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

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