CGHD’s Simon Presents Malaria Report to Congress

In Rwanda, a network of 60,000 community health workers trained in managing malaria has been credited with helping to reduce mortality among children by 50 percent since 2005.

In Kenya, where 4.5 million insecticide-treated bed nets have been distributed, the percentage of pregnant women and children under five protected by nets climbed from 6 percent in 2003 to more than 45 percent by 2009.

These are just a few of the programs undertaken through the President’s Malaria Initiative (PMI), launched in 2005, which aims to reduce malaria-related deaths by 50 percent in 15 African countries that have a high incidence of the disease.

Today, Jonathon Simon, director of the BU Center for Global Health & Development (CGHD), will give a presentation on Capitol Hill on the findings of a top-level evaluation of the PMI done by him and a team of researchers, hosted by two Congressional caucuses, the Caucus on Malaria and Neglected Tropical Diseases and the Global Health Caucus. The findings deem the program “very successful,” while cautioning that sustaining those successes will require changes in approach to overcome increasing resistance to insecticides and to artesunate-based drugs.

Ongoing success, the team concludes in its report, will be expensive and require continued commitments from international donors and participating countries.

“The history of malaria control has been one of temporary success followed by failure,” according to the team led by Simon, a School of Public Health professor and chair of the department of international health. “PMI has helped create a success in this latest attempt at malaria control; figuring out a strategy for sustaining these advances and adapting to biologic, political, and financial challenges is essential for keeping history from repeating itself.”

The review of the first five years of the PMI was done by a team of researchers from the CGHD, former World Health Organization scientists, and other university faculty, who spent seven months conducting country site visits and extensive interviews with malaria program personnel.

The goal of the malaria initiative is to reduce malaria-related deaths through proven interventions, including insecticide-treated nets, indoor residual spraying (IRS), intermittent preventive treatment for pregnant women, and artemisinin-based combination therapies. The initiative was begun under the administration of President George W. Bush and has been extended through 2013. In 2009, President Obama launched the Global Health Initiative as the next chapter of American leadership and incorporated the PMI as one of its core components.

In each of the targeted countries, PMI collaborates with host governments and other partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Roll Back Malaria Partnership, the World Bank Malaria Booster Program, and nongovernmental and private organizations.

The evaluation found that PMI is “by and large, a very successful, well-led component of the USG [U.S. Government] Global Health Initiative…PMI has made substantial progress toward meeting its goal of reducing under-5 child mortality in most of the 15 focus countries.

“Though major biologic, political, and financial challenges exist that could seriously erode the accomplishments made to date,” the report goes on, “PMI, through its first five years of activities, has earned and deserves the task of sustaining and expanding the U.S. Government’s response to global malaria control efforts, and should be given the responsibility to steward additional USG financial and human resources to accomplish this task.”

In addition to recommending additional resources, the report says that to improve the program’s efficiency and effectiveness, there is a high-priority need to clarify interagency leadership roles. Simon’s team also recommends that PMI leaders reevaluate some of the existing malaria interventions, such as the use of indoor residual spraying.

“Amidst increasing insecticide resistance, tough financial pressure, and limited data on the additive benefits of combining IRS operations with universal coverage of (insecticide nets), PMI should reevaluate its IRS strategy,” the report says. “It is a relatively expensive approach and covers a small proportion of the at-risk population.”

The report notes that the program has developed strong partnerships with almost all of the national malaria control programs in the 15 African countries, and that its leadership is “well appreciated by most of the partners.” The initiative is led by the U.S. Agency for International Development (USAID) and implemented with the Centers for Disease Control. It is overseen by a U.S. global malaria coordinator and an interagency steering group made up of representatives from USAID, CDC, the Department of State, the Department of Defense, the National Security Council, and the Office of Management and Budget.

The report recommends that the PMI move carefully to increase individual countries’ control over the program; the evaluation team found “high levels of variability” in the willingness and capability of countries to assume leadership responsibilities.

“In some PMI-supported countries, the human capital base and management control systems are insufficient to transfer many PMI responsibilities” to people on the ground, the report says. “In other countries, where the human resources are adequate and management control systems meet foreign assistance standards, the transfer of responsibilities should be accelerated.”

The report notes that the political and economic climate around malaria control is changing rapidly, as the strong global commitment to the cause is being balanced by cost considerations, now that “the period of rapid growth in the global resource base for global health is likely over.

“There is a profound imperative…to maximize cost-effective program interventions as financial resources flatten or decline,” the report says.

Besides Simon, CGHD researchers on the report include Kojo Yeboah-Antwi, an SPH assistant professor of international health, and Mohamad Ibrahim (Bram) Brooks, CGHD senior program manager.

The full report can be found here.

Lisa Chedekel can be reached at chedekel@bu.edu.