Integration of Health Services Ensures “No Missed Opportunities”

In time for World Malaria Day, Elaine Roman blogs on the advantage of integration
By Elaine Roman

This year’s Roll Back Malaria theme for World Malaria Day (April 25, 2012), Sustain Gains, Save Lives: Invest in Malaria, speaks to the importance of maintaining the successes of the last decade while balancing that effort with a continued commitment to move malaria prevention and control to the next level: scaling up country-level programs, controlling the epidemic and eventually eliminating this disease.That’s the call to action, the imperative across the developing world. But on the frontlines, in communities and clinics throughout sub-Saharan Africa, integration of services offers the best chance to ensure that a pregnant woman,a mother of three children,or a child under five receives malaria prevention, treatment and care services whenever she visits a health clinic or accesses services in her community.

That’s smart. That’s strategic. That’s lifesaving.

Malaria is a maternal, newborn and child health issue because of this hard truth: the disease disproportionately affects these groups. In 2011, among the nearly 700,000 deaths due to malaria, approximately 600,000 occurred among children under five and most were in sub-Saharan Africa.Approximately 10,000 maternal deaths each year are attributable to malaria.For pregnant women, malaria has a trickle-down, negative effect in that it causes higher rates of anemia, which contributes to low birth weight and ultimately infant mortality.And a child’s mother and family are her first line of defense and best chance for surviving malaria.

For all of these reasons and complicating factors, integrating malaria prevention and control activities as a core component of both maternal and child health services is a fundamentalstep in helpingcountries further reduce malaria illness and death, as well as in achieving the Millennium Development Goals that seek to keep more women and children alive and healthy.


Integration of the health services needed within a population is, in itself, “smart.” Such integration builds on what is already in place and strengthens the health system’s capacityto provide all clients-women, children and their families-quality services.For malaria, a disease that affects the most vulnerable populations,including people co-infected with HIV,strengthening the health system with integrated care requires a coordinated and collaborative approach at all levels within the country-beginning with improved policies, leading to strengthened health services and community level-interventions.The importance of such coordination/collaboration for integration of services is particularly true in countries throughout Africa, where health systems are generally weak.But commitment to a comprehensive, smart integrated approach will lend toimproved health outcomes for women and children-effectively, efficiently and cost-effectively.

Because the majority of pregnant women attend antenatal care (ANC) services at least once and often twice during pregnancy, ANC is an ideal platform for pregnant women toreceive a broad range of services-including malaria prevention and control services.All sub-Saharan African countries where malaria is a year-round threathave adopted the World Health Organization’s three-prong approach:

  • Giving pregnant women at least two treatment doses of an antimalarial, currently sulfadoxine-pyrimethamine, following first movement of the fetus andmonthly thereafter;
  • Promoting the use of insecticide-treatedbednets; and
  • Ensuring that individuals diagnosed with malaria receivethe approvedtreatment promptly.

Health care providers who are trained to prevent malaria as a core component of a woman’s care-integrated with ANC services, throughout her pregnancy-can have a tremendous,positive impact on the health of mothers andbabies who are at risk.

Comprehensive ANC, sometimes referred to as focused ANC or FANC, is the smart way to deliver health promotional and preventive services to pregnant women.The focus of FANCis on the quality of care received at each visit rather than the quantity of visits: health promotion and disease prevention; early detection and treatment of complications and existing diseases; and preparation for birth and complications that may occur.Integrating malaria prevention and control services with the FANC platform is both smart and effective as a strategyfor reaching pregnant women with lifesaving care.

Likewise, integrating malaria prevention and control services with existing child health programs,including vaccination services, can have a direct, positive impact on child health and survival. For parents seeking services for their children, either in their own community or at a health facility,integrated services not only help combat malaria but also address other major contributors to child morbidity and mortality, such as malnutrition, diarrhea and pneumonia.

In Kenya, Jhpiego worked with the Ministry of Health’s Division of Reproductive Health to introduce and scale up FANC services as a platform for delivering prevention and treatment services for malaria in pregnancy. We developed a user-friendly orientation package for frontline health care workers and trained 3,000 providers and 264 trainers-to train even more providers.As newly trained providers returned to their health facilities, they received mentoring and supportive supervision to ensure that their new learning was transferred into practice with actual clients.As a result of this intervention, the number of providers updated on malaria in pregnancy virtually doubled within the intervention area. But more important: uptake of intermittent preventive treatment in pregnancy (IPTp) increased from 19% to 61% in the intervention area versus 17% to 28% in the control area; the number of women who received the first dose of IPTp increased to 77%; and providers who said they gave the appropriate drug, sulfadoxine-pyrimethamine,increased to 93%.


Although many countries have made great strides in addressing and combating malaria, resulting in a drop in malaria cases by 38% in the last decade alone, too few have achieved their goals in reducing malaria illness and deaths.In the last three years, the global community under the Roll Back Malaria Partnership has recognized and promoted the value and necessity ofsmart and effective integration.Within countries, to varying degrees, national malaria control programsare working closely with reproductive health and child health programs, as well as HIV/AIDS programs.

Indeed, these are critical steps in ensuring that malaria prevention and control efforts provide “quick gains” and,ultimately, lasting and sustainable results.

But such results will require ongoing commitment of policymakers and health care providers to work together in achieving smart, strategic and lifesaving integration of services, and “no missed opportunities,” for reducing morbidity and mortality due to malaria illness and other preventable causes.

Elaine Roman is a Senior Technical Advisor – Malaria for Jhpiego, a global health non-profit organization and affiliate of The Johns Hopkins University.

Bill Gates: Charting a Course to End Malaria

As the Gates Foundation hosts a global forum on malaria, Bill Gates commits to the eradication of the disease.

In the past 10 years, the number of people who die from malaria has declined 20 percent.

For the past three days, the global malaria community has been meeting in Seattle, talking about what it’s going to take to get rid of the other 80 percent. The eradication of malaria is an ambitious goal and a long-term goal-but a goal Melinda and I are 100 percent committed to.

People used to say eradication was impossible, but we remain optimistic because human beings have a spectacular ability to innovate.

The tool that’s most associated with the recent progress against malaria is the long-lasting bed net. Bed nets are a fantastic innovation. But we can do even better. We can invent new ways to control the mosquitoes that carry the malaria parasite.

One of the problems with nets is that they can be uncomfortable to sleep under, so people sometimes choose not to. Researchers are testing spatial repellents that drive mosquitoes away right now. A family could hang a small coil from the ceiling and be protected, without having to accept a terrible night’s sleep.

One innovation the malaria community has been pursuing for decades is a vaccine. We have never had a vaccine for a parasitic disease, and the scientific complexity is dizzying. But at this week’s meetings I was pleased to announce interim results from the final phase of a trial for a vaccine candidate called RTS,S. Among five to 17-month-old children, the vaccine prevented clinical malaria (which was defined as the presence of fever and parasites in a child who was ill and brought to a health facility for care), in 56 percent of trial participants over a period of one year. We still need to analyze the complete data when it’s available, but this vaccine could be licensed and protecting children by 2015.

We’ll keep on innovating and improving on this vaccine, but these results are a huge milestone in the history of our fight against malaria.

The malaria parasite has been killing children and sapping the strength of whole populations for tens of thousands of years. It is impossible to calculate the harm malaria has done to the world. But we have the ability to make generation after generation of better tools, and we can chart a course to end malaria.

Bill Gates is co-chair and trustee of the Bill & Melinda Gates Foundation. This piece and accompanying photo are reprinted with permission from the Impatient Optimists Blog.

Major Milestone in Malaria: RTS,S Vaccine Within Reach

An interview with researchers integral to the success of this large-scale RTS,S vaccine trial:

The first set of results from the large-scale Phase 3 efficacy trial of the world’s most clinically advanced malaria vaccine candidate, RTS,S, were published today in the New England Journal of Medicine (NEJM) and announced at the Malaria Forum in Seattle, Washington this morning.

A Phase 3 clinical trial is typically one of the final stages before a regulatory decision is made about a vaccine, and is used to confirm its safety and efficacy. The results show that RTS,S provides significant protection to young African children against malaria, a disease that kills more than 600,000 kids in Africa each year. If the safety and efficacy profiles are deemed satisfactory, the World Health Organization (WHO) has indicated that a recommendation for RTS,S is possible as early as 2015, paving the way for African countries to make decisions about large-scale implementation of the vaccine through their national immunization programs.

Dave Poland, senior communications officer at the PATH Malaria Vaccine Initiative (MVI), recently sat down to interview two individuals that have been integral to the success of this large-scale RTS,S vaccine trial and the results announced today.


The Need is Clear

Mandy Moore joins Cameroon’s fight against malaria with Nothing but Nets

Today I landed in Yaounde, Cameroon.

It’s an incredible feeling – Cameroon is preparing for its largest ever mosquito net distribution. The nets will help protect hundreds of thousands of families from malaria, the leading cause of death in Cameroon, and I’m really glad to be playing a role in this historic campaign to save lives.

Over the next four days, I’ll write about my experiences on the ground and share some of what I learn and a few stories about the people I meet and how malaria impacts the people of Cameroon.

Read more


Q & A With Dr. Roma Chilengi, Kemri

John Donnelly interviews Dr. Roma Chilengi, head of clinical trials at the KEMRI-Wellcome Trust Research Programme in Kenya.

Dr. Roma Chilengi was the head of clinical trials at the Kenya Medical Research Institute(KEMRI)-Wellcome Trust Research Programme in Kilifi, Kenya, from 2008 until April 2011. While he worked on several vaccine trials, Chilengi specialized in malaria vaccine research and was the coordinator of programs and trials at the African Malaria Network Trust. Part of his work was on RTS,S, the world’s most advanced malaria vaccine candidate. Chilengi has been a lead malaria researcher since 2003 and recently joined the Center for Infectious Disease Research in Lusaka, Zambia, where he will be overseeing the rollout of a rotavirus vaccine in a pilot project.

He spoke with John Donnelly from Kilifi, Kenya. This is the fourth of five pieces on the importance of global health research and development that coincides with the Global Health Technologies Coalition‘s (GHTC) annual report, and GHTC’s May 3 Hill briefing.

Q: How did you get started in malaria research?

A: In 2001-02, I received a fellowship for a training program at GlaxoSmithKline Biologicals (GSK) for post-grad learning in clinical research and vaccine development. The program was modeled around vaccines, and it was working with the RTS,S vaccine in its development pipeline. I was then hired by GSK Trust to set up a clinical trial platform that would look for orphaned malaria vaccines and prepare trial sites across Africa.

Q: What are some of the lessons in setting up a clinical trial?

A: There are many lessons, I think. From a trial sites’ setup perspective, you have to do a clinical trial properly. … Most of the institutions in Africa … are not in a position to invest resources that are necessary. The institutions that have done well with clinical trials are those in which the head of institution recognizes a need to invest in them and give them enough resources. There are only a few of them in Africa.

Q: Is there too much reliance on international organizations?

A: I would call it a proper reliance.

Q: Why? Because of funding?

A: A large part of it is due to funding, but a fair proportion is due to the initiative and the drive by the heads of institutions. A clinical trial initiative has to be a five- to ten-year dedicated investment, not a one- or two-year trial. The organization I work for has been in an ideal situation over the last ten years with dedicated support from the Wellcome Trust, which has put in the structure and investment and created a dedicated leadership team.

Q: Still, running trials often is a very challenging process. What challenges most concern you?

A: Internationally, there’s been an issue with populations that have been over-researched. This is inevitable. When a good trial site is established, they will do more and more research there. In time, you have a population that is participating in several trial and research studies, and that raises two main issues. One is that to conduct clinical trials, we are obligated to produce the best possible care for those enrolled. There are no excuses. When you do that in an environment with poor health care, this disparity brings some tensions at the community level, and there is discussion whether volunteers are doing this under voluntary consent or doing this because of the benefits from the trial.

The other issue comes up when the community begins to perceive the volume of research as too much. Questions come up about where we get our resources to have such vehicles run around the trials. Other times, people said the research is associated with some sort of devil worship and sacrifices. This is heightened because we typically have to take a lot of blood samples. From time to time, we invite members of the community into our lab so they can see what happens to our blood samples.

Q: The RTS,S vaccine is the world’s most advanced malaria vaccine candidate in trials. What’s the future for a highly-effective malaria vaccine?

A: It is obviously a very great achievement to the global malaria community that we now are at this point. A lot of malariologists had problems believing or even thinking about the possibility of a malaria vaccine. What we have done is bring this possibility very, very close.

Q: What motivates you to do this work?

A: Earlier in my career, I worked as a doctor. I was very quickly faced with the fact that health care practice is very hard in resource-constrained environments. You are faced with the same patterns, same constraints, and things aren’t going anywhere. I felt I could be of more value if I moved up to a research career. I felt I could do something with a bit more results and more meaningful in terms of helping more people.

Q: What has been the impact of US Government and philanthropic investment in infectious disease research?

A: I’m broadly aware of the great impact of programs from National Institutes of Health and the President’s Malaria Initiative, and the ability of those funds has enhanced research activity across Africa. … If MVI (the PATH Malaria Vaccine Initiative) had not partnered with GSK on RTS,S, we probably would not be talking about a malaria vaccine right now. The Bill & Melinda Gates Foundation philanthropy has had a huge impact.

Q: Why was MVI critical to this effort?

A: Through the partnership, MVI gave the money to move the program forward. GSK, although it invented the vaccine, was not going to do much about it without outside investment. RTS,S was like many malaria vaccines out there in academic laboratories and institutions without support. What MVI did in the partnership was to give resources to GSK to move the vaccine. To put this in perspective, the European Commission has identified three vaccine candidates and is putting eight million Euros (more than $11 million) toward it. For RTS,S, you are talking about hundreds of millions of dollars of investment. Without money, these things can’t be done.