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

Sunday, December 23, 2007

Cost effective anti-malaria interventions

Dear Colleagues

Over the past five years there has been a major increase in the fund flows related to anti-malaria interventions. It is expected that in 2008, there will be more than $1 billion disbursed related to malaria work.

But it is interesting to note that the easy sound bite about child death ... "A child dies in Africa because of malaria every 30 seconds" ... or "some 3,000 children under 5 years of age die in Africa every day" remain the same now as they were two and three years ago. Is this lazyness on the part of the PR people ... or is this because the impact of the funding is insignificant.

With so much funding, it is reasonable to expect that there will be some cost accounting and performance analysis. President Bush made it clear that this was going to be a characteristic of the President's Malaria Initiative (PMI) and everyone talks about the importance of performance metrics. But in reality, the presently available performance metrics are simplistic and merely confirm that certain activities have been carried out ... which is a start ... but there is little about how effective these activities are in addressing the burden of malaria.

What is the goal? To reduce the burden of malaria in the society.

What is the burden of malaria? There are many elements of which the following are important. How much cost does this have?
1... High mortality among young children
2... High mortality among pregnant women
3... Mortality among all other groups in the population
4... Morbidity among all groups in the population ... which has a big economic impact when working age adults are incapacitated
5... Lost working time due to malaria
6... Cost of anti-malaria interventions
...1... Medical care
...2... Personal protection (coils, sprays, etc)
...3... Personal protection (bednets)
...4... Interior residual spraying (IRS)
...5... Source control ... larvaciding
...6... Adult mosquito control ... ULV adulticiding

What are the key metrics that show progress and relate progress to the costs of the associated anti-malaria activities?
1... Reduction in mortality among young children
2... Reduction in mortality among pregnant women
3... Reduction in mortality among all other groups in the population
4... Reduction in morbidity among all groups in the population
5... Reduction in lost working time due to malaria
6... Reduction in the cost of needed anti-malaria interventions
...1... Medical care
...2... Personal protection (coils, sprays, etc)
...3... Personal protection (bednets)
...4... Interior residual spraying (IRS)
...5... Source control ... larvaciding
...6... Adult mosquito control ... ULV adulticiding
7... Reduction in the prevalence of malaria parasite in the human host
8... Reduction in the prevalence of malaria parasite in the mosquito population
9... No emergence of resistance in any of the anti-malaria interventions
10.. No environmental damage
11.. No negative side effects for the human population

What is the cost? What is the optimum cost? How to get the least cost and the most benefit for anti-malaria interventions
...1... Medical care
...2... Personal protection (coils, sprays, etc)
...3... Personal protection (bednets)
...4... Interior residual spraying (IRS)
...5... Source control ... larvaciding
...6... Adult mosquito control ... ULV adulticiding
...7... Cost of data collection, data logistics, data analysis and administration

The metrics described here are a lot more substantive than anything that seems to be available at the present time in the malaria sub-sector ... though there will be around $1 billion disbursed in 2008 to address the malaria component of African health.

The international relief and development sector does not have a good track record on financial control, cost accounting and related matters. The good news is that there is some discussion of the need for performance metrics. The bad news is that what currently goes for performance metrics is very limited in quality and comprehensiveness.

With limited performance metrics ... performance is compromised. The cost is huge. Good management information is possible. Good management information is used in the corporate sector, but good management information is almost entirely absent in the public sector, and especially in the international relief and development sector. This is obscene, and serves only those that want to rip off the system or are engaged in activities that have little or no value.

Your comments are welcome.

Peter Burgess
The Tr-Ac-Net Organization

Friday, December 21, 2007

Performance Metrics

Dear Colleagues

The international relief and development sector is very weak on performance metrics, and so also is the medical profession.

WHO and others in the health and international relief and development community have worked for a long time to develop useful performance metrics about the malaria situation and the activities being funded.

The outcome shows, however, that there has been a serious absence of accounting input and the basics of cost accounting are missing.

Instead of measuring how much it has cost to do various things, and what has been achieved by doing these things in terms of the reduction of the burden of malaria in the community, there is instead a set of measures that simple show how much "coverage" has been achieved for the subject intervention.

Coverage versus cost shows something about the efficiency of the operation ... but nothing about the efficacy of the activity. Does the activity actually reduce the burden of malaria or not ... and how much does that cost?

Top leadership has made bold statements about the need for good performance metrics. Whenever President Bush has spoken about the President's Malaria Initiative (PMI), a very large US international commitment for health, he always adds in something about performance metrics. Unfortunately the examples he gives are usually simply about quantities delivered rather than the reduced burden impact to be achieved.

Even though I have tried to find quality information about cost effectiveness of mosquito and malaria control interventions, there is very little that is available. I am sure there is information in some archive, but it is not easy to find, and less easy to access and use.

Even though there is increased funding for malaria control, it is not enough to eradicate malaria unless it is used in the very best way possible. That requires data and decision making that is focused on cost effectiveness and multi-year results.

The Tr-Ac-Net Organization in cooperation with the Integrated Malaria Management Consortium (IMMC) has set out to provide a way for these data to be collected and stored in an easily accessible form for operational and analytical use. The goal is a low cost way to do this, and have it in a useful form for decision making.


Peter B in New York
The Tr-Ac-Net Organization

Thursday, December 20, 2007

Increased Funding

Dear Colleagues

Malaria has been underfunded for about 40 years. As a consequence many areas in the tropics continue to have high levels of malaria for all or part of the year.

But in the years since 2000, there has been a substantial increase in the funding available, and the idea of eliminating malaria in the foreseeable future is now, once again, on the table.

It is anticipated that there will be in excess of $1 billion disbursed in the fight against malaria in 2008.

But even though there is increased funding being promised, there are some serious questions about how much will be achieved. Though there is talk about performance metrics, it is apparent that most measurement presently being done relates merely to the activities being undertaken, and very little to the ultimate benefit.

If the funds are used badly, even though there is adequate funding, the results will unsatisfactory. This is not acceptable, and is the driving force behind Tr-Ac-Net's commitment to deploying a range of performance metrics to measure the cost effectiveness of malaria control interventions.


Peter Burgess
The Tr-Ac-Net Organization

The Malaria Crisis

Dear Colleagues

Over the past few years, and thanks to a great extent to the work of Jeffrey Sachs, the malaria crisis in Africa has become quite well known. The phrase "3,000 children die in Africa every day from Malaria" has been repeated many times, and now appears frequently in the mainstream media.

If six Boeing 747 airliners full of children were to crash in a day's time, this would be a catastrophic event ... but the same number dying quietly from malaria passes unnoticed.

More children die every day from malaria than were killed in the USA as a result of the terrorist events of 9/11/2001.

But what is particularly concerning is that malaria ought not to be killing anyone.

This blog aims to address some of the issues around the present malaria situation, and the issues around the fund flows and activities being deployed to reduce the burden of malaria. It is written primarily by Peter Burgess of the Tr-Ac-Net community with the help of experts associated with the Integrated Malaria Management Consortium.


Peter Burgess
The Tr-Ac-Net Organization