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Testimony, Enid Wamani, National Secretariat Coordinator,
MACIS (Malaria and Childhood Illness NGO Secretariat) in Uganda
Presented before the House Committee on Foreign Affairs,
Subcommittee on Africa and Global Health
April 25, 2007

My name is Enid Wamani and I am the National Secretariat Coordinator for MACIS (Malaria and Childhood Illness NGO Secretariat) in Uganda. MACIS is a registered coalition of over 70 Non-Governmental Organisations, Faith Based Organisations and Community Based Organizations in Uganda that are engaged in malaria and child health activities. The mission of MACIS is to provide leadership to Civil Society Organizations (CSOs) in Uganda in coordination and promotion of Ministry of Health-recommended interventions in malaria and child health and advocacy for appropriate policies at all levels. I am also pleased to say that recently I was selected as one of the Developing Countries CSO delegation members to the Global Fund Board.

I am very thankful to Johns Hopkins University, Center for Communication Programs and Voices Malaria Project for supporting me in my efforts to participate at this hearing. On behalf of the communities that are affected by the deadly malaria disease and the organizations that I represent, I would like to sincerely thank the Government and people of the U.S. for the invaluable investment you are making in saving millions of lives in malaria endemic countries. I am a mother of three children and have had a personal experience with malaria when my 4 year-old daughter fell ill with a high fever, refused to eat, looked very miserable and later was diagnosed with malaria. I have experienced the panic and anxiety malaria can cause and I thank God I am among the few privileged Ugandan women who can access prompt treatment. My daughter was able to quickly recover. But not all malaria victims are that lucky.

That is why I feel so passionately about my work in Uganda and why this hearing today is so important. Malaria is preventable and treatable, and we are making great progress in turning the tide against this terrible disease. Through effective partnerships and sustained funding for successful programs, we can continue to make an impact.

The Malaria Burden

Malaria is a global emergency and it's a huge burden in African countries, communities and families. Nearly 500 million people get sick with malaria each year; two-thirds of them are in Africa. Every 30 seconds someone dies due to malaria and the great majority of deaths are among very young children. Malaria is responsible for more illness and death than any other single disease in Uganda. According to Dr. J. B. Rwakimari, National Malaria Control Programme Manager, in Uganda alone malaria kills over 300 people daily, most of them children less than five years old. Pregnant women are also harmed daily by this disease, becoming anemic and running the risk of losing their babies.

The Good News

Malaria can be beaten. We do not need to have a child buried every 30 seconds due to a preventable calamity. Governments in malaria endemic countries have demonstrated the political will to fight malaria. These governments also realize that they can not fight malaria on their own and have therefore welcomed partnerships that are now tremendously boosting malaria control efforts through programs like the U.S. President's Malaria Initiative (PMI), the World Bank Booster program, the Global Fund and others. These partnerships are supporting the necessary systems and tools to control malaria.

In Uganda, the PMI and Global Fund are working in partnership with the National Malaria Control Programme and civil society organizations to support malaria control strategies as identified in the national Health Sector Strategic plan. One of the key malaria preventive interventions is to sleep under insecticide treated bed nets which protect people against mosquito bites. As of February 2007, over 800,000 people in Uganda have received insecticide treated nets through the PMI and another batch from the Global Fund of over 1.3 million nets is in the process of distribution. PMI is already demonstrating achievements in bringing down the burden of malaria. Helen Onen a community health worker in Ongaka, an internally displaced persons' camp in northern Uganda, had this to say about the bed nets distributed under PMI, "With the net distribution I have noticed that fewer patients have come to visit me," she said. "The families who have received the nets have reported less malaria cases." PMI is also supporting Indoor Residual Spray (IRS) in targeted districts. According to Dr. Stephen Ssebudde, District Director of Health Services in the Kanungu district where 85% of households have been sprayed, the number of cases of malaria at the health facilities has decreased from the time the intervention was introduced. The PMI initiative is a clear demonstration of an effective partnership that is helping to alleviate the burden of disease. I therefore appeal to the U.S. government to support PMI to reach its targets.

What Then is Missing?

We urgently need more commitment, sustainable resources and more coordination of the available resources to ensure that the tools reach the households that need them and that these are effectively used. Commitment should continue to come from every government, every leader, and every member of the household if we are to deal a deadly blow against this devastating disease.

Support Coordination of Partners

Some resources are already in place for malaria control and a lot more is still required. It is critical that these human, financial and organizational resources are well coordinated to reach the desired targets. For proper implementation to happen, governments in endemic countries need to coordinate partnerships that will help to show: who is doing what, where and what gaps still exist. We need to have robust national partnerships between the public and private sector. Once the gaps are identified, we are able to make informed plans and direct resources where they are most needed.

A good example of partnership in my country has been the Global Fund's Country Coordinating Mechanism (CCM). As a member of the CCM, along with representatives of FBOs, NGOs and other civil society organizations, the CCM model empowers our various constituencies to sit at the table when proposals are developed and when funding is allocated. This is an important opportunity for these groups to have input into the process. The CCM was recently reorganized with new leadership and a stronger role for the CSO sector. As a result, we expect to have strong reporting and transparency in implementation. This experience emphasizes the critically important role that civil society organizations play in malaria control and in development.

Partnerships with Civil Society Organizations (CSOs): CSOs contribute a great value in the malaria fight and this accrues from their strategic positioning within communities. For a long time, the challenge was that activities by CSOs were not coordinated, which led to the need for networks. Presently in Africa, CSO malaria networks exist in: Cameroon, Ethiopia, Kenya, Tanzania, Uganda and Zambia. Appreciation goes to USAID and GlaxoSmith Kline (GSK) who funded establishment of these networks through the CORE Group and Malaria Consortium. Through the robust networks, CSOs are bringing solid experience from communities, including the difficult to reach communities, to the national level where malaria control policy is made. The networks are increasingly becoming important for ensuring that CSOs implement technically sound malaria interventions while minimizing duplication of efforts.

PMI in Uganda has engaged collaboration with some CSOs especially in net distribution, retreatment and activities for indoor residual spraying. However, given the target for 'quick win' there has been very limited opportunity to build the capacity of the local Community Based Organizations (CBOs). And yet these organizations have proved to be very effective in community mobilization and will always remain strategically positioned in the communities to promote sustainability of all interventions. As someone working with the CBOs, I therefore appeal for more involvement of CBOs through training and funding that will build their capacity to promote, implement and monitor malaria interventions. The CSO networks are committed to ensuring that CSO contributions to national malaria control strategies are of top quality as well as extremely inclusive. The networks at the national level need to be supported to meaningfully contribute to the regional networks and subsequently to the global Roll Back Malaria partnership. These networks need solid financial base, currently critically lacking, so as to harness the benefits from the diverse and collective experience of CSOs.

Promote the Right Mix of Interventions

Resources targeted at malaria control like PMI, Global Funds, the World Bank Booster programme and others need to focus on interventions that will deliver commodities as well as ensure that these commodities achieve the desired impact. Delivery of large quantities of commodities like insecticide treated nets is commendable but these nets will only save lives if they are properly used. Similarly, as long as people are not mobilized to seek prompt treatment, many will continue to die while batches of anti-malarials lie in health facilities. Countries should therefore be supported to have robust systems for advocacy and delivery of the commodities. The CSO networks again add value in building capacity for their members to promote commodity utilization and monitor retention in homes. A recent survey carried out by Malaria Consortium in northern Uganda shows that 90% of the PMI net beneficiaries still had the nets six months after the distribution and of these, 94% had used the nets the night before the survey. It takes intense advocacy for people to start changing their behavior towards such desired standards. Funding for commodities should be balanced with budgets for advocacy and monitoring of commodity use.

Strengthen Monitoring and Evaluation within the Health Systems

Improved performance in a country-led malaria programme depends on the quality of the health system. Countries should be supported to develop health systems that are equitable, efficient and accountable. Monitoring and evaluation forms a key aspect of a strong health system. Monitoring and evaluation is very essential for national strategic planning and policy formulation. Through an effective monitoring system all stakeholders are informed about the performance and impact of the malaria interventions. It is important that national programmes have quality health management information systems that collect accurate data based on standard targets and indicators monitored by partners in both the public and private sector.

Promote Integrated Approaches

Malaria control takes on an integrated approach to reduce the burden of disease. This includes prompt effective treatment of those affected and interventions to protect individuals from mosquito bites. In addition to the above, other main interventions include: Intermittent Preventive Treatment (IPT) during pregnancy, Information, Education and Communication/Social Mobilization, Monitoring, Evaluation and Research; and Health Systems. Integrated approaches that combine malaria control with other health activities have been found to increase the reach and impact of interventions as well as optimize resource utilization. In Uganda one PMI focus is on training health workers to implement prevention of malaria amongst pregnant women through an integrated package of antenatal care services called Focused Antenatal Care (FANC). This FANC needs to be scaled up to support protection of more pregnant women against malaria. The FANC package includes health education sessions to ensure that the pregnant woman knows how to protect the rest of her family against malaria.

More promising integrated approaches that need to be supported include linkages with schools. There is growing evidence that students are an effective vehicle for promoting behavior change including promotion of malaria control behavior right within the homes where they live. For example in Uganda MACIS' NGO partners like AMREF (African Medical and Research Foundation) and UGACAD (Uganda Child AID Development Foundation) are supporting malaria clubs in secondary schools. Students are educated about malaria control and encouraged to spread the information within their communities. Some boarding schools have gone a step further and made a regulation that requires each student to have an insecticide treated net. Behavior change calls for such collective effort and this is critical for the success of any public health intervention including malaria control. I therefore urge the Committee to call for more support for interventions that promote behavioral changes.

Conclusion

I wish to thank the Committee for this great opportunity to testify and share with you some of my convictions on the progress we are making in the fight against malaria. I hope that my testimony has provided some insights into some of the important aspects of leadership, partnership and funding that we need to collectively strengthen as we support affected countries to move towards a malaria free future. It can be done, we are making progress and we must continue to press on. Thank you and may god bless you all.