Agenda for Action

The final plenary session of the conference began with report-outs from all four program-process groups: assessment, planning, implementation, and monitoring and evaluation. What we know and what we don't know about each stage of the process is given along with a list of actions. These report-outs are summarized in the boxes in Section 4.1.

The session concluded with an affirmation of USAID's commitment by USAID Administrator J. Brian Atwood, given here in its entirety in Section 4.2, and closing remarks by co-moderator Dennis Carroll, summarized in Section 4.3.

Presentations from Process Groups

Box 4-1: Agenda for Action: Assessment

Knowns	We know that. . . The primary focus of assessment should be on the customer Generic and sector-specific tools exist for understanding: users/customers the disease itself distribution channels The private sector has a wealth of knowledge about marketing that the public sector lacks.
Unknowns	We don't know. . . How to apply existing demand assessment tools to ITM programs How to predict demand for ITMs.
Actions	Compile an inventory of useful tools and techniques Synthesize/disseminate experiences for adapting existing tools and techniques for use in ITM programs Adapt and apply existing tools in ITM programs Conduct TIPs (trials of innovative products) to assess product demand Use periodic post-market surveillance to assess product sustainability Include the private sector as a partner in the design of ITM programs Draw on the global marketing skills of the private sector.

Box 4-2: Agenda for Action: Planning

Knowns	We know that. . . Defining the final goal or objective of an ITM project is essential in designing the overall plan or strategy Planners have various options from which to choose: public, private, and mixed It is critical to get buy-in from key stakeholders: the national ITM strategy must be part of the national malaria control strategy the needs and point of view of the end-user must be taken into account for a national ITM strategy, the commitment of the national government is indispensable without it the program will fail Information collected at the assessment stage must guide the planning stage The plan must be implementable, i.e., it: includes a limited number of realistic objectives clearly states all assumptions on which it is based is flexible enough to adapt to changing circumstances incorporates a budget identifies indicators for monitoring performance.
Unknowns	We don't know. . . The extent to which the consumer will buy into the ITM approach (How many nets will they buy?) What level of commitment exists among: governments (can they promote Acommercial activities?) donors the commercial sector (they don't see a big market) How to prevent subsidies from undermining the commercial market Technical unknowns: pyrethroid resistance: the immediacy of the threat existence of suitable non-pyrethroid alternatives impact of a malaria vaccine on ITMs.
Actions	Foster debate on the issue of private/public sector mix Test mixed approaches and models (larger scale) to see if sustainability and equity can be combined Establish mechanisms to exchange lessons learned from past experience Produce a guide for ITM planners Test non-pyrethroid alternatives Promote (Asell) ITM plans and programs.

Box 4-3: Agenda for Action: Implementation

Knowns	We know that. . . Short-term projects have been carried out, but there is no experience with long-term projects Enthusiasm exists for starting ITM programs among multiple players; this needs to be channeled through leadership, coordination, collaboration, and action. The supply of nets must be increased Technical problems are still to be solved concerning retreatment, timely supply of nets and insecticides, cost recovery, and recycling funds An initial capital investment from public and private sources's needed Implementation should be phased to anticipate a program's growth stages start implementation on a zonal basis, then expand Ripple effects to neighboring communities for rapid coverage with minimal inputs can be achieved through prioritizing geographical program starting points A continuous source of technical support must be available within easy reach: communications, accounting, administration, education, etc. Existing community structures can be used to identify those who may need assistance to acquire ITMs (e.g., women and children) Promotion is one of the most significant aspects of an ITM program Generally, subsidies are not a good idea, but the poorest of the poor may need help.
Unknowns	We don't know. . . How to create public/private sector partnerships at the local level. (The public sector should not be marginalized; they have a role which is mainly to establish mechanisms and regulations to smooth the way for the private sector.) What mechanisms and roles are necessary for control and regulation by the government What the long-term effects of ITMs are on malaria immunity Easy methods for retreatment of nets. (Good experience exists with community-based retreatment but none with home-based retreatment.) The amount of ITM coverage required to have an effect on malaria A simple, accurate technique for detecting the level of active insecticide on netting material The applicability of insecticide-treated curtains and other ITMs under varied geographic and cultural settings.
Actions	Increase sources of supply and distribution channels for ITMs and options for retreatment services Build the capacity to implement ITM programs at the country level, both in human resources and funds Start large-scale programs within the existing health infrastructure.

Box 4-4: Agenda for Action: Monitoring and Evaluation

Knowns	We know that. . . It is difficult to define indicators without defining models There are limitations as to how much additional information can be added to current health information systems Ongoing data collection is not necessary for all indicators A heavy investment in monitoring and evaluation of ITM programs is justifiable at this initial stage Mortality and morbidity data are often unreliable It is difficult to attribute changes in morbidity and mortality to specific programs Private companies are unwilling to share their data Self-evaluations are usually biased.
Unknowns	We don't know. . . How to apply existing monitoring capabilities to ITM programs.
Actions	Generate a menu of standardized indicators for specific models, including: source of data collection methodologies frequency of collection cost of collection responsible parties Develop guidelines for community-based monitoring Conduct field tests to evaluate insecticide resistance Test methods of evaluating residue on bednets.

USAID's Commitment: Presentation by J. Brian Atwood,
USAID Administrator

I would like to thank you all for your participation in this conference, which I know has been productive. Combatting malaria is clearly more than just a vital public health issue, it is a dilemma whose resolution is fundamental to development as a whole.

We have seen growing recognition of the tremendous problem posed by malaria this year. The Atlantic ran a cover story on the resurgence of the disease. The New York Times published a long feature on malaria and noted that the cumulative statistics concerning malaria have so many zeros that it is impossible to conceive of the heartbreak they represent. Senators Leahy and McConnell Senator McConnell, who himself suffered polio as a youth have helped lead the Congressional charge that we need to do more to fight infectious disease in the developing world. Jeffery Sachs, in a thoughtful piece in the Economist, detailed the devastating economic effects of tropical diseases and their costs to developing nations.

Many of these commentators have been bluntly critical of the international community's response to malaria. The Times commented, "The extraordinary thing about the mosquitos is that in the current battle against the best minds of 20th-century science and medicine, the mosquitos may be winning." There are bountiful statistics to buttress this criticism, with which most of you are familiar. Malaria causes more than 2 million deaths a year, principally among children and infants. Ninety percent of these deaths occur in sub-Saharan Africa. Between 300 and 500 million people now get malaria each year. Someone dies from malaria about every fifteen seconds. During the last decade, malaria has killed about ten times as many children as all the wars in that period combined.

The direct economic cost of malaria in Africa including lost wages, the cost of treatment, and the expense of traveling to a clinic or a hospital was estimated to have been $1.7 billion in 1995. That already astronomical figure is expected to double over the next five years to $3.5 billion. At the household level, approximately 20% of disposable income of low-income African households is spent on mostly ineffective malaria treatment. And, in many African countries out-patient treatment for malaria accounts for up to 40% of all public health expenditures. Even as malaria already extracts a heavy toll on Africa, over the coming years it is estimated the region can expect a 7-20% annual increase in malaria-related deaths and cases of severe illness.

Despite these grim statistics, the international community has had difficulty marshalling resources to combat malaria. While figures vary, it is clear that spending on malaria control and research remains very low, especially when you look at the number of fatalities caused by the disease. In short, to all those who would criticize the international response to malaria I would say this: you're right. We aren't doing enough, and that has to change. We have to do a better job combatting not only malaria, but a range of other infectious diseases, or we will risk seeing important economic gains in the developing world undone by a growing public health crisis.

The growing visibility of the malaria problem is an important part of the response. We need to educate the public and the Congress about the severity of this problem. As an agency, USAID is operating in a time of very tight resources. This situation is replicated at the United Nations and among most donors. Not only in the public health field, but across all of our activities, the international community is too often forced to rob Peter to pay Paul.

Do we cut funding in agriculture to fight AIDS? Do we abandon environmental programs to fund family planning? Do we fund basic education or microenterprise? The choices are extraordinarily difficult and it is incumbent upon all of us to help educate the public that combatting infectious diseases is a public investment that we cannot afford not to make. We must also do a better job leveraging resources from the private sector to help fight malaria if our efforts are to be successful.

USAID-as the lead U.S. government agency in the fight against malaria and other infectious diseases in the developing world is working at a number of levels to address the root causes of these public health issues. USAID's approach to infectious diseases consists of four interrelated elements. First, we are working to change the social and economic conditions such as poverty, lack of sanitation, rapid population growth and environmental degradation that allow infectious diseases to flourish. Second, we are working to improve health systems so developing countries themselves can better control infectious diseases. Third, we are carrying out specific targeted programs to address priority diseases. Lastly, we are continuing to enhance our capability to respond to emergency disease situations.

USAID's health programs focus on the major killers of children under the age of five pneumonia, diarrhea, measles, malaria and HIV/AIDS. In 1996, USAID devoted an estimated $320 million to the prevention, surveillance, and treatment of these diseases and the development of simple and affordable technologies to ameliorate their effects.

USAID's malaria control efforts in recent years have focused on the development of new approaches and technologies for its prevention and control. The emergence and spread of strains of malaria that are increasingly resistant to available treatments pose real problems. As an agency, we are continuing our support for the development of a malaria vaccine. In Africa we are field testing options for practical and sustainable control of the disease, as well as working with the World Health Organization to strengthen the capacity of national malaria programs.

The lessons learned from these programs have significantly increased our understanding of the impact of malaria and options for its prevention and control. As a result, we, along with many of you, have reassessed the options for malaria control and added new interventions, and strategies for a more targeted application of existing control measures have emerged.

USAID's approach is a package of maternal and child health interventions for malaria control that emphasizes improved management of the disease and its prevention. One of the major constraints we face in trying to reduce the burden of malaria, especially in its association with the emerging drug resistant strains of malaria, is the lack of simple and effective tools for the prevention of malaria infection.

The success of the recent Abednet trials in East and West Africa has been dramatic, as you have discussed during the last couple days. The use of treated bednets, first used by soldiers during the Second World War fighting in the tropics, could give us an upper hand in fighting malaria. The bednet trials showed that insecticide treated nets can significantly reduce deaths from a number of causes, not just malaria, and that we can significantly reduce malaria related mortality even in areas that have been traditionally hardest hit by the disease.

But we all appreciate that a few successful field tests do not necessarily mean that bednets can widely be transformed into an effective program against malaria. In many areas, bednets are too expensive for families struggling with profound poverty, and issues relating to market access and retreatment of the nets with insecticide will also have to be addressed.

Again, I cannot over emphasize that to successfully meet the challenge of malaria will require a concerted and well coordinated effort of not simply the donor community working with national programs, but will also need to involve a partnership with the private sector who manufacture critically needed nets and insecticides.

I can assure you that USAID will be a steady partner in these efforts. USAID's commitment to expanded efforts in malaria are linked to our agency infectious disease initiative, led by the Congressional support of Senators Leahy and McConnell, which is currently working its way toward passage.
In 1998 we plan on supporting an expanded application of recently proven interventions for the prevention and control of malaria, including expanded field trials in Africa, within the context of our existing maternal and child health programs. We will also be undertaking an initiative in Africa to promote insecticide-treated mosquito nets.

We look forward to the opportunity of working with you to explore how best to apply the findings and recommendations you have made during this conference. This meeting has provided a unique opportunity to bring together new combinations of ideas and experiences, which we hope will lead to innovative approaches to addressing the problem of malaria. And we all look forward to a time when people will reflect back upon these days as the time when we turned the corner in our fight against malaria.

Meaning of the Conference and Next Steps:

Summary of the Presentation by Dennis Carroll

In closing this conference, I would like to acknowledge that 1997 celebrates the twentieth anniversary of smallpox eradication. We should not forget the lessons that may be drawn from this stellar accomplishment. Smallpox eradication was no small feat. In 1966, when the program started, smallpox accounted for a major proportion of childhood deaths. Eleven years later the disease was wiped out, and 5 million lives per year were saved. I am not suggesting that we can wipe out malaria the way we wiped out smallpox, but we should take solace in the fact that what seemed an insurmountable problem was overcome.

The campaign for smallpox eradication was predicated on a shared vision, as we also have begun here to fashion a shared vision of what we want to achieve and how we intend to measure our success. As Christian Lengeler told us, we have the potential of saving 400,000 child lives per year. As Trevor Penhallrick made us remember, we shouldn't look at Africa as a lost cause: it ain't broke, don't fix it.
He gave us the vision of a new paradigm for doing business in Africa-one that offers us a wealth of opportunities. Valerie Curtis's insights from her experience in Burkina Faso centered around the vision of giving people what they want. What ITM programs deliver should be what people want and need. The whole conference has given us a vision of the strength inherent in a public-private partnership.

This conference underscores that together we will find answers to the big issues of demand, access, affordability, and appropriate use. It is the beginning of a dialogue on opportunities to work together.

We hope to reconvene in the next 18 months somewhere in Africa to track our progress and further cement our partnership. This and subsequent periodic meetings will keep us in touch and keep us motivated.

A vision is organic: it changes like a living creature. If we stay true to our vision and the partnerships we have formed, we can accomplish the unimaginable. Two million lives per year lost to malaria is unacceptable at the end of the twentieth century.

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