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