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