Abuja Declaration Research Articles

Review of "A realistic strategy for fighting malaria in Africa" by William Jobin

Review The latest World Malaria Report (2009) brought much good news in terms of the global progress in malaria control. So did recent reviews on the changing burden of malaria in Africa and the progress achieved since the signing of the Abuja declaration in 2000. Optimism reigns to such extent that the words ‘elimination’ and ‘eradication’ are now liberally used within the global malaria community. Jobin’s book, however, serves as a contrasting wake-up call, and tries to shed light on what he claims to be ‘the mess we are currently making in Africa’. With a wealth of experience, built up over 45 years of involvement in operational malaria control campaigns, Jobin provides a frank and thought-provoking opinion of the current attempts to control the disease, and is (negatively) outspoken about the roles therein of major players like the PMI, WHO, and USAID, all of whom Jobin worked for during some stage of his career. Accordingly, Jobin speaks of the need ‘to inject realism into current naive and ephemeral efforts to control malaria in Africa’. He argues strongly against the renewed eradication euphoria, calls vaccine developers ‘dreamers’, and tells us that malaria is here to stay. The best we can do is to be clever and reduce it to very low levels over prolonged periods of time. So what does his realistic strategy look like? First, Jobin urges us to learn from past experiences. That it took six decades to eliminate malaria from Italy, that malaria control sec is not sufficient to remove it permanently, and that historic attempts to eliminate malaria in Africa (notably the Garki project in Nigeria and the Gezira project in Sudan) ended in dismal failure. The maths clearly showed that, even with massive reductions in mosquito biting density, transmission cannot be permanently disrupted. For Sudan, it was cessation of funding that resulted in a massive epidemic after a decade in which malaria was virtually eliminated. The classic mistakes made by PMI before, during, and after the IRS programmes that were staged in Angola and subsequently Zanzibar are telling examples that, as recent as five years back, there was no learning from past mistakes. Malaria control can be summarised as: Aid money arrives, intense (spraying, nets) campaigns bring prevalence down to <1%, aid dries up, malaria comes back. Malaria control in Africa is like a trampoline. Secondly, Jobin uses example after example of badly designed malaria control programmes, with minimal baseline data, lack of evidence-driven action plans, and insufficient quality control. Here he lashes out at WHO, RBM and the GF. Only with a thorough and basic approach to impact evaluation, he argues, will control campaigns come to bear fruit over prolonged periods of time. Thirdly, there is a strong need to revive training centres for malaria personnel if endemic countries are to set their own tailor-made agenda to control malaria. Such capacity building should shield NMCPs from the agenda-driven influences by multiple small or large NGOs that flood endemic nations with their preferred mode of attack. Jobin argues that more permanent solutions are within reach but not on the radar of donor organisations. Simple improvements to houses (screens and improved air circulation) can make a house less prone to mosquito attack whilst at the same time increasing comfort for its occupants. Larval source management, although gaining more interest, is still only used on a marginal scale but should complement adulticidal methods. Integration of tools, or the ‘Goat cheese strategy’ as Jobin names it, is likely to yield much more benefit than single interventions. Correspondence: bart@malariaworld.org Division of Infectious Diseases, Tropical Medicine & AIDS, Academic Medical Center, F4-217, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands Full list of author information is available at the end of the article Knols Parasites & Vectors 2010, 3:68 http://www.parasitesandvectors.com/content/3/1/68

Bob Snow: championing malaria in Africa

Bob Snow: championing malaria in Africa

Economic Effects of Childhood Exposure To Tropical Disease.

To what extent do tropical diseases contribute to the poverty characteristic of tropical countries? Estimates of the impact of health on income are difficult to obtain because health is a normal good-countries with higher income will buy more of it-and third factors such as remoteness and bad government might impede both productivity and public health. In the Abuja Declaration of 2005, African heads of states claim that malaria has depressed income growth in Subsaharan Africa since the 1960s, so much so that GDP in the region today is 40% lower because of malaria. Estimates of this magnitude have been mocked at cocktail parties and clambakes. But how ridiculous is this number?

Malaria eradication back on the table

After a lapse of almost 40 years, malaria eradication is back on the global health agenda. Inspired by the Gates Malaria Forum in October 2007,1,2 key organizations are starting to debate the pros and cons of redefining eradication as an explicit goal of malaria control efforts. Attempts to eliminate malaria in southern Africa3 and Pacific Island states,4 and WHO’s Global Malaria Programme agenda and field manual for malaria elimination,5,6 foreshadow this movement towards another global attempt at eradication. When marking 60 years of WHO’s commitment to fighting malaria, we must ask what has been achieved, but also what can we learn from the past. We now know so much more about the biology of parasite-host responses, the determinants of endemicity and transmission dynamics, the social, economic and cultural implications of malaria at household, community and national levels, and the demands made upon health systems in endemic countries. We do not yet know how to synthesize and integrate this knowledge to achieve elimination in different settings. Regional malaria elimination campaigns were first conducted in the late 1940s, preparing the ground for the Global Malaria Eradication Program in 1955. This campaign succeeded in eliminating malaria from Europe, North America, the Caribbean and parts of Asia and South-Central America.7 But no major success occurred in sub-Saharan Africa, which accounts for 80% of today’s burden of malaria.8 When the aspiration of global eradication was abandoned in 1969, the main reasons for failure were technical challenges of executing the strategy especially in Africa. The post-eradication era from 1969 to 1991 focused on technical issues, and research and development for new tools, leading to advances in drug and vaccine development, vector control and insecticide-treated nets. These decades also brought a better understanding of the social, economic and cultural dimensions of malaria. There was little global support provided specifically for malaria control in the newly independent states of Africa that were struggling to establish broad-based health systems and primary health care. By 1992, the combination of a worsening malaria situation and promising technical developments led to renewed global focus on malaria control. The Roll Back Malaria initiative, launched by WHO in 1998, led to the Abuja Declaration in 2000, which defined progressive intervention coverage targets for control designed to eliminate malaria as a public health problem, while emphasizing that this could only be achieved through vastly strengthened local health systems.9 Increased resources through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank’s Booster Program, the US President’s Malaria Initiative and many others has meant that this page is finally beginning to turn as intervention coverage is rising.10 It is against this background that we hear this call for elimination/eradication. The challenges remain formidable. We all know that elimination in Africa is not possible with current tools. But efforts must focus beyond simply developing better tools, to include how existing and future tools can be strategically combined for maximum synergistic effectiveness when integrated into different health and social systems prevailing in endemic areas. Aiming at elimination and eradication further implies the need for effective surveillance strategies to monitor progress (again a challenge for health systems). This in turn requires a better understanding of malaria transmission heterogeneity in a globalized world with rapidly changing dynamics in environment, climate, migration and transnational cooperation. Maintaining long-term momentum in the face of success in regional elimination while waiting to achieve final eradication will be a major challenge. Shrinking the map by starting on the malaria margins with the “easy-to-eliminate” settings will boost morale initially but may bring marginal benefits to such areas at the expense of those where the burden of malaria is highest. Any strategic plan – and here we learn again from the past – needs to be a synchronous global effort, locally adapted in all endemic areas. Although we lack sufficient knowledge, systems and tools to eradicate malaria today, we do have a window of political will and financial resources to refocus on the goal of effective control through universal coverage of appropriate interventions. The prerequisites for a successful start are: (i) a process of inclusive discourse to agree on global vision, goals and strategy; and (ii) a global plan for all endemic areas describing how, where and when we move from control towards elimination. What must distinguish the new era, especially in Africa, is a real rather than rhetorical emphasis on health systems. ■

Health research agenda for East AFrica in the new millennium: Looking ahead

The Regional East African Health Research agenda was presented as a keynote speech during the first East African Health and Scientific Conference, held in Kampala, Uganda from 28th to 30th March 2007. The agenda was developed through a critical analysis of the global, African and Regional East African health challenges and mitigating strategies, taking into account the Millennium Development Goals (MDG), the Abuja declaration and the New Partnership for African Development as background environment, within which the agenda will operate. It is proposed to establish a joint mechanism for research coordination, promotion and regulation; establish stronger collaborative mechanisms for research and training; create a joint Regional East African Community health research and development fund; create joint intellectual property rights protection mechanism; enhance patenting and link research to industry; create a mechanism to enhance translation of research to policy and practice; strengthen clinical research capacities; and strengthen innovation and discovery research capacities. Effective implementation of this agenda will greatly raise the profile and quality of research in the region and improve the health status of the East African populations.

Uncertainty in Malaria Control in Tanzania: Crossroads and Challenges for Future Interventions

In Tanzania malaria is the leading cause of morbidity and mortality, especially in children under 5 years. The disease ranks number one in both outpatient and inpatient statistics. The socio-economic impact of malaria is so high that it contributes highly to poverty and underdevelopment. Efforts made during the past century to combat and control malaria have not been successful. The prospects of achieving the Abuja declaration targets are uncertain within the remaining period of time. Currently, the Ministry of Health through a 5-year strategic plan advocates four main approaches in the fight against the disease. These include improved case management, vector control using insecticide treated mosquito nets, prevention and control of malaria in pregnancy and epidemic preparedness, prevention and control. However, these strategies face various challenges including inadequate human, financial, and material resources; inefficiency in the healthcare system that is incapable of providing quality health services and access to prompt diagnosis and treatment; lack of an effective disease surveillance system; and an inefficient health education communication mechanism. Tanzania is at the crossroads and is challenged with the need to introduce a new antimalarial treatment regimen and the reintroduction of DDT for indoor residual spray. Unless malaria control strategy adopts an integrated approach its success is far from being realized. This article reviews the current malaria control strategies and its challenges in Tanzania and proposes new strategies.

Sixth Africa Malaria Day in 2006: how far have we come after the Abuja Declaration?

Each year on the 25th April Africa and the rest of the world commemorate Africa Malaria Day as was agreed upon at the African Summit on Roll Back Malaria held in Abuja, Nigeria on 25th April 2000. The summit also called upon the United Nations to declare the period 2001–2010 a decade for malaria. The 1st Africa Malaria Day was commemorated with the theme "Communities Play a Central Role in Tackling Malaria". The 6th Africa Malaria Day was observed in 2006 with the theme "Get Your ACT Together" and the slogan "Universal Access to Effective Malaria Treatment is a Human Right". This article by the Secretariat of the Multilateral Initiative on Malaria (MIM) was also part of the commemorations for the day. MIM was founded in 1997 as an alliance of institutions and individuals concerned with the malaria problem, and aiming at maximizing the impact of scientific research on malaria through strengthening African research capacity and coordinated global collaboration. The MIM Secretariat has been hosted in rotation by the founding institutions, and is being hosted for the first time in Africa by the African Malaria Network Trust (AMANET) in Dar es Salaam, Tanzania. This article reviews the malaria situation in Africa six years after the Abuja Declaration, highlighting the disease burden trends, failures, achievements, challenges, and the way forward.

A steep decline of malaria morbidity and mortality trends in Eritrea between 2000 and 2004: the effect of combination of control methods.

BackgroundMalaria is a huge public health problem in Africa that is responsible for more than one million deaths annually. In line with the Roll Back Malaria initiative and the Abuja Declaration, Eritrea and other African countries have intensified their fight against malaria. This study examines the impact of Eritrea's Roll Back Malaria Programme: 2000–2004 and the effects and possible interactions between the public health interventions in use.MethodsThis study employed cross-sectional survey to collect data from households, community and health facilities on coverage and usage of Insecticide-Treated Nets (ITNs), Indoor Residual Spraying (IRS), larvicidal activities and malaria case management. Comparative data was obtained from a similar survey carried out in 2001. Data from the Health Management Information System (HMIS) and reports of the annual assessments by the National Malaria Control Programme was used to assess impact. Time series model (ARIMA) was used to assess association.ResultsIn the period 2000–2004, approximately 874,000 ITNs were distributed and 13,109 health workers and community health agents were trained on malaria case management. In 2004, approximately 81% households owned at least one net, of which 73% were ITNs and 58.6% of children 0–5 years slept under a net. The proportion of malaria cases managed by community health agents rose from 50% in 1999 to 78% in 2004. IRS coverage increased with the combined amount of DDT and Malathion used rising from 6,444 kg, in 2000 to 43,491 kg, in 2004, increasing the population protected from 117,017 to 259,420. Drug resistance necessitated regimen change to chloroquine plus sulfadoxine-pyrimethamine. During the period, there was a steep decline in malaria morbidity and case fatality by 84% and 40% respectively. Malaria morbidity was strongly correlated to the numbers of ITNs distributed (β = -0.125, p < 0.005) and the amount (kg) of DDT and Malathion used for IRS (β = -2.352, p < 0.05). The correlation between malaria case fatality and ITNs, IRS, population protected and annual rainfall was not statistically significant.ConclusionEritrea has within 5 years attained key Roll Back Malaria targets. ITNs and IRS contributed most to reducing malaria morbidity.

The Abuja Ministerial Declaration on Water

Africa faces major problems in its water resources sector, manifested in the periodic droughts and floods and compounded by population growth, urbanization, and environmental degradation. Africa has a large number of shared rivers, lakes, and aquifers, and the uses and protection of most are not regulated by any agreements between the riparian states. Where such agreements exist, they do not encompass all the riparians. A number of instruments were concluded by the African leaders with the view of addressing these problems. The most recent of those instruments is “the Abuja Ministerial Declaration on Water: A Key to Sustainable Development,” which was adopted in April 2002 and which establishes the African Ministerial Conference on Water. This article reviews the water resources problems in Africa and analyzes the various attempts to address them, including the Abuja Declaration.