malaria ... can you share with IMMC the data structures you are using for your database ... and the basic data architecture and data flows you are or will be using. The IMMC approach to data and its processing / analysis as one that is inclusive of both the data needed for science ... entomological, environmental, medical ... and the data needed for management ... disbursements (costs), activities, immediate results (values) and durable results (values). Much of what you are
aiming to do, and what IMMC aims to do is likely to be similar, and it should not be necessary to duplicate.

I have been working with the IMMC team for almost two years, and in this time I have tried to find cost / result information in the literature. What I have found has been enough to convince me that an integrated set of interventions can be implemented and result in the most cost effective program ... but the data are really not very good, and I hope we will be able to do much better in the future. We would certainly like to cooperate to help achieve this outcome.

Again thank you


Peter Burgess

It is tedious to have to work so hard to get any form of collaboration from the organizations in the relief and development sector.

Somehow, there has to be public outcry so that there is some reasonable level of responsiveness from the critical agencies charged with important global responsibilities.


Peter Burgess
The Tr-Ac-Net Organizations

Monday, December 24, 2007

Why is malaria such a burden?

Dear Colleagues

Malaria is a burden because it is so prevalent in Africa and it is a debilitating disease. It is a killer disease especially for very young children and pregnant women. People cannot work when they are suffering a malaria attack. There have been estimates of the loss of economic output caused by malaria ... and they are significant ... maybe as much as $15 billion a year.

This number is not particularly meaningful, because it does nothing to answer the question of WHY malaria is a burden.

Part of the answer to this question is that national and international leadership has failed to make malaria control a priority and has neither deployed enough money, nor has used the money in the most cost effective way. Though malaria has been brought under control in many places, it remains a serious disease in the malaria endemic areas of Africa.

The international campaign to ban the use of DDT had a serious impact on malaria control programs, and while this was a factor in the failure to control malaria, it was only part of the explanation. Another part was the lack of interest in malaria on the part of the international donor community as a whole, and another part was the lack of leadership on the matter from the governments of Africa.

Over the years, drug therapy to minimize the impact of malaria has become less and less effective, as resistance has built up. Low cost chloroquine is not longer and effective therapy and much more costly drugs have to be used. Few are able to benefit from these drugs unless they are funded by donors.

Since 2000, there has been more interest in malaria control, and a much increased donor funding of programs to address the malaria crisis. But though there has been substantially more money, there are questions about how effective the increased funding has been in reducing the burden of malaria in society.

Clearly there has been some success ... but success has been measured more in the amount of coverage a program has achieved rather than the results that have achieved. Yes ... more people have bednets, and yes ... more people slept under them last night ... but how much less malaria, and how much less prevalence of the parasite. These latter questions are not being answered.

There is significant focus on mortality, especially young children and pregnant women. This results in reduced mortality for these groups ... which has a human value, but not so much an economic value. One without the other is not enough.

There is little or no attention being paid to the morbidity of working age adults. This is the group that is needed to make the economy improve, and make it possible for the society to move forward. Without this, malaria will remain a burden.

There is a lot of work to do to optimise the fund flows in the malaria subsector so that the burden of malaria is reduced as rapidly as possible and in a way that is sustainable. Tr-Ac-Net models suggest that programs that have a clear geographic focus, that consider the whole population, that incorporate all possible control interventions and are optimized based on good data can have a very rapid impact ... but this is not what is being done in most of Africa and by most implementing organizations.

The programs developed by the Integrated Malaria Management Consortium aim to address the malaria problem using a full range of interventions, and using scientific and management data to drive operational activities and the allocation of resources.

It is going to be interesting to see how many programs will demonstrate a reduction in the burden of malaria in 2008.


Peter Burgess