Recommendation I: Broaden Attack on Malaria by Strengthening Cross-Sectoral Cooperation for Malaria Control

Background

Humankind's long history with malaria has provided ample opportunity for the trial and failure of many approaches. Earlier this century, "malariologists" alone were expected to be able to control malaria. It is now increasingly recognized that a much broader, coordinated approach, range of skills, and resource base are required in Africa. In addition to epidemiologists and parasitologists, for example, entomologists are necessary to study the occurrence and habits of the vectors; anthropologists are needed to ascertain the local beliefs and practices regarding the perceived cause of malaria, and local methods of prevention and treatment; community development specialists must provide the link to working effectively with communities to conduct the above assessments and to plan appropriate programs that respond to the problems and priorities identified by the communities. Economists, as well as specialists from development sectors that may have an adverse impact on malaria, must also be consulted.

Nevertheless, the health sector in developing countries and in donor agencies, such as USAID, is well placed to take the lead in strengthening a cross-sectoral approach to malaria control. Such an approach will serve to:

• broaden the expertise available. Because of the complexity and scope of this scientific, operational, and human problem in Africa, specialists need to be drawn from a variety of relevant disciplines.
• expand the resource base available for efforts to control malaria. Resources allocated to many development sectors are greater than those invested in the health sector.
• establish planning for malaria control in development efforts falling outside of the health sector. Malaria associated with development efforts can be contained by ensuring that prevention and control measures are built into project planning and implementation requirements.

Actions for National Governments

To enhance malaria prevention and control, the cross-sectoral integration of ministries involved in specific development efforts must be established or, in the case where such cooperation already does exist, strengthened. In particular, the Ministry of Health (MOH) must play a leading role in planning, implementing, and monitoring development efforts that may have an adverse impact on malaria.

The MOH should therefore take the initiative in developing a national group to coordinate anti-malaria activities, effectively involving other relevant ministries, NGOs, women's groups, schools, etc. This MOH-directed group would be responsible for:

• increasing awareness of malaria as a problem among ministries other than health. Ministries of education, agriculture, water resources, town and country planning, and housing, for example, should all consider malaria as being directly relevant to their respective missions. encouraging cross-sectoral cooperation at the regional, district, and community levels, for example:
  • fostering collaboration between a village health worker and an agricultural extension worker for community outreach, education, and training programs, and for regulation of insecticide use. In the Blue Nile Health Project in Sudan, the Health Education and Community Participation Unit utilizes extension officers who promote health education messages by linking up with farmers;
  • strengthening community-level collaboration in the maintenance of local water resources and small irrigation projects;
  • promoting research on community structures and behaviors to facilitate development of appropriate education messages and control strategies;
  • supporting cooperation among development workers from health and other sectors to convey malaria and other critical health- and development-related messages to the community, emphasizing the relationship between development and health.

Other priority functions of such a coordinating group include:

• conducting multi-sectoral prevention campaigns;
• improving the quality and quantity of treatment centers;
• promoting collaboration among the private sector, NGOs, international bodies, etc.;
• facilitating and supporting malaria research; and
• training medical personnel, managers, and extension workers.

Two of several interesting African examples are the cross-sectoral bodies in Ghana and the Sudan. The Blue Nile Health Project (BNHP) in the Sudan has established a participatory management structure, which includes a National Coordination Committee, Management Board, Scientific Advisory Group, and Health Education and Community Participation component. The National Coordination Committee, with wide national membership, has become an important component of the management structure. As the objectives of the project are shared by many governmental and non-governmental departments and agencies, coordination among them and the project administration has become a significant feature of the management system. Notably, the BNHP and the Health Committee on Water Resources in Ghana (described in greater detail later in this report) are both led by the respective country's Minister of Health.

Actions for Donors

Cooperation is required among the sectoral departments of single donor organizations, and among independent donor agencies. Structuring donors in a cross-sectoral manner will assist donors in encouraging cross-sectoral implementation, and in creating a program mechanism for funding cross-sectoral initiatives.

Health sector specialists in donor agencies must therefore establish coordinating bodies within and among donor agencies. These entities would increase awareness of malaria as a problem in sectors other than health, and ensure cross-sectoral planning, implementing, and monitoring of development efforts that may have an adverse impact on malaria.

USAID can also take the lead in working with other international development agencies to establish a model and protocol for cooperation between sectors to establish safeguards against increased malaria transmission. They will also undertake joint evaluations of the program impact on malaria and other health priorities. Lessons may be learned from the World Bank's large-scale efforts to reorganize and reorient staff and to strengthen the Bank's commitment toward safeguarding the environment from development's adverse effects.

Support Existing Cross-Sectoral Cooperation in Sub-Saharan Africa

Existing examples of cross-sectoral cooperation require financial support as well as evaluation to determine how they can best be strengthened, and with regard for potential replication in other settings in Africa. It is also clear that to be sustainable and effective, cross-sectoral bodies must have their own funding and clear authority. A few examples of networks specific to environmental and development-related health issues follow:

1. Ghana: The Ghana Health Committee on Water Resource Development (HCWRD) was inaugurated in 1979 with the objective of examining health implications of proposed water development projects to: encourage, promote, and stimulate research by appropriate agencies on health effects of water development; disseminate information on such effects; and determine resources necessary for improvement of adversely affected groups, etc. The Committee is composed of representatives from health, irrigation, finance, environmental protection, water resource development, and the Council for Scientific and Industrial Research. These individuals represent ministries and related research institutions. The HCWRD evaluates already-existing water development projects and reviews plans for new ones. Recommendations have been offered to groups responsible for implementation and monitoring of such projects, as well as to the Director of Medical Services. The HCWRD has suffered from a lack of funding for these collaborative efforts, resulting in a cessation of meetings for several years. Based on this experience, several recommendations were made: The collaborative body itself must be funded in order to be sustainable; high-level officials should be involved in the collaboration in order to lend credibility and authority to the effort; individuals likely to be involved in such efforts should gain exposure to interdisciplinary approaches through training courses.
2. Ethiopia: A diverse group of specialists, including members of the Ministries of Health and Community Development and the National Institute of Medical Research, organized themselves to apply a cross-sectoral approach to controlling malaria and other tropical diseases. Of particular concern to the Ethiopian group have been changing concentrations of human habitation because of both planned and unplanned migration and settlement.
3. Regional: The Environmental Education and Training Network of the African Ministerial Conference on the Environment is concerned primarily with environmental education at the university level. The members of this network, Centres for Environmental Studies at several African universities, have been active in running short courses in environmental management and have expressed interest in developing activities in vector research as well as other health impacts of development projects.

These cooperative efforts can play a pivotal role in developing cross-sectoral approaches to malaria control and other diseases associated with development.