Dispatches from the SAMC 2005 Conference – Maputo, Mozambique

Day 1 25 July 2023

The first day was taken up with the country reports from Angola, Namibia, Zambia, Botswana, South Africa, Swaziland, Mauritius, Madagascar and Mozambique.

Here are some of the key issues that arose from these presentations:

• Human resources are a major problem in malaria control, as it is in most healthcare programs in Africa, but on the upside, funding is greatly improved and all of those that presented were very optimistic about continued good funding for malaria control.

• When it comes to vector control, many countries are continuing with their roll out of insecticide treated nets (ITNs), but coverage is still low and no country could point to any kind of significant decrease in malaria morbidity or mortality as a result of ITNs. There seems to be a complete lack of decent monitoring of the impact of the various ITN programs and their effectiveness and this was admitted my many of the countries involved. Finally, there was a discussion, which seems to come up every year, about whether ITNs should be free or should be sold.

• Countries that are using Indoor Residual Spraying (IRS) can point to marked decreases in malaria cases. This is particularly true of Zambia. Although the presenter didn’t give any figures or data, he repeated again and again that cases are declining very rapidly in areas that are under IRS.

We understand that Mozambique is now going to be using DDT . The program manager mentioned that about 50% of his time is taken up with sorting out the various problems associated with this (logistical and political problems)

• The whole concept of integrated vector management seems to be poorly understood. This shouldn’t be a surprise given that it is fuzzy and seems to be a sort of catch-all for every kind of intervention , which mostly achieves nothing.

• Namibia, Zambia, South Africa all changed over to ACTs and are using Coartem. Angola is still conducting studies into ACTs, and I don’t think that they have changed over yet, although it wasn’t entirely clear from the presentation. Angola is doing efficacy studies on AQ + ASN and also Coartem..

Botswana has not changed over to ACTs as at the moment there is no need to. Botswana has so few cases that it is actually difficult for them to find cases to do decent drug efficacy studies.

• The need for improved diagnosis was discussed at length. Some countries are increasing the use of rapid diagnostic tests (RDTs) but there are ongoing questions about the reliability of these tests.

• The need for good monitoring and evaluation was raised several times. Along with this, operational research into the efficacy of insecticides and also drugs is needed and in many countries in inadequate.

• There was ongoing discussion of local production of Artemesia annua , but not much discussion of local production of drugs. However, the funky economics that local production = necessarily cheaper and more available is still a major feature when it comes to ITNs. Angola is particularly keen on local production of ITNs. I think mixing industrial policy with public health policy is a dangerous path to travel down. It seems I am alone in thinking this here though.

Day 2 continues with country presentations – from Comoros, Zanzibar, Zimbabwe, Malawi and Tanzania.

This will be followed by comments from WHO, UNICEF, GFATM. Also, we are due to hear about the Lubombo Spatial Development Initiative, PSI, and from the SADC secretariat on cross-border malaria control.

Dispatches from SAMC malaria control conference – Maputo Mozambique

Day 2 26 July 2023

The country presentations continued on Tuesday, starting with Comoros, then Zanzibar, Zimbabwe, Malawi and Tanzania

As with yesterday’s presentations, the major limitations to improving malaria control and treatment is a lack of human resources. The countries that presented today, including Zimbabwe interestingly enough, all claimed that funding for malaria control is greatly improved. Zimbabwe seems to have received GFATM funding. Another constraint – raised by Tanzania, was the affordability of ITNs, at a time when the country is increasingly using the more expensive Olyset Nets (although these nets last a lot longer than the traditional ITNs and cannot be compared with them equally)

Vector Control

1. ITNs remain the main intervention in Tanzania, Malawi and Comoros. In line with their presentations for the past few years, neither Tanzania nor Malawi could point to any significant impact on malaria morbidity or mortality from their scaled up ITN program. Zanzibar and Tanzania have started procuring Long Lasting Insecticide Nets (LLINs) from A to Z in Arusha – these are the Sumitomo Olyset nets that last between 5 and 7 years without re-treatment.

2. IRS is being expanded in Zimbabwe, but the recent improved funding for malaria control is likely to be because 2004/05 was an election year. Mugabe has held onto power (however illegitimately and fraudulently) and so it is not clear that the improved funding will continue. In any event Operation Murambatsvina (Clear away the trash – the illegal and outrageous destruction of people’s houses) is likely to have a severe impact on malaria control. The Zimbabwean delegation did not mention the impact this campaign, which has been condemned by all civilized people (and even the UN), would have on malaria control, even though it is likely to severely hamper malaria control. When I asked what the impact was going to be, I was informed that there had been an increase in malaria cases in Mashonaland following the land re-distribution process (if you can call it that) in recent years. Today the South African Press Association (SAPA) reports that the house demolitions are continuing, despite an announcement several days ago that it would be halted. In a nut-shell, if you are Zimbabwean and the government doesn’t kill you, a mosquito will.

Treatment

1. Zanzibar, Tanzania and Comoros have changed over to ACTs. Zanzibar has seen some steady declines in in-patient confirmed malaria cases and has apparently sorted out its problems in procuring ACTs – they are using blister packs of amodiaquine and artesunate, not the single dose Coartem.

2. Zimbabwe is treating malaria cases on a combination of chloroquine and Sulphadoxine-Pyramethamine (SP) as a first line and oral quinine as second line. Complicated malaria cases are treated on IV quinine. The Zimbabwean government reports that they plan to change over to Coartem in the long run and that the private sector has been given a green light to use Coartem.

3. Malawi is still using SP as first line, and quinine as second line treatment. No plans to change over to ACTs were announced.

4. All countries wish to improve diagnosis of malaria and improve their surveillance and reporting.

Other presentations

Presentations were also made by several other organsiations:

1. The WHO country representative to Zimbabwe made a presentation, followed by Khoti Gausi from WHO SAMC. I sat, pen in hand, ready to make notes but after both presentations had a blank sheet of paper in front of me … what did they say for 15 minutes each? … Not much.

2. UNICEF – which detailed their malaria control efforts. They have increased funding for malaria control from $17m in 2001 to $40m in 2004, but they still remain fairly minor when one compares them to the GFATM or USAID.

Most of their work seems to be in procuring and delivering ITNs for countries and in procuring ACTs. They try to deliver ITNs for free or at highly subsidized prices as they are not comfortable with the notion of selling the nets. UNICEF charges 4% for the procurement of ACTs – tomorrow we will hear a specific presentation from a UNICEF procurement officer – can’t wait!

One of UNICEF’s major challenges was the shortage of ACTs – particularly Coartem – however they report that they are now working with all partners to ensure better forecasting and timely procurement.

3. A presentation was expected from the Global Fund, however the GFATM representatives have not arrived, perhaps casualties of the SAA strike.

4. The Lubombo Spatial Development Initiative was reported on by Elizabeth Street – the LSDI continues to show remarkable successes with dramatic declines in malaria cases in all three countries – South Africa, Swaziland and Mozambique. The LSDI now protects 4.7million people in 1.8million houses over an area of 100,000 Km²

Parasite prevalence in children between the ages of 2 and 15 was between 60% and 70% when the program began in 2000 – it is now less than 5%.

In Swaziland and South Africa, malaria cases have fallen by more than 90%.

5. Ricky Orford from Population Services International made a presentation on that organization’s activities. He went to lengths to explain that they are not just a social marketing organization, that they are not just US based, that they are a genuine NGO and non-profit and that they were committed to working with in-country malaria control operations. It is safe to say that his presentation was received with extreme skepticism.

The WHO representative from Madagascar challenged PSI on their recent history of arrogantly forcing countries to change their programs to suit PSI, and not the country in question. PSI are going to have to do a lot of work to convince the malaria control community in Southern Africa that they are not just self-serving

USAID contractors.

6. A representative from the Southern Africa Development Community health desk reported on a new initiative at cross-border disease control funded by the African Development Bank. The ADB has pledged $30m to fund cross border activities in the region aimed at controlling HIV/AIDS, TB and malaria. If this money is used effectively, I think this could be a worthwhile project.

That is all that occurred of interest (or lack of interest) on Day 2. Day 3 begins with presentations on case management, drug policy and malaria in pregnancy, followed by IEC (information education and communication) and advocacy. Presentations on vector control and personal protection will end the day off.

Dispatches from the Southern Africa Malaria Control Conference – Maputo, Mozambique

Day 3 - 27 July 2023

Day 3 began with case management and diagnosis and progressed to advocacy and issues concerning vector control and personal protection. Discussions went on till after 7pm after some extensive debates..

The day began with the WHO’s Noel Chisaka who outlined the drug treatment guidelines and protocols.

1. In a nutshell, the WHO now recommends that countries with endemic malaria change treatment policy to Artemesinin-based combination therapies (ACT). However changing policy is a complex affair and there are a number of complications.

Combination therapy is considered to be the use of two or more blood schizontocidal drugs with independent modes of action and different biological targets. In deciding which combination therapy to use, countries should consider the following:

Whether or not the drug in question is safe and well tolerated and effective as well as whether it will be accepted by the consumer/patient and whether the regime will be complied with.

The stability and shelf life has to be considered when choosing a combination therapy as well as the duration of the therapy. Cost effectiveness is of course a critical element in any change of therapy and will affect the potential for wide spread use. Finally, countries need to consider the ability of the combination therapy to delay the development of drug resistance.

So far, 24 African countries have changed over to ACTs, while 5 have opted for non-artemesinin-based combinations (among them Malawi and Zimbabwe). 3 countries are still using Sulphadoxine-Pyramethamine (SP) and 13 are still using Chloroquine as first line treatments.

Dr Namoboze from WHO in the East African and Great Lakes region commented on the importance of improved procurement plans. Namboze urged countries to place orders for ACT quickly so that the orders can be factored into the manufacturing process – vital given the substantial lead time required by manufacturers.

Improving diagnosis is very important in improved malaria treatment. WHO recommends that for children over 5 years old, treatment should only be given after positive laboratory diagnosis. Children under the age of 5 however should be treated according to clinical diagnosis based on the Integrated Management of Childhood Illness (IMCI) guidelines because of the risk of developing severe malaria. Pregnant women should be treated after parasitological diagnosis using rapid diagnostic tests (RDTs). According to WHO there is insufficient evidence to suggest that children under the age of 5 should not be treated with anti-malarials in favor of awaiting a positive parasite test. The delay involved in obtaining a positive laboratory diagnosis can often mean the difference between life and death for those under 5 years of age.

Many questions were raised about the quality of diagnosis in many malarial countries. Many countries do not have enough microscopes or laboratory technicians and do not have the budgets to buy RDTs. Countries were urged to improve funding for this critical element in malaria treatment.

Compliance, home management of malaria (discussed below) distribution and storage, cost and sustainability are all important issues that countries must address before they consider changing

over to new combination therapies.

2. Both Zimbabwe and Malawi presented data on their monitoring of drug efficacy. The Zimbabwean government has made the policy decision to change over to ACTs, however to date has been unable to finance the change in policy (no doubt because Robert Mugabe prefers to spend taxpayer’s money to buy batons and bulldozers with which his police beat people and destroy their houses).

Zimbabwe reports that treatment failure rates to chloroquine (CQ) ranged between 0% and 41%. In 2005 a limited study showed that the combination of CQ and SP resulted in treatment failure in just 4% of cases, however the population size was too low for this to be statistically significant. Some of the problems that Zimbabwe is having in running drug efficacy studies include a lack of petrol to drive the sentinel sites and unreliable telephone systems which prevents effective communication (I mean really … it is the 21^st century … Zimbabwe really is the most unimaginable tragedy).

4. Malawi has been using SP since 1993, when it replaced CQ because of drug resistance, however now SP resistance is as high as 31%. The Department of Health is currently planning further studies which should inform the change over to new effective combination therapies.

5. Neither Botswana nor Swaziland have changed over to ACTs or any combination therapy. Malaria cases have been so low in both these countries that it is unlikely that the drug resistant gene has drive through the population. Conducting studies into drug efficacy has been impossible in both countries because of the low number of malaria cases. As Swaziland’s Simon Kunene noted on their failure to do drug efficacy studies “we failed because we achieved”.

In Swaziland for the first half of 2005, there were only 279 confirmed cases of malaria and there were only 362 in Botswana – hardly enough to do a drug efficacy study. Well done to these countries for ensuring that their malaria control is so successful – even if it results in problems associated with studying drug efficacy.

6. Angola has been doing some interesting studies into drug efficacy after it changed over to ACTs. So far Coartem has been 100% effective and AQ + AS and SP + AS are both more than 99% effective. Angola has also confirmed other studies that show that ACTs clear parasites and reduce fever far faster than mono-therapies. In the face of drug resistance to SP, Namibia has changed over to ACTs, but as yet no efficacy studies have been done.

7. Dr Namoboze – WHO East Africa and Great Lakes Region - presented a paper on home based management of malaria, which is being promoted by WHO. Given that more than half of all malaria cases are treated at home and not in public clinics, improving this home based management is important. Studies in Uganda have shown that improved home based management can significantly reduce morbidity and mortality. Any kind of home based management program will have to be tailored to the specific circumstances in each country as the size of private and public sectors vary widely in Africa. According to Namoboze, in order for a home based management to be successful, countries need to improve communication, develop skills within the community, ensure good access to effective treatment and improve monitoring.

As countries move over to ACTs, countries are going to have their work cut out for them if they want to ensure that ACTs are used well in homes. Storage of ACTs in climate controlled facilities so that they do not get too hot is but one consideration.

8. South Africa’s Tsakane Furumele shared her department’s experience with rapid diagnostic tests (RDTs). RDTs are being used increasingly in South Africa, especially s the country has moved over to new ACTs. Although the traditional microscopy tests are still considered the gold standard, RDTs are encouraged because they are not labour-intensive, they are quick and easy to use and they are relatively cheap. The cost of an RDT is less than US$1, while the cost of ACT treatment in South Africa is around US$ 6 – so using RDTs to ensure rational drug use can result in significant cost savings.

The high cost of ACTs in South Africa – compared to just $2.4 for an adult course of Coartem in other countries was put down to South Africa’s program of Black Economic Empowerment. BEE favours companies that are black owned or black managed which, according to Tsakane, has allowed companies to win tenders despite the fact that their drugs are almost three times more expensive than in other countries. If this is true, this is a pretty serious indictment of the BEE policies – we will seek clarification and confirmation of this – watch this space.

9. Malawi then discussed its program to provide intermittent presumptive treatment to pregnant women. According to the presenter, there is a need for good advocacy and improved communication to convince women that receiving the prophylaxis during pregnancy is important. Malawi reports that at ante natal clinics, (ANC), 93% of mothers receive their first treatment of IPT, but only 60% receive the second. One reason for this may be that mothers only present at ANCs in an advanced stage of pregnancy, so the 1^st treatment should actually be considered a 2^nd therapy and by the time a 2^nd therapy should be administered, the baby is already born.

Zambia followed on and reported that it is getting some good date on malaria in pregnancy from various clinics, but that improved operational research and better coordination between the National Malaria Control Centre and the Health Management Information Systems is needed.

10. Discussions then moved to pharmacovigilance with a comprehensive presentation by WHO’s Noel Chisaka. WHO, we are told, supports good pharmacovigilance to ensure safe and rational use of drugs. This is very important in malaria control where the prospect of drug resistance to the current stock of anti malarials is too ghastly to contemplate.

11. Noel Chisaka was followed by Dr Menendez who gave a fascinating presentation on HIV/AIDS and malaria. As we know, there is a great deal of overlap between HIV and malaria in Africa. The countries worst effected by high HIV rates and malaria are the Central African Republic, Malawi, Mozambique, Zambia and Zimbabwe. A study conducted in Uganda showed that HIV in non-pregnant women leads to increase parasitaemia, and HIV prevalence means that a patient is twice as likely to develop clinical malaria.

Importantly, the presence of malaria parasites can lead to increased HIV transmission and a higher viral load.

There is no evidence to suggest that HIV leads to sever malaria as not enough studies have been done. But, HIV may reduce the effectiveness of malaria drugs – as studies conducted in Ethiopia and Zambia suggest.

The evidence of the risks of malaria to HIV positive pregnant women is confusing and there is no that malaria increases the incidence of mother to child transmission of HIV – more studies are clearly needed on this.

Another area that requires more work is the on interaction of malaria treatments on antiretroviral treatments. Interactions between the co-trimoxizole prophylaxis used in HIV and SP prophylaxis in malaria could be potentially serious as both are sulphur based drugs, but again, more studies are needed.

12. A representative of the Global Fund for AIDS, TB and Malaria then made a presentation on the role of the Fund. The GFATM has signed malaria projects to the value of $140m and has disbursed $77m.. He made commitments to improved performance of the fund and was challenged by several countries for delays in signing agreements and disbursing funds as well as for continually changing the program managers.

So far for Round 5 proposals (for all 3 diseases) there is a shortfall of $600m, which the GFATM considers will be met, given the recent G8 commitments to the GFATM.

13 Towards the end o the day, a presentation was made by Malawi on their net -retreatment program, which apparently reached 61% of net owners last year. Ricky Orford from PSI congratulated Malawi on having achieved high distribution of ITNs. Apparently Malawi will soon reach its Abuja targets. Given that PSI is so heavily involved in Malawi, Orford was really congratulating himself. But that aside, during the past 4 SAMC meetings, Malawi has announced improvements in its ITN program, but they haven't been able to point to a change in morbidity or mortality due to the ITNs (or at least haven't reported on it if it is there). When Malawi can demonstrate that its ITN program is actually saving lives, then perhaps we should be singing their praises

The good news is however that Malawi is planning to start indoor residual spraying in 2 areas – if other countries are anything to go by, they should see a dramatic reduction in malaria cases – unlike their ITN program.

13. Martin Netsa from Zimbabwe presented a paper on the recent improvements in that country’s IRS program. Given the despotic government under which the malaria control teams work and the lack of decent or predictable funding, I have to take my hat off to the dedicated team that it trying against all odds to improve malaria control.

14. UNICEF then made a presentation on their procurement of long lasting insecticide nets (LLINs) and artemesinin-based combination therapies (ACTs) The key feature of his presentation was the importance of improved forecasting, placing firm orders and better coordination between the various procuring partners.

In 2004, UNICEF procured 11.4 million doses of ACT for Ethiopia, Burundi, Sudan and Somalia (made up of AS + AQ, AS + SP and Coartem).

UNICEF now stockpiles ACTs, except for Coartem (apparently they do not get the supplies from WHO)

WHO’s Noel Chisaka once again urged country programs once again to put in firm orders with the drug manufacturers.

According to the UNICEF representative, they will be reducing their charges for procuring medicines and will be better value for money. Perhaps responding to this, the indefatigable and most impressive Luciano Tuseo (WHO representative to Madagascar) reminded the conference that GFATM funds were meant to build capacity in departments of health and not enrich agencies and NGOs involved in distributing or procuring commodities. If there is a thorny issue to be tackled, Luciano is always ready, willing and able. Bravo Luciano.

The day ended eventually with a brief an uneventful side meeting on DDT. Mozambique requested the meeting so that its various malaria partners could raise any possible concerns as that country is soon to be using DDT. But when it came to the crunch, there were no concerns. I’m suspicious of this as there are plenty ‘agents of virtue’ floating around Mozambique that are anti-DDT and I have a nasty feeling that they may be waiting to stick their ‘do-gooder’ oars in at a later stage. In any event they would do any oar sticking behind the scenes and not in front of pro-DDT (for which read effective malaria control) advocates like Simon Kunene (Swaziland) John Govere (WHO AFRO), Tsakane Furmele (South Africa) and yours truly.

That is all.

Tomorrow we deal with epidemic preparedness in the morning and then monitoring and evaluation. The rest of the day will be taken up with ‘group work’ when the country programs break up to go over their plans in time for their presentations on Friday. I will be missing that and visiting some clinics in and around Maputo.

Dispatches for the Southern Africa Malaria Control Conference – Maputo, Mozambique

Day 4 - 28 July, 2005

Day 4 began with a prayer from Bishop Sengulane and then a presentation on the good work that he is doing through the Anglican Church in Mozambique to increase awareness of malaria and improve knowledge about the interventions that communities and individuals should seek. Amen to that.

And then something completely different – Joan Larosa, the USAID country representative for Mozambique made a presentation on the President’s Malaria Initiative. We have reported elsewhere on the AFM website on this initiative and our position is that more USAID money will only ever be useful if USAID changes the way that the money is used – specifically USAID should stop spending the vast majority of its money on consultants and workshops and airline tickets and fat salaries and start spending that money on commodities that actually save lives.

Ms Larosa did say that money would go towards commodities and that USAID was emphasizing monitoring and evaluation. This would be great as in the past US taxpayer’s money has gone into a malaria black hole and the USAID folks have no idea whether that money was put to good use or not. In fact it seems that it is in their direct interest to ensure that no monitoring and evaluation is done – that way they can continue to fund their friends in the DC beltway and, as with so many government programs, conceal their incompetence and failures.

So, curious about how they are going to spend their money, I asked Ms Larosa the following:

“What assurance can you give us that USAID will break from the past and spend most of this money on drugs, insecticides and ITNs.? In the past USAID has spent more than 70% of its budget in the US and not in malarial countries.” I went on to ask “Given that we are in southern Africa and most of the countries represented here use DDT in malaria control, will USAID use the new money to buy DDT?”

Here is what she said:

“The claim that USAID only funds technical assistance is not quite true – some of the spending on commodities and local cost supports has been lost in the contract of the technical assistance – so some of the claims made about USAID funding are not true”

Well forgive us Ms Larosa, but USAID is so cagey about its information that the US taxpayer is kept very much in the dark about how his or her money is spent. In fact, as Senators Brownback and Coburn recently found out, even the US Senate is kept in the dark. So, Ms Larosa, if you would care to give us more detailed information on exactly what USAID spends its money on, we would all be very grateful.

Ms Larosa continued:

“The percentage of money that will go to commodities is not defined yet and depends on the needs of each country and it also depends on what the Global Fund for AIDS, TB and Malaria is already funding. USAID will seek to fill in gaps and fund any other commodities. But there is no fixed percentage that has been legislated on what has to go on commodities, unlike PEPFAR (President Bush’s AIDS program) which were legislated.”

OK, so lets say we have a country like Angola which has signed a Round 3 Global Fund grant for more than $28million and is getting commodities via the Fund, then USAID could very well decide simply to put its money in more consultants and workshops and mental masturbation …hmmm.

Ms Larosa went on …

“USAID wants to fund operations research. We want to adapt malaria control programs to better meet the circumstances of countries – this is not getting much funding from the GFATM and we consider this to be complementary funding. If additional commodities are needed it will come out of that.”

Uh …What? Operations research is good and very necessary. We have to find out all the millions of dollars that have been pumped into distributing insecticide treated nets is actually working or not. But why should additional commodities come out of the budget for operations research? Unfortunately Ms Larosa disappeared after a short question time so there was no opportunity to press to explain this.

Concerning DDT, Ms Larosa kept up the standard USAID line.

“When it comes to IRS and DDT this is very interesting”

Well yes it is. It is particularly interesting if you happen to live in a house that has been sprayed with DDT. It is interesting because you are very unlikely to be suffering from malaria and more likely to be working, growing up, going to school and skipping about – yes, Ms Larosa, it is VERY interesting.

“The US is not precluded form supporting IRS and we are supporting it in certain countries.”

Yeah right … holding a workshop that on spraying isn’t really “supporting” as it costs a minute fraction of the malaria budget – buying insecticides and pumps … now THAT is supporting. … but back La Larosa

“The decision on which insecticide will be made by the host government in consultation with USAID and will be based on the best scientific evidence. There is no prohibition on DDT and the US is a signatory to the POPs Convention which includes an exemption to DDT”

Yes we know all this and USAID has been saying the same thing for years – but never actually buys DDT. As the evidence in favour of DDT gets stronger and stronger, USAID still plays with words and twiddles its thumbs.

Ms Larosa ended off with the old USAID standard:

“USAID requires an Environmental Impact Assessment before it can use DDT, or any other insecticide for that matter. There are the usual environmental concerns about the use and disposal of insecticides etc etc etc”

We have said it before and will say it again. How about a MALARIA IMPACT ASSESSMENT instead of an ENVIRONMENTAL IMPACT ASSESSMENT? When will the people funding malaria control start to put lives ahead of unsubstantiated concerns about the environment.

Am I the only one that thinks that USAID is like a stuck record? Its time to give that gramophone another good kick.

OK – back to the conference.

Nothing was quite as exciting as the USAID lady. There followed a session on epidemic preparedness and the very able Dr da Silva of WHO/AFRO drummed home the point that countries really need to improve their collection of data and submit weekly malaria reports. Once the ministries and WHO/AFRO can analyze weekly malaria data, they can respond far more effectively to epidemics – and much of southern Africa is epidemic prone. In epidemic prone areas, people do not have the partial immunity to malaria that people have in endemic areas and so case fatality is usually high.

Zimbabwe then made a presentation on its malaria epidemic preparedness. Mr Charimari gave a comprehensive presentation on the different ways of measuring thresholds which once breached, indicates an epidemic. According to da Silva, Zimbabwe is pretty good when it comes to epidemic preparedness, by Charimari noted that they have all manner of problems, such as unreliable telephone systems which makes reporting difficult. At the risk of sounding repetitive, so much is wrong with Zimbabwe, it is difficult to know where to begin.

After Zimbabwe, Khoti Gausi made a presentation on monitoring and evaluation, which basically gave an outline of what M&E is and why it is important. Without wanting to state the obvious – monitoring programs means that managers can fix problems and evaluations can determine whether the interventions are actually reducing malaria cases and deaths. Unfortunately there isn’t enough M&E out there.

The irrepressible Simon Kunene, manager of the Swazi malaria control program, gave an interesting presentation on the geographic information system (GIS) that Swaziland has instituted as part of the Lubombo Spatial Development initiative. GIS is used to pin point the types of houses (traditional or western), record whether or not they have ITNs, log the number of children and pregnant women, whether or not a house has decent sanitation and water and so on. Among other things, the GIS has been able to show that in many instances, health facilities are not located where there are most houses and the greatest population density, but where the Chief happens to live.

After Simon’s presentation, the conference broke up for group work to discuss the various issues raised over the past four days. This was followed by a speech given by the Mozambican Minister of Health. I missed this talk, but am told that it was pretty standard really. The fact that he turned up though is important and confirms that his department takes malaria seriously. But actually, the fact that they have decided to start spraying DDT in Zambezia Province is proof enough.

The rest of the day was taken up with the various country programs preparing their plans for the next year, which will be presented tomorrow, the final day.

That is all for today.

Dispatches from the Southern Africa Malaria Control Conference – Maputo, Mozambique

Day 5 – 29 July 2023

The final day of the conference was taken up with country presentation on their plans for malaria control for the upcoming year.  Most countries presented their strengths and weaknesses, followed by their plans.

On the whole, strengths included strong political will and commitment to fight malaria and improved funding.  Weaknesses almost consistently among all countries included a lack of personnel and high attrition of malaria control staff.  The programs are also compromised by poor laboratory skills (or a lack of laboratories) so that definitive diagnosis is often a problem.  Delayed access to diagnosis and treatment is also a problem, increasing case mortality. 

When it comes to the plans for the coming year, almost all countries pledged to improve diagnosis, access to treatment, the management of malaria in pregnancy and to improve vector control.  Increasing the distribution of insecticide treated nets and/or long lasting nets and scaling up indoor residual spraying.  Malawi is planning on starting IRS in two districts and Angola is looking forward to using funds from the new President’s Malaria Initiative to fund IRS. 

Several countries, such as Madagascar and Angola are planning on improving their monitoring and evaluation of their programs.  That countries are planning some structured operational research of their programs is welcome indeed.

So all in all, the plans sound promising – whether or not they will be turned into actions is another matter however.  One country to watch is Zimbabwe, for a number of reasons. Their plans include improving case management and vector control, but nowhere did they mention the potential problems that will inevitably arise from Operation “clear away the trash.”

Another thing to watch is whether or not countries will improve their planning and procurement.  Despite the fact that several WHO and UNICEF officials requested counties to put their firm orders for commodities in early if they want to get drugs, nets and insecticides, this did not feature among the strengths, weaknesses or overall plans.

Overall the conference was successful and many countries are making good progress with malaria control.  Increasing IRS, an increasing acceptance and use of DDT as well as wider use of effective artemesinin-based combination therapies all spell improvements.  The battle with donors to put their money behind effective interventions continues.

The conference ended with a few speeches from WHO officials and officials from the Mozambican Ministry of Health. 

All in all, the WHO/AFRO organized the conference well – many thanks to Dr John Govere and his team.