London School of Hygiene & Tropical Medicine

"The APPMG is convinced from all the testimony and evidence we have been given that the key to reducing deaths from malaria is delivery, and the key to delivery is recognising there are multiple steps where delivery can fail, all of which need to be tackled simultaneously, rather than expecting a single intervention to provide a quick and easy fix."

This fourth report by the All Party Parliamentary Group on Malaria and Neglected Tropical Diseases (APPMG) [1] explores the landscape of malaria in 2008. As the opening sections of the report demonstrate, in many respects the picture is much more positive than it was when the first AAPMG report was launched in 2005. For example, interventions including artemisinin-based combination therapy (ACT) and insecticide-treated nets (ITNs) contributed to a 90% decline in malaria deaths in Zambia's southern provinces between 2001 and 2005. Hope that trends like this will continue is grounded in fact that many of the interventions that were at the stage of being tested in trials in 2005 are now available widely. For instance, APPMG notes that rapid diagnostic tests (RDTs) have become widely available, and their quality and heat stability is improving. In addition to the new tools available, APPMG points out, there has been a substantial commitment to malaria control from major donors and northern governments in support of southern governments described as essential in the first report to the APPMG.

What all these positive changes have in common, APPMG argues, is that they have not depended on a major new technological breakthrough, but, rather, on the proper delivery of existing tools for malaria control and treatment. In many areas, malaria is as much of a problem as it ever was, and in areas associated with conflict, malaria can often increase, as control mechanisms break down. In these areas, "[t]he millions of deaths annually are largely due to failure of delivery of these tools to those who need them, particularly the poorest, and especially children." Thus, the argument here is that, although excellent tools like drugs and ITNs exist, they will be of limited effectiveness if they do not reach the right people.

To understand how to enhance delivery, APPMG looks at the multiple ways in which effectiveness can be reduced, proposing strategies to resolve these challenges. Some of the approaches explored in the report are communication-centred. For example, when it comes to ensuring coverage with anti-vector methods, APPMG observes that children and their parents may not have information about how to maximise the effectiveness, and therefore use ITNs at the wrong time of day (e.g., to ward off flies, not mosquitoes), or do not use them in the peak malaria season because they feel too hot. For this reason, one official quoted here (Dr. Graham Root of the Malaria Consortium) emphasises that (in APPMG's words) "All delivery programmes need to include both an effective communications component and adaptive implementation to increase appropriate usage. He cited a LLIN [Long-lasting Insecticidal Net] programme through antenatal clinics in Uganda, where several months after launch 92.8% of the women who reported receiving a LLIN still owned it, and 93.8% of women who had retained the LLINs slept under them the previous night. This was contrasted with some campaigns elsewhere showing 40% usage. Sufficient attention to communication and follow-up can therefore clearly avoid such low usage."

Given this picture, the report extends 6 key recommendations, several of which imply the centrality of communication to the effort to meet global goals related to malaria eradication. APPMG urges that steps be taken to:

1. Link methods of delivering ITNs through the public and private sector to interventions to promote use and retention.
2. Base decisions on evidence of what works, not on ideology, when deciding how the public sector, civil society, and the private sector can help improve delivery of treatment.
3. Combine interventions as packages tailored to particular settings, since the reasons for failure of delivery of existing tools are complex and context-specific.
4. Invest in new drugs and insecticides, because development of resistance to insecticides and antimalarials is inevitable. (According to APPMG, this should occur in parallel with investment in research into better ways to deliver existing tools.)
5. Increase current funding, continuing it for long enough to see through what has been started. (APPMG argues that maintaining support for the Global Fund to fight Aids Tuberculosis and Malaria (GFATM) in this work so that the flow of funds is predictable and sustained is also vital.)
6. Engage in advocacy to ensure political support for more coordination of efforts globally and nationally.

Email from Sarah Pickwick to The Communication Initiative on December 17 2008; and "All Party Parliamentary Group on Malaria and Neglected Tropical Diseases Launches Its Fourth Report on Delivery" [12], Malaria Consortium Press Release, December 17 2008.