Thursday, 19 May 2011

MALARIA: Redrawing Roadmaps - can we get there from here?

Bill Brieger : 15 May 2011
The Roll Back Malaria Partnership guided countries to develop 2010 roadmaps for major malaria commodity and support service availability and gaps. The aim was to aid planning to reach universal coverage by the end of 2010. Forty-seven countries/locations on the African Continent and surrounding islands completed the analysis and started moving down the road to success.
In the case of 36 countries the road became a little longer than anticipated. Part of the challenge was international - there are only a few manufacturers of long lasting insecticide-treated nets, for example. Some of the barriers were internal, inadequate estimates of the logistical costs to distribute commodities, even if they were in hand. Now we have 2011 roadmaps in an effort to meet up with the original 2010 goals of 80% coverage with essential malaria commodities.

proportion-of-countries-that-missed-2010-rbm-roadmap-sm.jpgAt least one-quarter of countries that actually targeted a specific intervention in 2010, did not meet the 80% goals. Of particular concern is the fact that Rapid Diagnostic test use is both off target and not keeping up with ACTs.
Meeting procurement and distribution targets is one step, but getting people to use malaria control interventions is another challenge. As the director of a prominent Nigerian NGO recently said, “… ‘though about 35.6 million nets have been distributed across the country, it is highly under utilized,’ which according to him is responsible for the high death rate associated with malaria.”

Nigeria provides an instructive case. The roadmap for 2010 called for 62.9m LLINs of which 4.4m were already in place and pledges were set for 49.4m. This left a gap of 9.2m. While the RBM 2010 roadmap analysis shows that Nigeria met its LLIN target, the implication is that the target did not include the gap. Now the 2011 roadmap for Nigeria now shows that resources are in hand for both the 9.2m gap from the 2010 campaign plus an additional 8.2 m for routine distribution in clinics as a keep-up measure.
The gross figures do not fully reflect the fact that of the 36 states (plus one capital territory), campaign distribution of LLINs continued from 2010 into 2011 in 17 states. So far 9 or the 17 have completed distribution, but by carrying the campaign into 2011 additional delays were met in the remainder due to national elections, delayed local funding for the effort, and distribution logistics. So again while the roadmaps help identify commodity gaps, they do not always identify the challenges at the level of distribution and use.
The roadmap process is an important planning tool. It needs to be supplemented with plans for logistical support and health education to encourage use of the malaria commodities and services that are eventually distributed. For example, Nigeria estimates that it needs close to $17m for Monitoring and Evaluation and Information. Education and Communication. We can see from the Nigerian roadmaps that this planning needs to be a continuous process - not only is annual resupply of ACTs, RDTs and SP for IPTp needed, but also continuous stocks of nets for routine, keep-up services.

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