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