THE MULTILATERAL INITIATIVE ON MALARIA
(MIM)

after the meeting in The Hague , 8-9 July 1997

Thomas Nchinda and Barend Mons

The meeting in The Hague was meant to discuss the practical consequences of the recommendations made in Dakar and what was needed to realise co-ordinated investment into broad malaria research activities, such as proposed in the Letters of Interest. To that end the meeting brought together 60 participants from 17 countries (mostly donor countries) and international bodies, such as WHO, the EC, The World Bank and UNESCO .Most participants were senior administrators in their respective agencies.

Overall scope of the MIM

It became clear that the MIM has a double role to play in the international efforts to understand and control malaria:

1. An immediate role :To facilitate Collaborative Efforts between scientists and control workers and therefore also between supporting agencies and thereby providing a context and a suitable environment for training and capacity building of young scientists from developing countries.
2. A potential long-term goal: To serve as a Global Forum for malaria-related discussions and political awareness and a political context for co-ordinated action of traditionally separated bodies, such as research and development agencies.

The long-term goal is of much wider implication, involving all possible players as much as possible. This aspect was discussed mainly at day two of the meeting. Day 1 concentrated on the practical possibilities of national and international research agencies to work more closely together (related to a).

It was decided to attempt to achieve the MIM objectives initially within existing research funding mechanisms and to achieve the desired added value mainly through co-ordination and synergistic action. Especially in the field of Research Capacity Strengthening (RCS), immediate and common actions could be envisaged.

I. Collaboration between the research agencies (day 1)

1. Focus

• The short term aim of MIM is to foster international and mutually beneficial scientific partnership between (more) African Scientists and their colleagues in the North working on malaria-related aspects.
• The focus of the actual collaborative efforts of the agencies will be those types of studies that can not be efficiently handled by one agency.
• As recommended in Dakar, especially multicentre approaches will fall in this category.
• The agencies will use the consensus principles as laid out in the Dakar recommendations as criteria for developing the MIM further.
• A clear distinction should be made between funding of the major body of research in- and with Africa and underpinning activities like networking of existing research, mobility and training of researchers, communication and repositories

(here captured under Research Capacity Strengthening -RCS- in the broadest sense)

2. Co-ordination.

• Co-ordination is needed. In turn, co-ordination needs optimal information and effective communication (see 4.)
• The agencies commit themselves to take specific measures to improve communication and co-ordination amongst them in a structural manner by:

a. Preparing a Compendium which succinctly describes mandates and procedures of each of the participating agencies and provide this to the scientific community at large. All agencies will contribute and WHO/TDR will collate this compendium and make it widely available through all appropriate mechanisms.

b. Designating a Focal Person for each agency to participate in the perceived Clearing House function of the MIM.

c. Continually and structurally plan activities of common interest and exchange transparent information via these focal points about recent new initiatives and funding decisions as soon as procedures allow wider communication.

1. In case the operational phase reveals the need for additional mechanisms, specific working groups may develop proposals for adapted procedures acceptable for all participating agencies in close consultation.

 

3. Response to the Letters of Interest.

A positive feed back will be given to the scientific community at large regarding the inventory exercise of the call for letters of interest containing at least the following elements:

• The exercise was very useful to focus thoughts and develop a reasonable strategy in The Hague.
• The agencies, in most but not all cases by co-funding multi-centre studies, will jointly contribute to selected research efforts proposed by the scientific community.
• Selection of these efforts can not be based on the letters of interest alone, as they were not designed as proposals.
• The agencies will (in addition to 2a.) provide to the focal group their areas of specific interest based on the call for letters or additional if appropriate (non exclusive mechanism)
• Where needed, the agencies will jointly take responsibility for providing necessary funds for proposal-development workshops. This could be of specific interest for those areas where the letters revealed an obvious need for synthesising different proposed activities and weeding out of unnecessary overlap.
• The compendium and the information on specific areas of interest will assist the scientific community to define the most appropriate agencies to engage in further development of their approach.
• The focal group can advise scientists on procedures and limitations not fully explained in the compendium (which has to be concise).
• The signatories of the Letters of Interest will receive the matrix analysis of the Letters and the full list of addresses of signatories. This will allow them to efficiently get together a group of interested scientists working on related topics. Proposals can be developed in workshops for which funding can be provided on a competitive basis by one or more of the participating agencies.

 

4. Communication and access issues.

• The Dakar conference put such a clear emphasis on communication and exchange that the agencies will already now take a specific initiative in a co-ordinated fashion to get this aspect started as soon as possible.
• The major expressions of interest to assist in this field are from The National Library of Medicine, USAID, the Malaria Foundation, Satellife (harbouring Healthnet and AFRONETS) The World Bank and SHARED.
• These parties, potentially complemented by others, comprise most of the high quality expertise needed to try and solve the technical problems associated with more effective communication between scientists, notably in Africa, but will need to be provided with the operational funds to make it happen. For this aspect active collaboration will be sought with agencies involved in the social development process.

II. The wider perspective (mainly day 2)

At the second day a broader picture was discussed, which stretched beyond what research agencies alone can do within their mandates. The organizers of the DAKAR conference had realised that important other sources of support to the malaria research and control community are needed for the MIM to have an impact beyond more efficient use of existing research resources.

Two main categories of players were identified:

• The agencies supporting development-related activities in the South
• Industry.

Representative of these two groups joined the meeting and discussed with the research agencies. There was a strong feeling of consensus that the MIM could generate the long-awaited forum for structural collaboration between research agencies, development (government) agencies and industry, complemented where appropriate with other players such as NGO’s.

Briefly, the presentations in the morning revealed the following key points.

The Development Agencies have their focus more on downstream issues of research and on the control aspects of diseases. RCS and implementation projects as well as application-oriented and operational research are therefore more likely to fall in their area of interest. It became clear that there is an increasing awareness all around the globe that science is an important instrument for development. Therefore, we witness a growing interest from the side of the development agencies to co-ordinate their efforts with the research agencies. The research agencies in turn recognise more and more that supporting high quality and relevant research in Africa is not enough in the long term. There must be a context for growth of the research opportunities and the implementation of research results. It became very clear from the discussions, that this continuum can only be created if the research and the development agencies co-ordinate with the governments of the African States and develop a coherent research and implementation policy.

The industry representatives stressed that the private sector is very conscious of the enormous medical need for better tools in malaria control, but that two principle elements hamper industrial involvement. First of all, the demonstration of feasibility of novel candidates for drug and vaccine development is not easy. Academic products frequently still have a major risk of downstream failure. In-house discovery and development programmes bearing the full range of potential no-go decisions, are even more difficult to justify in the present industrial climate. Second, Although it is obvious that the potential market for new malaria tools will be enormous in size (virtually half of the world’s population) but not in financial volume. The core of the problem is therefore the risk/benefit ratio. Public Sector Research supporters and the Development Agencies as well as the African Governments can contribute to reduce the risk/benefit ratio in different ways; Evaluation of candidate drugs and vaccines up to the phase where they become attractive to industry should be taken up by the public sector, and the support to governments of endemic countries could finance the market. The latter aspect would be crucial if we talk about either a vaccine designed for use in Africa or drugs that have no use as a travellers prophylactic.

Such products can not be financed through tiered pricing like other vaccines via the UNICEF system. Consortia of Private and Public sector institutes should also be explored.

Outcome of the discussions

The participants first discussed the Research & Capability Strengthening aspects as formulated in Dakar:

• Research, particularly of a collaborative/partnership nature, must be of the highest quality, must encompass all disciplines and must be guaranteed by peer review.
• Genuine partnership for research must involve jointly setting the research agenda in which there will be a clear distribution of tasks between the partners.
• Training should be the cornerstone of all collaborative research with the TDR method being a useful and pertinent model.
• The training should be as far as possible be in African institutions, particularly those with a good track record of relevant research. Good regional co-ordination will be essential.
• Good electronic communication facilities should be developed to facilitate contact with other scientists and the access to scientific literature.

In a plenary discussion these principles appeared to be acceptable to all concerned and during the afternoon session the following issues were discussed and proposed:

1. MIM should concern itself with the Development of a Strategy to bring malaria higher on the political agenda.

• MIM should gradually move from a reactive to a more pro-active role
• It should be concerned both with the research and the wider aspects of the challenge posed by Malaria in Africa in a global perspective.
• MIM should acknowledge that a malaria-specific effort may cause tension with other important areas in International Health, and that it should not result in a vertical approach.
• The messages to Politicians should be clear, even if the picture is complex, and strong co-ordination between all supportive agencies is crucial for success.

2. The entire range from basic research to control and development issues related to malaria should be viewed as a continuum and the role of each player in that process should be identified to facilitate co-ordination.

• To that end, a matrix was developed for further completion during the follow up of the Hague meeting (see table at the end of this report)

3. Assuring a reasonable market in a context of cost-effectiveness can be a major contribution of Development Agencies to promote the involvement of Industry in the development of new and improved tools.

• The world Bank and possibly others are prepared to finance the market if products meeting internationally approved criteria of efficacy and cost-effectiveness are met.

 

4. Demonstration of feasibility to a much higher extent than up to now could be a valuable contribution of the public sector research to promote the industrial development of drugs, vaccines and diagnostics.

• Both NIH and the EC have developed plans for concerted activities in the field of malaria vaccine development- and evaluation
• The Wellcome Trust, WHO, the World Bank and others are involved in a consortium approach towards the development of new drugs.

5. The comparative advantage of the MIM vis a vis this big challenge should be spelled out clearly, to result in concerted efforts where scientifically feasible and to generate a significant increase in resources invested in malaria.

The following agencies have agreed to take part in the development of a consolidated approach towards this challenge (the major public role of MIM) , each within their own mandates.

CDC, EC+ contact several EU research councils, NIH, Malaria Foundation, MRC (UK), NLM, NWO , OAU, UNESCO, Wellcome Trust, WHO/TDR, World Bank, WRAIR.

These organisations will participate in the Clearing House function when appropriate (see also day 1 for research agencies)

6. The malaria Foundation was mandated with the PR issues for the MIM and will do so in close co-ordination with the other partners concerned with communication, such as the National Library of Medicine, SHARED, Satellife and the World Bank (see day 1).

‘Immediate Homework’ assigned on day 2

(partly additional to day 1) :

1. Assessment of Scientific Needs (based on Letters of Intent and other sources): WHO/TDR
2. Public Relations: Malaria Foundation & partners
3. Macro-Economic + Marketing Analysis: World Bank
4. Basic Research issues: NIH
5. Initial Response to Letters of Interest: core group under auspices of WHO/TDR
6. Internet Connections (NIH/NLM/USAID/WB/SHARED/GTZ)

 

Positive recent developments (apart from MIM itself)

• NIH/NIAID is planning selective increase of malaria funding
• In the EU a council resolution of the ministers of Development has been adopted in June 1997, emphasising the importance of research for the development process.
• The recent assembly of the Heads of State and Government in Zimbabwe (June 1997) did adopt a Declaration Malaria Prevention and Control in the Context of African Economic Recovery and Development, in which malaria is not only identified as a serious impediment to Africa’s development (costing over 4000 lives and over 5 million USD loss every DAY), but also calls upon its member states to promote basic and operational research for the development of new tools and better use of existing ones.
• The Fifth Framework Programme of the European Commission is presently under consideration by the EU member sates and these resolutions can be used to put malaria high on the agenda.
• Co-ordinated action between the players represented at the meeting can be invaluable in the process of political awareness (see below)

 

 

Scientific Response to the Malaria Challenge in Africa Managing the transition from one phase to the other requires close collaboration between agencies of different nature time frame: 10 years (at least)

Step in Continuum	Aims/products	Partners	Location of operation	Support from:
Basic Research (laboratory based)	Leads for tool and strategy developments (example: Genome projects)	Public Sector	North and South	Research Agencies (B)
Application-Oriented Research	Vaccines, Drugs, Diagnostics and Strategies	Public Sector Private Sector	North and South	African States (A) Research Agencies (B) Development Agencies (C)
Product Development	Vaccines, Drugs, Diagnostics, Insecticides, Nets, Traps etc.	1.Private Sector 2. Public Sector*	Mainly North, but increasingly South	Private Sector (D), Public Sector (B)
Field Evaluation**	Efficacy of Tools/Strategies	African Scientists, with logistical support from ‘Producer’	Mainly South	African states (A), Development Agencies (C), Research Agencies (B) Industry (D)
Implementation	Control Strategies/improvements	Control managers/ governments	Mainly South	African States (A), Development Agencies (C) NGO’s (E)
Post-Marketing Research, evaluation and feed-back to Basic Research	Improvements, Detection of problems, cost-effectiveness	African Scientists/Control managers/Industry	Mainly South	Industry (D), NGO’s (E) Development Agencies (C, Market assurance)
Co-ordination	optimal use of resources, and smooth transition from one phase to the next, especially when different players are involved	All/ mainly contact persons in participating agencies	South and North	All (part of overhead)
Communication/PR/Political Awareness	Increased investment in malaria as the biggest killer in Africa	Malaria Foundation & Partners (see text)	South and North	All (part of overhead)

• * Major public sector initiatives are under construction to facilitate the transition from basic research findings to product development in the fields of vaccines and drugs (see appendix 1.)
• ** Establishment of field sites for effective evaluation of any malaria intervention, but notably vaccines and vector control effects (long-term) is a painstaking and long process, which has to be started far before actual products come down the pipeline to be tested. This is a particular area where different players have to co-ordinate far ahead where to invest.

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