Against Malaria Foundation - February 2013 Update

Published: February 2013

Summary

Plans for future distributions

• AMF currently has $8.4 million available to purchase nets for future distributions. • It has committed$719,100 for the purchase of approximately 235,000 nets to distribute in two districts of Malawi: Balaka and Dedza, which will take place from January-July 2013 and be carried out by Concern Universal.
• AMF is currently exploring the possibility of funding distributions in 8 additional countries.

Follow up on past distribution in Ntcheu, Malawi

• AMF has continued to gather malaria case rate data from Ntcheu district (the location of the last distribution it funded in early 2012). The most recent data is consistent with the notion of a substantial decline in malaria cases after the AMF-funded net distribution.
• One round of post-distribution surveys of net use in Ntcheu has been delayed from January to March 2013 because Concern Universal, the survey-implementer, did not have enough capacity to carry out the survey in January.

Funds available

As of February 2013, AMF had $8.4 million available to purchase nets for future distributions.1 AMF also received a$500,000 donation from Good Ventures in January 2013 that was restricted for non-net distribution costs, of which $246,500 was still available in February 2013.2 Planned distributions Balaka and Dedza, Malawi Funds for nets and non-net costs • AMF has committed$719,100 for the purchase of approximately 235,000 nets for upcoming distributions in two districts of Malawi: Balaka and Dedza.3
• AMF is also allocating $253,500 to cover the non-net costs for these distributions from a$500,000 donation that was restricted for non-net costs.4 This is the first distribution for which AMF has covered non-net costs in addition to funding nets. It explains this decision on its website, noting that it does not intend to cover non-net costs for many, or potentially any, future distributions.5

Logistics of the distributions

• AMF expects that the upcoming distributions will require approximately 80,000 nets in Balaka and 155,000 nets in Dedza, but will not have official estimates until pre-distribution registration surveys have been conducted in both districts and the data from those surveys has been verified.6
• AMF has published the distribution proposals for Balaka and Dedza on its website7 (also available here and here).
• AMF told us that distribution activities began in Balaka in early January and are projected to last through April 2013. As of late February, AMF reported that the pre-distribution registration survey had been conducted, data entry and verification were currently ongoing, and the distribution of nets was expected to begin in March.8 The timeline for the distribution in Dedza is April-July 2013.9

Distribution partner

• AMF has reached an agreement with Concern Universal (CU) in Malawi that CU will serve as the distribution partner for these distributions. CU was the distribution partner in AMF's previous distribution in the Ntcheu district of Malawi, so AMF has confidence in CU's ability to effectively carry out the distribution, as well as pre-distribution registration surveys, post-distribution surveys, and reporting of malaria case rate data in the months after the distribution.10 (See here for our explanation of these requirements.)

Differences from previous distribution in Malawi

Unlike AMF's distribution in Ntcheu district, Malawi, the upcoming distributions in Balaka and Dedza are happening soon after a separate universal coverage campaign funded by the Global Fund distributed nets in these districts.11

• AMF's upcoming distribution is intended to fill in the gaps of this recent campaign, so it expects to find a higher baseline coverage rate of households in Balaka and Dedza than was found in Ntcheu.12
• A higher baseline coverage rate could present additional challenges to accurately assessing the remaining need for nets: surveyors will likely have to assess the condition of a greater number of nets already present in the households, and there will be more opportunities for households to under-report how many nets they have, as more households will already have nets. In addition, AMF expects to find many nets that are present but not hung, and may therefore have to emphasize net hang-up activities more than it has in the past.13

AMF's view on the need for nets in Balaka and Dedza

Despite the recent Global Fund campaign, AMF believes that there are still large enough gaps in net coverage in Balaka and Dedza to justify its upcoming distributions.

• Based on communication with the Alliance for Malaria Prevention and Concern Universal, AMF had the impression that the Global Fund distribution was insufficient to achieve universal coverage.14
• In order to spot-check net coverage in these districts, AMF asked Concern Universal to conduct a survey to assess how many nets were present and hung in a sub-set of households covered by that distribution.15
• The survey was conducted in 6 villages in the districts of Balaka and Dedza, which CU reports were randomly selected.16 The survey sample amounted to <1% of total households in those districts.17
• The survey found that, of the estimated nets needed to achieve universal coverage,18 only 60% were present.19 Of the nets that were present in households that were received during the Global Fund distribution, 41% were not in use.20
• AMF believes that these survey results, though lacking robustness because of the small sample size, support its view that the previous campaign left significant gaps in coverage, and therefore that its upcoming distributions can effectively cover more people, both through encouraging net hang up and increasing net presence in households.21

Progress in planning future distributions

In our previous update, we wrote that AMF was planning to build a "pipeline" of potential future distributions in order to more quickly move money into purchasing nets. AMF told us that it is currently exploring the possibility of funding distributions in 8 countries (Angola, Burkina Faso, Cameroon, Malawi, Mali, Nigeria, Senegal, Sierra Leone).22 AMF now has a page on its website to track the development of potential future distributions: http://www.againstmalaria.com/FutureDistributions.aspx.

AMF told us that it is closest to confirming an upcoming distribution in Nigeria. AMF has found a distribution partner there that it feels is capable of meeting AMF's requirements and has agreed to do so, but to confirm the distribution, AMF still needs a commitment that the National Malaria Control Programme in Nigeria will allocate the non-net costs out of a grant from the Global Fund.23

Follow up on past distribution in Ntcheu, Malawi

AMF has shared with us additional data on malaria cases through December 2012 for the 37 health districts covered by the Ntcheu distribution, which took place during early 2012.24 AMF has excluded data from 4 of these districts for the whole time it has been tracking data on malaria cases, noting that this data is "unreliable" or does not exist.25

For the other 33 health centers, this set of data is complete through September 2012.26 The malaria case rate data for July-September 2012 is the first set for which year-over-year comparisons can be made based on data collected using rapid diagnostic testing (RDT) kits.27 (AMF reports that the health centers in Ntcheu began using RDTs in July 2011.)28 It is our understanding that RDTs are the agreed-upon best practice for malaria diagnosis,29 so we believe that the year-over-year comparisons for July – September 2012 provide the most accurate estimates we have yet seen of the decline in malaria after AMF's distribution. This data continues to be consistent with the notion that malaria rates have fallen significantly following the net distribution in Ntcheu.30

AMF has also shared with us preliminary data for October - December 2012, which is incomplete and not yet ready to be published. Preliminarily, it too appears to be consistent with the notion that malaria rates have fallen significantly following the net distribution in Ntcheu.31 AMF has asked Concern Universal to implement a more rigorous auditing procedure of malaria case rate data, after which it expects to publish the data for October – December 2012.32

Additional malaria education and net hang-up activities

In September 2012, AMF had Concern Universal conduct additional malaria education and net hang-up activities in the 10 areas of Ntcheu with the lowest hang-up rates, as determined by the 6-month post-distribution survey.33 Then in October, AMF wrote on its blog that it planned to publish updated hang-up data for these 10 areas in November.34 However, AMF told us that in early November 2012, AMF and Concern Universal agreed that a hang-up survey immediately after this intervention was unnecessary, as data on net hang-up levels would be gathered in the second district-wide post-distribution survey, which is now planned for March 2013.35

Round of post-distribution surveys delayed

AMF delayed a round of post-distribution surveys from January 2013 to March 2013, because Concern Universal was in the midst of carrying out a food program and would have required additional funds to conduct the survey on schedule. AMF told us that it was not concerned about delaying this round of post distribution surveys, as March is still during peak rainy season and it expects to see high usage rates.36

Sources

• 1.

Rob Mather, email to GiveWell, March 7, 2013.

• 2.

Against Malaria Foundation, "Non-net costs."

• 3.

"We decided for nets of one type, Olyset nets with a price of $3.06/net for a total of$719,100."
Rob Mather, email to GiveWell, March 2, 2013.

• 4.

Against Malaria Foundation, "Non-net costs."

• 5.

"Why we do not currently expect to cover non-net costs for many, or potentially any, other distributions..." Against Malaria Foundation, "Non-net costs explained."

• 6.

"Approximately 80,000 long-lasting insecticidal nets (LLINs) will be distributed in Balaka District to achieve universal coverage - all sleeping spaces covered. The exact number of nets to be distributed will be known once a comprehensive district-wide pre-distribution survey is complete establishing the number of sleeping spaces per household requiring nets." Against Malaria Foundation, "Balaka District, Malawi."

"Approximately 155,000 long-lasting insecticidal nets (LLINs) will be distributed in Dedza District to achieve universal coverage - all sleeping spaces covered. The exact number of nets to be distributed will be known once a comprehensive district-wide pre-distribution survey is complete establishing the number of sleeping spaces per household requiring nets." Against Malaria Foundation, "Dedza District, Malawi."

• 7.

Against Malaria Foundation, "Balaka District, Malawi."
Against Malaria Foundation, "Dedza District, Malawi."

• 8.

"The work in Balaka started in early January. The pre-distribution registration has been completed and data entry and verification is now being carried out. The nets are in production and will be delivered in the third week of March to Balaka. The distribution of the nets will then immediately follow."
Rob Mather, email to GiveWell, February 28, 2013.

• 9.

Against Malaria Foundation, "Dedza District, Malawi."

• 10.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 11.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 12.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 13.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 14.

Rob Mather, email to GiveWell, September 20, 2012.

• 15.

"There are concerns that the number of nets distributed was insufficient to ensure universal coverage and that there may therefore be some gaps in coverage of the mosquito nets across the country. It is against this background that Against Malaria Foundation has asked Concern Universal in Malawi to conduct a snap survey to assess mosquito net coverage in Malawi using data from 6 randomly selected villages in two districts."
Concern Universal, "Six Villages Mosquito Net Coverage and Usage Survey Report," Pg 5.

• 16.

"The survey was conducted in a total of 6 villages (3 villages in Dedza and 3 villages in Balaka). A total of 559 households from the 6 villages participated in the survey. To come up with the six villages, firstly 3 Traditional Authorities were randomly selected in each of the two districts. Then one village was also randomly selected in each of the 6 TAs which gave a total of six villages sampled in the two districts."
Concern Universal, "Six Villages Mosquito Nets Coverage and Usage Survey Report," Pg 6.

• 17.

Rob Mather, email to GiveWell, September 20, 2012.

• 18.

CU used the total number of sleeping spaces found in the surveyed households as an estimate of the number of nets needed to achieve universal coverage of those households: "This is very close to the number of nets that this survey found were required based on number of sleeping spaces (1224)." Concern Universal, "Six Villages Mosquito Nets Coverage and Usage Survey Report," Pg 4.

• 19.

"The 559 households that participated in the survey had a total of 1224 sleeping spaces and a total of 736 nets available. Based on the total number of sleeping spaces, this represented 60% net coverage."
Concern Universal, "Six Villages Mosquito Nets Coverage and Usage Survey Report," Pg 4.

• 20.

"Forty one percent (41%) of the nets received during the universal net distribution were not being used for various reasons."
Concern Universal, "Six Villages Mosquito Nets Coverage and Usage Survey Report," Pg 5.

• 21.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 22.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 23.

Rob Mather, phone call with GiveWell, February 6, 2013.

• 24.

Against Malaria Foundation, "Malaria case rate data for Ntcheu, Malawi – Updated February 6, 2013."

• 25.

"These four health centres are small and under resourced. We have asked what is the plan to resource these health centres and Robin’s most recent view was ‘not much’ so we have chosen to exclude them from all data until such time as the district health authorities change their resources levels. We regularly revisit this issue and ask the question of CU – to ask it of the District Health Officer (DHO)."
Rob Mather, email to GiveWell, February 22, 2013.

• 26.

Against Malaria Foundation, "Malaria case rate data for Ntcheu, Malawi – September 2012," Pg 1.

• 27.

"The last three months of malaria case rate data are particularly important because the data we are comparing for these months and the same months in 2011 are both based on Rapid Diagnostic Testing Kit (RDTK) blood diagnosis, whereas (as explained in the previous update, below) the 2010 data were based on observation."
Against Malaria Foundation, "Ntcheu Update."

• 28.

"Pre July 2011 data was from clinical observation and not Rapid Diagnostic Testing Kit (blood testing)"
Against Malaria Foundation, "Malaria Case Rate Data – July 2012," Pg 2.

• 29.
• Rapid diagnostic testing kits (RDTs) diagnose malaria from a blood sample: "For these reasons, the development, in the early 1990s, of a simple immunochromatographic test to detect malaria parasite antigens in a fingerprick blood sample was a major advance. RDTs do not require water, electricity or laboratory facilities and can easily be performed in remote rural settings." World Health Organization, "Universal Access to Malaria Diagnostic Testing," Pg 4.
• Clinical observation relies on a clinician’s judgment. Often, fever is mis-identified as a sign of malaria, when it is actually caused by other illnesses: "Last year, the WHO Global Malaria Programme issued revised guidelines for the treatment of malaria in which it was recommended that all suspected cases of malaria receive a diagnostic test prior to treatment. In many settings, especially in Africa, this represents a real paradigm change. For far too long, fever has been equated with malaria throughout most of the continent." World Health Organization, "Universal Access to Malaria Diagnostic Testing," Pg vii.
• This results in clinical observation overestimating the number of malaria cases, while RDTs are more accurate.
• 30.

Against Malaria Foundation, "Malaria case rate data for Ntcheu, Malawi – September 2012."

• 31.

Against Malaria Foundation, "Malaria case rate data for Ntcheu, Malawi – Updated February 6, 2013."

• 32.

"Several months ago, I asked CU for their thoughts on how we could conduct a thorough and independent review of both the data collection process and the accuracy of the data at all health centres to allow us to revisit what confidence we have in the data. We have agreed CU Malawi’s internal auditor* will conduct a week long review. We have recently defined the scope of the review and the outputs. FYI, I will forward several emails post this one so you can see the nature of the discussion and what has now been decided. Issues being addressed and information being sought includes: Is rapid diagnostic testing always being carried out, each day and in each health centre? (data sought would include: RDTK and rubber glove stock level over time and now; # people qualified to conduct tests; days when no qualified staff present; demonstration of RDTK test being carried out; interviews with health centre head and staff). The aim is not to catch out staff but to gain a true picture of the functioning at each facility. I have asked if copies of logs/records can be collected. We will be put up a blog post next week describing the audit and the information being sought. Subsequently we will publish the results.

My belief is the data is generally good. This is based on Robin Todd’s assessment of the competencies of the health centres – good - and the scale of the decline in malaria case. However, we are assuming nothing as we start this audit and wish to look critically at procedures and the data. We wish to find out if there are inconsistencies from day to day, week to week, month to month, and if so what is their magnitude, if there are other issues and what can then be done about any issues we find. […]

All health centres have reported and the figures for some or all months for the nine health centres came through to the CU office with zeros. These data have been questioned. The most likely reasons, but here I am speculating, would seem to be: no ability for some reason to carry out testing or an error in reporting. We will know more in ten days when the internal CU auditor reports.

*I am happy at this stage for this audit to be carried out by the CU Malawi internal auditor as I am satisfied up until now that:
1. The chances CU Malawi will not report thoroughly and honestly are very low. Their performance over the last few years gives me evidence of their honesty, attention to detail and thoroughness.
2. There is no evidence yet this merits the expense and time required to bring in an external auditor."
Rob Mather, email to GiveWell, February 22, 2013.

• 33.

"For 27 of the 37 areas that make up the district the hang-up rate was a very high average of 95% (range: 91-98%). For 10 districts the average was 84% (range 78-88%), 11 percentage points lower. AMF and Concern Universal (CU) both believed it possible to increase the hang-up rate in the 10 areas by 10 percentage points through additional, structured malaria education and hang-up activities with full involvement of the local communities. These activities took place between 23-27 Sep 2012. We expect to receive, and will publish, updated hang-up data for these 10 areas by the end of November 2012. The reason for this additional low-cost intervention was to seek the optimal impact of the nets distributed."
Against Malaria Foundation, "Achieving very high levels of net use: Hang-up follow-up in Ntcheu, Malawi."

• 34.

"We expect to receive, and will publish, updated hang-up data for these 10 areas by the end of November 2012."
Against Malaria Foundation, "Achieving very high levels of net use: Hang-up follow up in Ntcheu, Malawi."

• 35.

Rob Mather, email to GiveWell, February 8, 2013.

• 36.

Rob Mather, phone call with GiveWell, February 6, 2013.