MAJOR PROGRESS IN MALARIA CONTROL: THE ROLE OF THE GLOBAL FUND, ITS DETRACTORS AND SUPPORTERS.

PREAMBLE: Over the past two issues we have taken note of decisions by several European entities (Germany, Ireland, and Sweden and the European Commission itself) to suspend funding to the Global Fund on AIDS, Tuberculosis and Malaria (GFATM). In part, this decision was made ostensibly due to concerns about corruption in recipient countries, even though this was limited to only 4 countries (among over a hundred recipients) and was discovered, investigated and openly reported by the Global Fund itself. This level of corruption, independently analysed, is significantly lower than that of the EURO block.

The truth behind this decision is that Europe has been financially mismanaged, with bank failures in some countries, and problems of corruption and mismanagement. European captains of industry (like their Americans counterparts) walked away with fortunes under their belts in the form of self-awarded bonuses, even as their operations have been bailed out by their taxpayers. Several governments are now at risk of unprecedented financial defaults.

The decisions of these European entities smack of old style colonialism: arrogance from the top down. It damages their hard won (or restored) reputations for being global leaders.

To use developing countries and the Global Fund as a scapegoat for this is unconscionable: at least be honest! Instead, these particular European entities should have had the integrity to own up and say “sorry, we cant afford this now, because we ourselves are in such a mess”.

Thankfully, the Bill and Melinda Gates Foundation, being evidence-based, has stepped in to shore up Global Fund finances due to this donor default. Also, former Japanese prime minister Naoto Kan said his country would contribute $340 million to the fund this year. Two years ago, Japan contributed $200 million, but it gave only $110 million last year because of domestic needs from the earthquake and tsunami. Of course many other countries are honoring their pledges, even as many of them also have financial challenges at this time.

“These are tough economic times, but that is no excuse for cutting aid to the world’s poorest,” Bill Gates said in announcing the $750 million contribution.

We congratulate the Gates Foundation, and the government of Japan, a nation that knows more than most the meaning of hardship and tragedy, and apparently has a high sense of integrity.

We dedicate this issue to the major successes now taking place in malaria control, largely thanks to support from the Global Fund. With this purpose, we have partially extracted verbatim the report below which appeared in the Health and Development Global Update published by the HLSP Institute in June 2011.

Reference: Brown D, Gates Foundation gives $750 million to Global Fund. Washington Post January 27, 2012. http://www.washingtonpost.com/national/health-science/gates-foundation-gives-750-million-to-global-fund/2012/01/26/gIQAHKw5TQ_story.html Accessed February 18, 2012.

MALARIA: A GLOBAL UPDATE
The latest WHO World Malaria Report in April 2011 documents impressive increases in intervention coverage and reductions in malaria morbidity and mortality. WHO estimates that the number of malaria cases has fallen by more than 50% in 43 countries over the past decade. Eleven countries in Africa have shown a reduction of more than 50% in either confirmed malaria cases or malaria admissions and deaths in recent years. In Asia, four countries saw a decrease in the number of malaria cases of more than 50% since 2000.

Africa in particular has seen tremendous progress in increasing access to insecticide-treated nets (ITNs) in past 3 years. However, given an estimated lifespan of three years, nets delivered in 2006 and 2007 are already due for replacement and those delivered between 2008 and 2010 will soon be. The challenge is in ensuring that the high levels of coverage achieved are maintained.

We still have incomplete information on access to treatment in general, and particularly for the significant proportion of patients treated in the private sector. We do know that the number of procured rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs) is increasing globally yet, especially in African countries, most patients are receiving ACTs without confirmatory diagnosis. This continues to represent a significant financial, technical and personal challenge for many patients, health care providers and national malaria control programme managers. One exception is Senegal, which has introduced RDTs on a national scale in public facilities and, with high levels of adherence to diagnostic results, achieved dramatic reductions in ACT consumption . On the other hand, another study in urban Tanzania shows that the introduction of RDTs also had the unintended consequence of increasing inappropriate antibiotic prescription (from 49% to 72%) – a behaviour ascribed to clinicians’ insufficient knowledge and training on other causes of fever. This is why RDTs able to diagnose a range of common illnesses are high on the malaria community’s R&D ‘wish list’.

Coverage with intermittent preventive treatment for pregnant women (IPTp) remains far from target levels – ranging from 2.4% in Angola to 62% in Zambia. No country has yet adopted a national policy of intermittent preventive treatment for infants (IPTi), as recommended by WHO.

In the countries with greatest progress, the decreases are associated with intense malaria control interventions. But this progress is fragile. The resurgence of the disease in 2009 in Rwanda, Sao Tome and Principe, and Zambia shows that control programmes need to be maintained even if numbers of cases have been reduced substantially.

Source: HLSP Institute. Health and Development Global Update. July 2011. http://www.hlsp.org/LinkClick.aspx?fileticket=VxUphqNpW_w%3D&tabid=1575

Envoie: The prevention and control of AIDS, Tuberculosis and Malaria represent moving targets. Only with sustained international support from both public and private sectors, and perseverance by the countries mostly affected, will eventual success be achieved. The results as reported in the above extract are extremely encouraging and should be taken into account by the European entities mentioned in our preamble, when they eventually reconsider their support: which they surely will.

MATERNAL MORTALITY – AN INTEGRITY TEST FOR POLITICIANS

PREAMBLE: One of the world’s most intractable public health problems is the high mortality of women due to pregnancy related causes. Over several decades (until recently), maternal mortality in developing countries appears to have been non-responsive to a range of interventions, perhaps because of inadequate intervention design or the inability to scale these to a level that can have impact on population health. In many countries, social and health policies that could facilitate the status of women, particularly in their right to make independent decisions with regard to their own health, have remained underdeveloped; it is of low priority in the world’s male-dominated political systems. Health services also have been inadequate to help lower maternal mortality: insufficient attention to prevention and inadequate access to treatment services of quality when critically needed.

Most donor countries recognize maternal health as a global public health priority. However, in Canada (under the regime of Conservative Prime Minister Stephen Harper), this global imperative is being sacrificed to partisan politics of the most ill-informed kind: it risks becoming a platform for the “religious right” to rail against the use of donor funds for abortion rather than to address in a holistic manner the most important needs of women that can assure improvement in their health.

Only last year, the administration of US President Barack Obama rescinded the global “gag order” of the preceding Bush regime, that required recipients of US aid – even in the realm of reproductive health – to deny access to safe abortion services if accepting US funds. This enlightened policy shift brings the US international development policy in line with that of the global community generally. It is ironic therefore that Canada – once a leader in this respect – appears to be taking a giant step backwards. Given the removal of access to safe abortions from the frame of reference, it is extremely doubtful that a recent Request for Proposals to guide the policy of the Canadian government in this regard, could attract anyone with a rigorous track record in this area of international health development.

Taking Africa as an example, as the recent "African Century" series of articles in the Globe and Mail (ref: May 11, 2010 issue) makes clear, more than 90% of Africans live in countries where abortion is restricted. It is legally prohibited in 14, while in others it is only permitted only to preserve the life or physical health of the woman. As a result, virtually all of the estimated 5.6 million abortions performed annually in Africa are unsafe, carrying with an unconscionable risk of complications and death.

Simply put, along with access to contraception, antenatal care, safe deliveries, reliable transportation to advanced care when this is urgently required (otherwise known as emergency obstetric care, which includes surgical intervention if needed as well as prompt treatment of post-partum infection and hemorrhage), access to safe abortion is part of any coherent plan to improve reproductive health and reduce maternal mortality. Knowing all this, and both the health and international development arms of the Canadian government surely should know this, to specifically and deliberately exclude funding of safe abortions in an aid package aimed at reducing maternal mortality would render the donor complicit in those deaths.

We labeled this issue “Maternal Mortality – an Integrity Test for Politicians” after realizing that many politicians are intellectually challenged by the technical nature of what is scientifically sound evidence regarding the nature of the problem at hand, and what works or doesn’t in addressing it. It is also an ethical test… in essence whether they (the ruling political party) are in it for cheap political gains among their home base, or whether higher reasoning will prevail in the interests of the health of millions of women around the world. Just how the G8 countries deal with this in their upcoming meetings will be a direct reflection of their collective political integrity. Based on public utterances to date, it seems like all the G8 countries except Canada may pass this test.

For the lead item of this month’s blog, we therefore attach below the polite but authoritative view of the Lancet on Canada’s G8 Leadership. This we follow by the first good news in many decades, that maternal mortality globally is finally being reduced.

CANADA'S G8 HEALTH LEADERSHIP
The Lancet May 8th, 2010
As a World Report in The Lancet today shows, Canada's pledge, as host of this year's G8 Summit, to make maternal and child health one of its key issues is moving forward. At a meeting in Halifax, Nova Scotia (April 27—28), the G8 development ministers agreed to back Canada's provisional set of principles to improve the health of women and children in developing nations.

Canada should be praised for making maternal and child health a priority issue for the G8. As an Article by Margaret Hogan and colleagues in today's issue shows, around 350 000 women die during childbirth every year. 9 million children younger than 5 years also die every year. Most of these deaths are preventable. Canada's health plan to address this situation is still thin on details but it promises to include training and support for frontline health workers; better nutrition and provision of micronutrients; treatment and prevention of diseases such as pneumonia, diarrhoea, malaria, and sepsis; screening and treatment for sexually transmitted diseases, including HIV/AIDS; family planning; immunisation; and clean water and sanitation.

However, a few key elements are missing from the framework. For example, there is no talk of emergency obstetric care. This omission is likely to be an oversight and should be rectified. Improving access to safe abortion services is also absent from the plan. Sadly, this omission is no accident, but a conscious decision by Canada's Conservative Government not to support groups that undertake abortions in developing countries.

This stance must change. 70 000 women die from unsafe abortions worldwide every year. The Canadian Government does not deprive women living in Canada from access to safe abortions; it is therefore hypocritical and unjust that it tries to do so abroad. Although the country's decision only affects a small number of developing countries where abortion is legal, bans on the procedure, which are detrimental to public health, should be challenged by the G8, not tacitly supported. Canada and the other G8 nations could show real leadership with a final maternal health plan that is based on sound scientific evidence and not prejudice.

Source: The Lancet, Volume 375, Issue 9726, Page 1580, 8 May 2010

SUMMARY: Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5
(Note: Details of source and authorship given below)
Background: Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. We assessed levels and trends in maternal mortality for 181 countries.

Methods: We constructed a database of 2651 observations of maternal mortality for 181 countries for 1980—2008, from vital registration data, censuses, surveys, and verbal autopsy studies. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods.

Findings: We estimated that there were 342 900 (uncertainty interval 302 100—394 300) maternal deaths worldwide in 2008, down from 526 300 (446 400—629 600) in 1980. The global MMR decreased from 422 (358—505) in 1980 to 320 (272—388) in 1990, and was 251 (221—289) per 100 000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1•3% (1•0—1•5). During 1990—2008, rates of yearly decline in the MMR varied between countries, from 8•8% (8•7—14•1) in the Maldives to an increase of 5•5% (5•2—5•6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243 900—327 900) maternal deaths worldwide in 2008.

Interpretation: Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.

Funding: Bill & Melinda Gates Foundation

Source: Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet, 375, 9726, 1609 - 1623, 8 May 2010.

GLOBAL ECONOMIC CRISIS, FINANCIAL REFORMS & "THE BROWN DOCTRINE"

PREAMBLE: Over the past month, the world has faced an unprecedented near-collapse of its banking systems. The crisis is not over yet, and – it may fairly be stated – is due to a combination of poor political leadership in the United States (asleep at the wheel) and a combination of greed, negligence and corruption in its financial industry. This of course does not take the inaction and practices of other countries off the hook, as consequential national and global failures are documented extensively elsewhere, especially in Europe. Clearly, no country (rich or poor) has been spared, and it will take many years for individuals, families, communities and societies as a whole to recover from this crisis of greed, neglect and incompetence.

Perhaps needless to say, the necessities of life and the social fabric of all countries e.g, health and educational systems along with secure food supply, clothing and shelter depend on integrity in our financial systems. Trust must be restored in those systems.

Out of this morass some good has come in the leadership of UK Prime Minister Gordon Brown. He has put forward a 5 point plan which appears to have galvanized the world financial community around new principles, thereby giving some hope for the rest of us.

Implicit in the “Brown Doctrine” is an analysis of what is so seriously wrong with the world financial order. It forms a clear case for supra-national supervision of international finance, which clearly cannot any longer be left to the caprices of any one country.

The key features of the Brown Doctrine now follow, extracted from a media report.

Reference: Saunders D. The man who saved the world banking system. Globe and Mail Oct 15, 2008.

THE BROWN DOCTRINE
British Prime Minister Gordon Brown outlined a five-point program yesterday (October 14, 2008) to reform the world’s financial system. He hopes the principles will be the basis of a new set of global institutions to replace those that have governed international finance since 1944.

Transparency: Banks must fully disclose key information globally, not just nationally. Accounting standards will have to become international, and they must extend to the credit-insurance market, which has been heavily criticized.

Integrity: A worldwide effort is needed to end conflicts of interest, such as those involving rating agencies that receive fees from the firms they rate. Worldwide limits also need to be placed on pay and bonuses in banks, so that they reflect actual results and are no longer able to distort business practices.

Responsibility: All members of company boards must hold full responsibility for the company’s risk, and must not be able to walk away from their institutions. This will require international supervision.

Tighter Regulation: To create “a system with solvency and liquidity”, there must be “adequate protection through the economic cycle” to prevent speculators from distorting markets when they are rising and sort positions from having undue impacts when markets are falling.

New Institutions: The new system of banking cooperation will need “a new international financial architecture for the Global Age”. New institutions will provide “an effective global early warning system for the world economy, to alert us to the risks at hand”, and “globally accepted standards of regulation” and the cross-border supervision of global corporations.

Source: Saunders D. The man who saved the world banking system. Globe and Mail Oct 15, 2008.