In 2006, as a result of a meeting held at the Carter Center, these issues were identified among major donor organizations and global program implementers together with recommendations set forth to improve the situation. Unfortunately there has been no opportunity for these recommendations to be reviewed and revised from the perspective of organizations working “closer to the ground”, , namely, NGOs, CBO’s, and FBOs who for decades have worked with communities in well-established, trusting relationships.

ACAM will share the results of the 2006 meeting with collaborative groups working at national level in Kenya and Tanzania to discuss with them suggestions for improving the draft list of recommendations that came from the 2006 session.

In addition, ACAM will probe beyond these recommendations to provide candid feedback regarding the complexities that exist well below African national levels of collaboration. ACAM will present a description of current in-country organizational efforts to close the gap between those national organizational consortia already functioning at the community level, but in need of additional resources — organizational, communication, managerial and financial, to truly deliver the effective Global Health interventions to these communities who in turn take responsibility for achieving their sustainable availability for the poor residing there.

At the close of an old year, what better time to stop intentionally, to step away from all the noise and negotiations, and take an honest look at what we have done, where we are going, and how we are getting there.

For ACAM, 2010 has been a major year of change. Our Headquarters has shifted from Washington, DC to the “other Washington”—-Seattle WA, situated in the verdant Northwest. Venturing far beyond the Beltway is a challenge, but a healthy one in order to define a new perspective, within a new environment, with new partners influencing new technologies and strategies.

In 2010, encouraging advances in Global Health achievements continued despite significant economic downturns, especially in the United States and some of our European partners. Yet commitment to Global Health remains solid as evidenced by the following words of Pres. Barack Obama issued on May 5, 2009. He said. “We will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and ensure that the best practices drive the funding for these programs.” [1]At last, there is realization that all the emphasis on technical advances becomes relatively unproductive without a major re-thinking around the health systems themselves– so vital to deliver these life-saving improvements. This notion is further reinforced in the recent Global Fund proposals outlines calling for clearly defined plans for planning, implementing, and evaluating sustainable community-based health delivery plans.

More specifically, malaria funding has increased from $400 million in the year 2000 to over $1.4 billion in 2009.[2] And malaria program strategies have moved from “Scaling up”, now to “Elimination”. This is cause for celebration except for the uneven results seen across countries, particularly in Africa. Nonetheless, there is now a well-established evidence-base for widespread scale-up and universal coverage. Furthermore, continued progress in scale-up and elimination will require improved tools for malaria control and surveillance. Hopefully these will evolve over time as efforts to monitor antimalarial resistance and track coverage with RBM interventions mature. Lastly, currently the Phase III malaria vaccine trial in Kenya promises a future in which this disease can be prevented through application of a vaccine program to those at risk.[3]

So what can be holding us back?

Alongside the “good news” with its promising opportunities for the future, there is a dark side, an unseemly aspect in the quest to eliminate malaria as a threat to health, particularly for the poor of Africa. It is not discussed openly in “polite company”, but hangs over the eventual dream of “universal coverage” as a continual threat to achieving that dream. Namely, it is the rampant corruption that exists within the ranks of the public health officials who are responsible for discharging the respective national malaria programs.

Thanks to the vigilance of the Global Fund hierarchy in Geneva, there have been instances when Global Fund operations in some countries have been suspended due to corruption, with those responsible eventually brought to justice. In addition to these extreme cases, such practices are unfortunately the modus operandi in many countries, although operating at lower levels of responsibility and magnitude. The result is erosion of trust in these public health negotiations between key implementing parties such as, the private corporate sector— essential partners to address the logistics, procurement and distribution of RBM interventions. The invaluable voices of the community, even when organized in well-established collaborative groups nationally, are routinely disregarded when governments are discussing issues related to malaria program strategy, especially with the global donors.

Even more detrimental is the growing realization among the common citizens that their elected government officials are not reliable to carry out their tasks for the sake of the common good. In today’s world of rapidly expanding means for social networking, this climate of mistrust among these predominately youthful populations found throughout all the African countries can sow seeds for future violence erupting on the Continent; Kenya, for example, is slowly recovering from the post-Election Clashes of 2008. On the other hand, this same population is rapidly gaining skills using updated communication technology and with their demographic advantage (over 80% are youths in many African countries), if inspired by the hope of a better future, can usher in a generation of prosperity previously unknown.

What is needed now is an understanding that indeed we all are “our brother’s keeper”. Away with tribal divisions, rigid religious dogmas, and racial and economic segmentation. Enough of “Business as Usual”. Time is short; the time is now for more Community-directed program involvement, along with integrated program surveillance, monitoring and evaluation. Resources are urgently needed to strengthen the “Bottom Up” partners’ contribution in order to compliment and sustain the advances made so far by the current predominantly “Top Down” achievements.

[2] IBID

[3] Presentation by S. Patrick Kuchur, MD MPH, CDC –Div. of Parasitic Disease and the Malaria Center for Global Health on Nov. 25, 2010 at PHGR Malaria session titled, “ CDC’s Scientific Evidence for Scale –up and Positioning for Malaria Elimination”.

Tony Wilmot Library at AIU Receives Collection of Malaria Documents

Dr. Larry Casazza, director of African Communities Against Malaria (ACAM), donated a generous gift of books, training materials, CDs and reports about malaria to our Tony Wilmot Library.

This collection reflects the life- long passion of Dr. Casazza, MD, MPH. For 25 years, Dr. Casazza has dedicated himself to implementing community-based activities to improve the health and welfare of women and children. He has also worked for the World Bank and World Vision, and is a faculty member at Johns Hopkins University in the US. Larry has often resided on campus at the Hoenecker Centre and has built lasting friendships with members of the NEGST family.

A large portion of the resources donated are specific to eradicating malaria, the number one killer of Africa’s children. The materials in the library range from technical reports to very practical training materials for use in African villages.

Another portion focuses on designing and delivering community health initiatives on a grass-roots level, including the classic book “Just and Lasting Change: When Communities Own Their Future”, by David Taylor Ide and Carl Taylor. We now have many manuals for training trainers and for assessing the impact of health initiatives applicable to a wide range of issues beyond malaria eradication.

AIU’s Institute for the Study of African Realities Director Dr. George Renner welcomed the gift. The “reality” of malaria and other killer diseases are having devastating effects on rural Africa. Renner sees the collection being used to increase the church’s capacity to make a difference in people’s lives and to explore and benefit from the vast wisdom already present in rural communities. He sees churches being empowered to become centers of shalom in a comprehensive sense. Christian leaders can be trained to nurture sustainable community development initiatives.

The NEGST community says a big “Asante Sana” to Dr. Larry Casazza for blessing us with these valuable resources.

The objective for Sanofi-aventis was to assist their organization to better partner with communities to develop and sustain effective malaria prevention and control activities. Already Sanofi-aventis had undertaken the development of educational materials for this purpose; they understood that these materials alone could not be readily adapted by communities in order to create effective malaria activities in their local level. The opportunity to interact with several groups of residents from Usalama, provided by the NGO, Mwikali’s Gift, allowed for direct dialogue regarding the needs, current level of understanding of malaria program interventions, and their current access to these life-saving malaria program options in the context of the National Malaria Control Program (NMCP). 

From March 9-12, 2010, the team interacted in the field with local AMREF staff, together with the Usalama Project director, who facilitated organizing 186 enthusiastic community participants, who had had previous experience with their successful water and sanitation project. This greatly facilitated their ability to set forth a designated Task Force to move the malaria program forward and to create a shared vision for a MALARIA-FREE Usalama. It was soon learned that the current access to LLINs for malaria prevention and ACT for treatment, both interventions promoted by the NMCP policies, was non-existent.

In follow-up discussions at the Kibwezi Health Center (the closest govt. health facility to Usalama), it was confirmed that LLINs had been out of stock for several weeks, and that no pediatric ACT dosage was available due to unfilled orders from KEMSA, the Kenya Medical Services Agency. This effort did not attempt to investigate causality of these shortfalls, but rather defines the current situational dilemma and offered a plan for “strategic partnering” that was then discussed with the Usalama community leadership for incorporation by their Task Force.

Finally, the consultant’s team prepared a list of recommendations for consideration by Sanofi-aventis in their efforts to improve communications with communities, the “Last Mile Barrier”^], an analogy borrowed from telecommunications professionals, to effective malaria programming. The experience found in Usalama is unfortunately common in many African settings, but today’s innovative communication technologies can help to promote change.

The fact is, 2009 has been a pivotal year for ACAM’s operations. Backtracking to mid-year, in order to pursue “an upfront and personal” perspective on the new Obama Administration’s changes regarding global health and malaria programming, ACAM’s Director returned to Washington, DC for an intensive round of meetings in pursuit of this information —- all within the Beltway.

A brief list of the sessions (a total of 26 attended) include: a “Call to Action” held with key members of the new White House team; several sessions at the Center for Strategic and International Studies (CSIS), a major think tank located on K St.NW, intent on providing guidance to the new Administration for their Global Health Initiative (GHI) programs; several meetings hosted by the Global Health Council, including one targeting faith-based organizations with the key question, ” What Does Faith have to do with it?”; and the Grand Finale closing out AED’s NetMark project, a major effort to inject social marketing and private sector involvement into national malaria control programs, especially in Africa. Finally, PAHO convened a remarkable session celebrating their Region’s malaria activities; for the first time the role of the community in planning, producing, and evaluating these efforts was truly celebrated!

The good news was that at most of these sessions, when the audience got an opportunity to ask questions, ACAM’s Director invariably was selected to ask repeatedly the following question, “In your work, how are you involving the Communities you are called to serve to produce sustainability, equity and community ownership?” This was usually followed by comments about “grassroots” engagement, but lacking any clear definition of what “grassroots” meant to them. The Director then questioned, namely, “What grows in your “grassroots”; are there any weeds or stones. Or was it really Astroturf, doomed to a landfill eventually?”

After attending multiple sessions, a pattern began to emerge. It was the young students, usually seated at the back of the room, but with a keen interest in Global Health, who grasped the significance of the community perspective missing in the presentations from the panelists. Also “missing” was a clear sharing of their project’s budget priorities and allocations. More specifically, what percent actually impacted at the community\beneficiary level? This hopeful note reflects the new involvement of members of the Association of American Colleges and Universities (37 of its 837 members, or 16%) now offering majors or minors in global public health and the number is growing exponentially. Nevertheless, their impact on policy, program design and priorities will be some time in coming, perhaps a generation away.

Meanwhile, the first six months of 2009 were preoccupied with ACAM’s efforts to galvanize the NGOs, CBOs and FBOs to participate in Kenya’s Round 9 Global Fund Malaria Proposal. ACAM’s main focus was assisting the leadership within KeNaaM’s (Kenyan NGOs against Malaria) partners to mount a Civil Society Organization (CSO) component for Kenya’s Proposal. Of course, all this must be conducted within the consolidated efforts of the Kenyan Country Coordinating Mechanism (CCM) as prescribed by the Global Fund. In addition to preparing a PowerPoint training presentation based on Aidspan’s reference materials, the Director drafted both the Summary Rationale and Terms of Reference for Technical Assistance to CSOs for preparation of their Round 9 inputs

Unfortunately, due to communication difficulties and conflicting agendas, the CSOs failed to mount a timely and quality response for input into the Global Fund (GF) Proposal. As diagnosed by one of the hard-working team members, the process was ‘hijacked’ by certain self-interested CBOs (most who have been on the HIV “gravy train”) who don’t really know how to meaningfully work within communities. A Lesson Learned would be to screen out those organisations in the future and to work only with those who directly engage with communities and engage Community Health Workers (CHWs) using the Kenyan Community Health Framework. Finally, Kenya’s Round 9 Malaria submission was soundly rejected by the Global Fund’s Geneva Review Panel.

Furthermore, although GF Country Coordinating Mechanism (CCM) guidelines clearly delineate the roles and responsibilities of all the participating members, the balance between government and non-government members as designed by the Geneva headquarters, was not fully understood by the CSO members. Follow-up analysis of Round 9’s preparation performance will be critical before scaling up for any future proposal submissions from CSOs.

On a more positive note, building on the euphoria over Obama’s Inauguration on January 20, 2009, staff from Vestergaard-Frandsen journeyed to Kakamega for an exuberant local celebration involving one of Kenya’s Favorite Sons and America’s First Black President. It truly was a media extravaganza with the inauguration of a local health post health constructed with Vestergaard input in order to provide a convenient follow-up point for the many HIV-positive cases detected during its earlier successful HIV Screening campaign that achieved 90% community compliance.

Lastly, prior to departing from Kenya, ACAM participated in intense discussions with Japanese members of the G-8 on a Follow-up session related to critical policies for G-8 health investments hosted by AMREF. Once again, they provided solid arguments for their investment in community-based approaches for sustainability and equity.

As a parting shot before leaving Kenya, ACAM’s director developed  training materials . In addition, an opportunity to apply for the Global Fund Board NGO position representing developed countries surfaced; this required concise, but exhaustive innovative responses to a long list of Board requirements. for use by KeNaaM, the collaborative group of over 70 NGOs in Kenya united together to create a Malaria Free Kenya.  KeNaaM’s management recognized the need for a revision of their strategy with renewed endorsement by all of the membership for future malaria program activities.

In summary, for ACAM, 2009 was a year filled with challenges and disappointments. The vision of KeNaaM’s partners coming together to take advantage of the new CSO pathway for Global Fund proposals proved to be naïve and weak. The strength of all its partners, large and small ones, was found to be unprepared to work together in a spirit of unity. Unfortunately, many lacked a working understanding of the constructive Global Fund CCM statutes. These standards, refined over time to respond to past Fund failures and weaknesses,  strongly favor engaging CSO input into Global Fund planning and implementation. Yet they are ineffective if all of the CCM members are not fully aware of their purposed significance or are unwilling to value the contributions and strengths of each member to produce truly sustainable and effective efforts. The CSOs have much to learn as well to function in this challenging new environment.

Truly, living is learning and we will go on.

It was 8:45 PM on the night of June 19, 2007 that I stepped off the BA flight into Nairobi from Washington DC via Amsterdam to bring ACAM’s goals and objectives more precisely in contact with Africa–finally, ACAM was ready to interact with African partners directly in order to advance the newly available and highly- effective interventions that can beat back malaria on this continent.

For those who continued to access my website: www:ACAMalaria.org , since my move, I thank you for your patience and diligence in contacting me despite this major hiatus in any updates on the website itself. The explanation for this “break” is simple; I no longer had access to my faithful webmaster who served me back in Washington DC . Only now have I located a reliable, talented replacement here in Nairobi , Kenya to close this communication gap and to continue with timely updates from ACAM.

No longer would I be making only intermittent visits; this was the move ACAM needed to make in order to be available full-time as a partner with governments, donors, NGOs, CBOs and FBOs to facilitate communities and households to create a MALARIA-FREE AFRICA. Besides, now there was major global advocacy and awareness that malaria was Africa ‘s number one killer of children — and there are community- friendly means available that can change this!

After living here in Africa for almost two years, my only regret is that I did not make this move earlier. Perhaps ACAM could have been “on the ground” from the very inception of the two major international donor -supported malaria program resources, namely, the Global Fund for AIDS, TB, and Malaria (GFATM) and the Presidential Malaria Initiative (PMI). But then again, both programs had to go through their “startup” pains and program design revisions involving their innovative partnering mechanisms with the national African programs—all requiring a steep learning curve to cooperate and collaborate with the donors. Indeed, especially for the Global Fund, this meant major revisions in how the country recipients must align themselves with partners for planning and implementation– most notably with those organizations with community- based constituencies who are meant to be the ultimate recipients of the program benefits.

The lessons learned during my relatively short time here in Africa totally eclipse the decades of experience spent commuting from Washington DC to “where the rubber meets the road” in Africa. Living day-to-day with the people who truly understand the political realities, who daily struggle with the regular power and communication breakdowns, and yet patiently move forward with a grace that Africans instinctively show one another has been my valuable privilege. I still am reminded that my exposure here has been a limited one; there is still much to learn together.