DISTRICT LEVEL
MALARIA
ADVOCACY
Scaling up & Sustaining
Malaria Control through
Partnerships
Emmanuel Fiagbey
Country Director
JHU/CCP
Voices for a Malaria-free Future
Global Health Conf. 14 June 2010
Outline of Presentation
• Brief update- Current malaria situation and the
African scene
• Need for new partnerships and district level
advocacy
• The DMAT Model- Rationale and the Process
• Status of DMAT Implementation and benefits so far
• Challenges in implementing the district model
• Key Lessons Learned.
Malaria – Brief Update
Malaria still the most effective and persevering killer in
many developing countries, particularly Sub Saharan
Africa.
A significant contributor to;
– anaemia in pregnant women and children
– adverse birth outcomes such as spontaneous abortion,
stillbirths, preterm labour and maternal mortality from
severe malaria.
– disastrous effects on the foetus such as Intra Uterine
Growth Retardation, Intra Uterine Foetal Death and high
pre natal mortality.
In fact every one of the estimated 30.3 million pregnancies that take
place in Africa annually stands the risk of malaria.
Malaria - Brief Update
• In some countries, malaria consumes about 40% of
total government spending on public health and
accounts for up to half of all hospital admissions
and outpatient visits.
• Malaria is a major source of school absenteeism
reaching up to 28% in some countries. (4 learning
days per episode in Ghana)
• It is a major source of workdays lost to ill health (9
workdays per episode) and a loss of about 40% of
farmers’ harvests in Ghana.
Current Progress
World Malaria Day 2010 RBM partnership key message:
“Investment in malaria control is saving
lives and has far reaching benefits.”
This message is based on the fact that through
international partnership and support and the efforts of
various endemic countries, an appreciable level of
progress is being achieved in controlling the disease.
The statistics is interesting to note.
Current Progress
• Malaria deaths in all endemic countries throughout
the world have reduced from the estimated 1 million
to approximately 850,000 per year.
• Overall malaria cases have dropped from at least
350 million cases per year to 250 million a year.
• Among African children under 5 years, malaria
associated deaths have dropped from an estimated
3000 per day to 2000 per day.
Current Progress
• In Africa, approximately one child died every 30 seconds
from malaria at the beginning of the decade. Countries
saving an estimated one life every three minutes today
with current control scale up efforts. (RBM 2010)
– Ghana, moved from 8 million reported cases in 2006 to 3.2
million in 2008 and in the case of under five deaths from
almost 9000 deaths in 2000 to about 4000 in 2008.
– Tanzania 11.5 million in 2005 to 8.5 million in 2007.
(WMR 2009)
These significant results achieved through partnership and
support - African countries and institutions such as the Global
Fund, the PMI/USAID, CDC, the World Bank, DFID, WHO and
others.
Malaria in Africa
Improving Control Measures
Malaria as a development Issue
The advent of dedicated advocacy to Malaria by the
RBM partnership (from health to development). Calls
for harmonization of activities, mobilization of
resources and implementation of partners coordinated
actions to achieve joint malaria control targets.
Strengthening the Health System
Building capacity in critical components of the system
to achieve more equitable and sustained improvements
across all intervention areas and the support structures
required to achieve the desired outcomes and targets.
The New Partnership
An important component of a strengthened health
system is an active partnership between nonhealth public, private and civil society and the
health sector,
supporting health provision and not simply
receiving health services
Mobilization and organisation of the non health
sector to support the health sector in implementing
the approved interventions.
The heart of district level
advocacy for malaria control
Voices Goal & Objectives
Goal: To sustain resources and expand political commitment for
malaria control, contributing to a decrease in malaria
mortality.
1.
Mobilizing Leadership in Government and Civil Society.
(equipping national leaders with credible information to speak out on malaria, mobilize funds,
coordinate activities and address bottlenecks.)
2.
Increasing District Level Advocacy.
3.
Policy dissemination & reducing barriers to policy
implementation
Advocating for increased funding in Public & Private
Sectors
4.
(engage local leaders as malaria
champions to increase visibility and awareness, prioritize and facilitate the flow of malaria
information to the national level NGOs and the NMCP and maintain district and national level
funding.)
Why Foster District Level Partnership
Most NMCPs operate in a centralised national health
structure.
Linked to
• District Health Management Teams
• Expected to interact with district political and civil society
leadership.
For example, in Ghana, the NMCP under the Ghana Health Service
of the MOH has a structure that sets it up as a central point
coordinating three broad zonal levels of managing the malaria
control program. Each zone covers multiples of regions comprising
many districts and led by a Program Team/Officer based at the
NMCP in Accra with monitoring and other activity visits to the
regions and districts when necessary.
Why District Level Partnership ctd.
This structure provides no framework or prescribed
ways in which the over 166 DHMTs could each on its
own actively interact with the NMCP and the non health
sector to generate resources for malaria control and
ensure effective implementation of programs.
In recognition of this weakness an RBM Country Assessment carried
out in 2008 recommended,
“A more formal role for regional and district health
teams needs to be worked out so that the NMCP can
expect with confidence, that interventions will be
carried out down to the local level in a competent and
thorough manner.” (RBM Ghana Country Needs Survey, 2008)
District level Partnership for Focused
Malaria Advocacy
District level advocacy provides the
opportunity for the achievement of a focused,
thorough and competent malaria programs
delivery;
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It ensures that government and
nongovernment leadership, district political
and financial support becomes available.
Provides grounds for acceptance and
sustainability of community structures
required to facilitate service delivery.
Rationale for District Advocacy
The basis for recognition of the district as an
important unit for promoting increased
advocacy for malaria control lies in;
•
•
Decentralized system of local government
enshrined in the constitutions; and
Local Government Laws of the various African
countries including Ghana, Tanzania and
Uganda.
The Decentralized Local Government System
Article 240. 1992 Constitution of Ghana
• Parliament shall enact appropriate laws to ensure
that functions, powers, responsibilities and
resources are at all times transferred from the
central govt. to local units…
• That local government authorities plan, initiate,
coordinate, manage and execute policies in respect
of all matters affecting people in their areas…
– ACT 445 (1993) District Assemblies Common Fund
Law. 1% to Malaria Control Initiatives.
The Decentralized Local Government
System
Article 146; Constitution of the United Republic
Tanzania
Local Govt. Laws ACT 1999
Two of the three basic functions of the local
government system prescribe:
1. Promotion of economic and social welfare of the
people within their areas of jurisdiction
2. Ensuring effective and equitable delivery of qualitative
and quantitative services to the people within their
areas of jurisdiction
The District Malaria Advocacy Process
Involves constructively engaging district
leaders from all sectors of the district’s
development in planning, delivering and
monitoring of advocacy activities directed at
improving malaria control interventions.
Leaders – From politicians, government
officials and heads of Decentralized
Departments, private sector business leaders,
NGOs, to traditional chiefs and religious
leaders etc.
Objectives of the District Malaria
Advocacy Process
1. Increased involvement of all stakeholders in
mobilizing support for malaria control programs.
2. Increased community participation in malaria
prevention and treatment decisions.
3. Increased mobilization of resources including funds to
ensure constant supply of commodities and training
and motivation of health workers including volunteers.
4. Judicious and transparent distribution and use of
resources and commodities.
5. Increased participatory monitoring of activities to
ensure timely resolution of bottlenecks and improved
programming.
The Nine Steps Process
Step 3: Formation and Orientation
of DMAT
Central to the operation of the District Malaria Advocacy 9 Steps Model.
It is a team of interested advocates from recognized
institutions and organizations- public and private,
committed to influencing decisions affecting malaria
programming.
Membership:
Selected/elected members of District
Assembly/Council, DHMT, reps of relevant
decentralized departments, Councils of Chiefs &
religious bodies, reps of Private Sector, NGOs etc.
Objectives of DMAT
•
Promote sharing of information on current
developments in malaria control among
leaders and community members.
•
Promote involvement of policy makers and
decision makers in improving resource
generation and allocation for malaria
programming,
•
Motivate all stakeholders in the district to
be actively involved in malaria control
activities.
Objectives of DMAT
• Support the DHMT and the District Assembly
to strengthen existing systems and structures
and or create new ones when necessary for
sustaining malaria control programs and
activities.
• Promote effective implementation of national
malaria control policies in the district.
District Malaria Advocacy Team
Soroti District
Malaria Advocacy
Team - Uganda
Savelugu Nantom
District Malaria
Advocacy Team Ghana
Step 5 & 6: Advocacy Needs Survey and
Action Plan
• Gather evidence and promote fact-based
advocacy in the key intervention areas.
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Background of health provision
Status of malaria programs and activities
Partners and their roles
Key Issues, Challenges and Successes
• Develop Action Plan detailing activities,
responsible persons and groups with required
budgets.
Issues: IPT and ITN Uptake
Activities
Responsible Partners
Training of SHEP
District Education
Coordinators & formation of Directorate
Malaria-free Clubs in schools DHMT
Orientation of CHOs and
formation of Mothers and
Fathers Support Groups to
support IPT promotion
Community Leaders/Chiefs &
Queen/Women leaders
DHMT, NGOs
Harmonization of ITN
distribution systems –
Meetings with stakeholders
DHMT, NGOs, Donor
Institutions and Projects
DMAT Actions
Members of a School Malariafree Club demonstrate ITN Use
and its importance: Keta
Municipality
Chairman of the DMAT , a
traditional ruler (Chief)
addresses a Mothers’ Support
Group: Asuogyaman District.
Step 7: Special Session of District
Assembly/Council on Malaria
• Needs survey report and Action Plan presented to
District Assembly/Council
– Participation: All members of assembly or council, MPs
from district, heads of decentralized depts. Private
sector, Chiefs & religious leaders, NGOs in malaria.
Milestones:
• District Assembly and other sectors motivated to
provide greater support to malaria programming.
• Agreement reached on allocation of government
designated funds for malaria programs.
• Other sources of support for malaria control eg.
individual and organizational donations identified.
Special Session of District Assembly on
Malaria
MP & Minister of
Youth and Sports
presents funds to
DMAT Chairman at
Special Session of
the Kpandu District
Step 8: Implementation of Action
Plan
• All responsible institutions and individuals – the District
Assembly/Council and its relevant committees, the
DMAT, the DHMT, heads of the decentralized
departments, private sector leadership, chiefs, religious
leaders and NGOs and community members
• The Executive Committee of the DMAT and the DHMT
Supervises & Monitors.
Milestones:
• Increased collaboration between the DHMT and the District
Assembly/Council in the implementation of malaria control
programs.
• Increased commitment of resources to malaria control programs by
the District Assembly and other sectors.
Step 9: Monitoring & Evaluation
• Identification, affirmation and celebration of successes,
identification of challenges and failures, reviewing
strategies and programs and planning for improvement.
• The DMAT develops a plan for monitoring all malaria
control programs and activities in the district.
Milestones:
• Monthly /quarterly monitoring plan for malaria control
programs developed and implemented by all stakeholders &
partners.
• Quarterly malaria program review meetings instituted.
• Annual evaluation of malaria control programs carried out and
results disseminated to the district assembly/council and
other stakeholders.
DMAT Quarterly Monitoring Form
Region……………………
District…………………..
No.
Activity Description
Year…………….
Period: From …………to …………
No. of
Comms.
Target
Group
Participation
M
F
Outcomes
Total
1.
2.
3.
4.
Supporting
Organizations:……………………………………………………………………..
Key Challenges:
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
Name/Signature of DMAT Chairman:……………………………………
…………………………………………………..
Monitoring ITN Use
DMAT Members discus ITN
use with Community
leaders after Peer Monitors
had presented reports
Mother demonstrates how
she uses her net to DMAT
Members during a
Monitoring Visit. Yilo Krobo
District.
District Malaria Advocacy
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The DMAT
Advocate for resources and effective programming
Raise malaria as priority within District Assembly/Council
Influence allocations of government designated funds and other resources
Monitor use of funds/resources & distribution of commodities- ITNs, ACTs etc.
Promote fundraising with local & other partners
Monitor NGO programs in malaria
Request M&E info from DHMT on key malaria indicators - ITN distribution, Access
to ACTs & IPT, Diagnostics
Support community events - Durbars etc.
Partnership
DHMT
Implement DMAT nonadvocacy activities:
- Training health workers, SHEP
Officers, CBAs, etc.
- Providing appropriate malaria
prevention and treatment
information & services
NGOs
Implementation and
support for DMAT
activities:
- Mobilization of communities
- Formation and supervision of
community groups
- Promoting acceptance of
ACTs & ITN distribution, retreatment and promoting use
Other Partners
Private sector – Transport Unions,
Community groups, Schools,
Community Radio stations etc.
implement DMAT activities.
- Disseminating malaria
information/ IEC materials
- Supporting commodities
distribution ie. ITNs
Improving Malaria Prevention and Treatment in the Communities
Status of DMAT Implementation
• 8 Districts in Ghana and One in Tanzania on
the 9th Step - actively implementing advocacy
action plans & monitoring activities.
• 4 Districts in Ghana at the 7th Step – just
initiated implementation of advocacy action
plans
• Three Districts in Ghana & 1 each in Tanzania
and Uganda at the 6th Step – completed
advocacy needs survey and developing action
plans.
Benefits of the District Malaria Advocacy
Process
Transparency:
• District Malaria Advocacy program formally
brings on board other stakeholders who under
normal circumstances would have been left out.
• Strengthens partnership between District
Assembly (Political authorities) and DHMT–
reduced suspicion between the two institutions.
Benefits of the District Malaria Advocacy
Process
Transparency:
• Monitoring of application of donor, govt. and locally
generated resources being applied by all
stakeholders including NGOs is enhanced leading
to increased confidence in partners in resource
provision. (Eg. GCNM to receive $350,000 5 year
grant from NMCP)
• DHMT and District Assembly assume greater
transparency in the application of resources meant
for malaria control activities.
Benefits of the District Malaria Advocacy
Process
System Strengthening:
• Enhanced knowledge level of leaders on the actual
causes of malaria and its burden on the family and
the district/country as well as its prevention &
correct treatment through the advocacy training and
information sharing sessions.
• Improved capacity of health workers as DMAT
supports DHMT in reorienting staff and volunteers
in developments in - ITN use, acceptance & use of
new anti-malarials etc.
Benefits of the District Malaria Advocacy
Process
System
Strengthening
Enhanced image
& improved
performance of
CBAs.
• Eg. 105 trained
in Keta,
• 44 in Suhum
Kraboa Coalta,
• Peer monitoring
in several
communities
inYilo Krobo
Benefits of the District Malaria Advocacy
Process
System Strengthening
1. GCNM: Over 100 NGOs from the 10 regions form a
coalition to support programs delivery
2. GMAAN: a network of media practitioners trained in
malaria reporting to keep malaria in the news.
3. Ghana Malaria Action Alert: Periodic bulletin providing
information to DMAT members and other advocates on
prevailing malaria control issues.
The Ghana Malaria Action Alert
Benefits of the District Malaria Advocacy
Process
Supply Chain Management:
Effective management of the supply chain is
facilitated
– DMAT prevents diversion of supplies eg. ITNs
– DMAT monitors stock out of drugs and other
commodities and alerts DHMT
– Strengthening logistics for improved services;
eg DMATs include supply of microscopes,
weighing scales etc. in action plans – Keta DA
provided 1 more microscope to the DHMT in
2008
Benefits of the District Malaria Advocacy
Process
Resource Generation:
•
Opening of specific accounts for malaria by the DMATs
creates opportunities to halt misapplication of DA funds
meant for malaria eg. the 1% District Assemblies
Common Fund, thus increasing funds for malaria
programs in the district.
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Keta: had almost $2,550 this year for ITNs
Asuogyaman: Training of SHEP Cords; ITNS for all hospital
beds Akosombo hospital
Suhum Kraboa Coalta: 1200 ITNS
Yilo Krobo: Set up Lab services through Korean support
Savelugu Nantom: Almost $9,000 for net use promotion,
and RDTs
Benefits of the District Malaria Advocacy
Process
Summary
Summary
The District Malaria Advocacy program provides common
grounds on which the health sector, local government,
public and the private sector speak with one
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voice in;
Reviewing the district malaria situation
Identifying critical issues
Developing appropriate response programs
Coordinating stakeholders activities
Generating local resources and facilitating proper
use of all resources
• Ensuring equitable distribution and proper use of
commodities.
• Fast and effective response to emmergencies; eg
the Kilosa Floods in Tanzania
The Challenges
Ownership and sustainability
Who owns the DMAT?
• The DHMT and therefore the Ghana Health
Service, Ministry of Health
• The District Assembly and therefore Ministry
of Local Government
• Civil Society eg. an NGO
The Challenges
DMAT Stability & Sustainability
• Political activism of members of the District
Assembly/Council- National and Local
elections and campaigns disrupting
activities.
• Change in leadership at national and
district levels – govt. officials, District
Assembly members/ Councilors
The Challenges
Fear of loss of power
• Fear of loss of political and administrative
authority over govt. funds which holders of
such authority sometimes misapply for
personal gains.
Motivation for Voluntarism
• Volunteerism versus paid service –
Where are the funds to pay local leaders for
enabling them to do what they are expected to
do more effectively for their people?
Five Key Lessons Learned
1. Lack of knowledge & inactivity
Inadequate knowledge among leaders of the causes of
malaria and its socio-economic burden on society have
been responsible for failure of many leaders to get
actively involved in supporting malaria control activities.
“I know malaria can kill but not
sure to what extent. Participating
in DMAT activities has widened my
understanding of the problems
malaria brings to us and the safety
of the new drug. I will ensure the
1% DACF is provided to help fight
the disease.”
(Presiding Member, Yilo Krobo District
Assembly , Eastern Region )
Lessons Learned ctd.
2. Malaria as a development issue
District level social, economic and political institutions
would consider malaria control as equally important as
their core business if they recognize the fight against
the disease as an important development activity.
3. Local government responsibility
Local governments will not relegate malaria control to
the background when faced with competing priorities
regarding allocation of resources for developmental
issues if they understand health provision is part of
their core mandate.
Lessons Learned ctd.
4. Guidance for all sectors engagement
When clear directions are provided to local
government leadership on how to engage other
sectors apart from health in malaria control,
ownership of programs and the roots for sustainability
of activities are firmed up.
5. Effective use of commodities such as ITNs
When local leadership is involved, monitoring of
actual use of ITNS is strongly facilitated.
We
Thank
you!!!