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

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