Recommendation III: Strengthen Local Capacity, Including Developing Cross-Sectoral Approaches

In order to ensure achievement of the long-term goal of locally sustainable malaria control efforts in Africa, highest priority must be placed on investing in Africans themselves, principally by a broadened, more intensive approach toward building the capacity of African specialists and institutions.

It is thus necessary to support training and capacity-building, within local universities and institutions, as well as through less formal structures, for malaria specialists at the doctoral and post-doctoral levels, and also for multi-skilled workers, at lower levels.

Training

There is a shrinking number of trained malaria specialists in Africa. This lack is apparent at all levels, from the very specialized medical entomologists to the more general mid-level technicians to the community health worker as well. It is critical that the corps of expertise in Africa be strengthened, and in some disciplines entirely rebuilt.

• Program managers should be trained cross-sectorally -- through work in, for example, agriculture, health, education, water, and economics -- to prepare for cross-sectoral collaboration. Training should expose students to other perspectives, encourage exploratory ideas and provide experience working in a cross-sectoral team in order to prepare students for cross-sectoral work.
• Training in health sciences should include a special emphasis on malaria, because of the magnitude of the disease as a health problem in Africa.
• It is also critical for health workers at all levels to receive continuing education through seminars and conferences, in order to stay informed of the latest concerns and developments with respect to malaria, such as drug or insecticide resistance or possible side effects.
• Management training must be included in technical training curricula. Entomologists and malariologists need to be trained not only in research, but also in the design, management, and implementation of malaria prevention and control programs. Presently, the successful implementation of technically sound programs may be compromised because of a lack of management training for technical staff.
• In order to effect multi-level, cross-sectoral cooperation, trained manpower is needed at the ministry level in anthropology, community medicine, economics, epidemiology, health planning, information sciences, medical entomology, public health engineering, and sociology.
• There is a need to engage in other means of training/capacity-building. It is recommended that such programs could be effectively implemented by NGOs, and should be a funding priority of donors, including:
  • North/South and South/South exchanges that would facilitate appropriate technology transfer among individuals and institutions;
  • mentorships that encourage interactive relationships between junior and senior scientists; and
  • training programs, or short courses, sponsored by professional societies, networks, or other "unofficial" bodies.

Case Study: Training in Tanzania

• Diploma of Vector Control is intended for experienced health officers. It aims to improve their technical skills in vector control and enable them to plan, implement, monitor, and evaluate vector control programs at the district level of in large urban areas. The curriculum includes both theoretical and practical training.
• MSc in Tropical Disease Control aims to prepare individuals for work in ministries or institutes. Candidates are trained to: identify community health problems for purposes of research and control; investigate particular aspects of endemic diseases; design, implement, and evaluate disease control programs; and mobilize communities for participation in prevention/control. The two-year comprehensive curriculum includes courses in behavioral sciences, community health, epidemiology, biostatistics, microbiology, and immunology.

Candidates have university degrees in medicine, social sciences, engineering; admission is open to African nationals.

Also offered in Tanzania are diplomas in public health engineering, and in public health, as well as a Master's in community health. Training at Muhimbili Medical Centre is carried out by staff there, as well as by representatives from the National Institute of Medical Research.

Capacity-Building

In designing strategies for malaria control tailored to specific communities, a need was identified in Africa to establish a mechanism to utilize and build capacity (i.e., to strengthen the skills and knowledge of beneficiaries so that they can take responsibility for managing projects themselves).

Three different proposals were offered by participants to meet these needs:

• Option 1: Regional Resources Centers
• Option 2: Networks of Specialists
• Option 3: Malaria Institute

Since each proposal has relative advantages, each is individually summarized below. Following these descriptions, recommendations are provided regarding options for funding these regional structures.

Option 1: Regional Resource Centers

Structure

Four regional centers are proposed, of which two would be in Francophone Africa (one in the arid/Sahel region and one in the equatorial/forest region), and two in Anglophone Africa (one in East Africa and one in West Africa).

These centers, in general, need not be created de novo; they can be created from existing research/training centers. They are intended to increase affiliations, networks, and connections with experts in country, in the region, and internationally. These centers will be staffed by representatives of many disciplines, including: agronomists, anthropologists, clinicians, ecologists, economists, engineers (civil, public health, etc.), epidemiologists, health service administrators, medical entomologists, parasitologists, and sociologists. The centers will specialize in malaria control specific to different ecological regions, and will have satellite units accessible to and familiar with ecologically diverse situations within individual countries and across the region. However, no center will be directly responsible for a country's national malaria control program.

Multidisciplinary Team

Multidisciplinary teams prepared to collaborate with development planners, nationally and internationally, can be trained in and available through these resource centers. The teams will provide expertise to meet the requirements of a cross-sectoral approach (enumerated in Recommendation I) needed to prevent an adverse impact on malaria from development efforts including:

• performing baseline and longitudinal epidemiologic assessments for malaria;
• involving communities in the planning and implementing of the center's activities;
• designing and establishing safeguards; and
• modifying development plans, as necessary, to alleviate adverse effects.

Other Center Functions

• Service: Center staff will conduct or participate in the preparation of Environmental Impact Assessments and/or Malaria Impact Statements in response to preliminary project proposals and upon request of donor agencies. Center staff will also provide input into initial development plans to ensure planning to prevent potential adverse impacts on the transmission of malaria. Staff will also be expected to make recommendations for modifications to project plans as required to ensure a reduction in transmission. Moreover, they will monitor the implementation and long-term operation phases of development projects and ensure adherence to control strategies.
• Research: Each regional center will be responsible for an ongoing research program, specific to the expertise housed in the center and/or to the problems unique to the sub-region, for example:
  • evaluation of existing malaria control technologies for use in specific locales;
  • evolution of new control strategies;
  • follow-up evaluation and modification of older (sometimes prematurely discarded) technologies;
  • research in malaria-related topics, for example: epidemiology, immunology, chemotherapy, rapid diagnosis; and
  • research in the social, cultural, and epidemiological issues particular to affected communities, relevant to selection (and success) of appropriate control strategies.
• Training: Each regional center will provide training functions on several levels: postdoctoral, predoctoral, and mid-level (e.g., technicians, vector control specialists). The centers will provide managerial as well as technical training on all levels. Continuing education will also be provided by the centers, or their satellite units.
• Education of and interaction with the community: The centers will have longstanding, interactive ties with their neighboring communities. Their mandate will include the application of research on cultural factors that affect a community's perception of social and health problems, including disease and appropriate treatments (for example, identification of and cooperation with social and religious leaders as well as churches, schools, active women's and men's groups, and agricultural extension workers).

The centers will also disseminate health education messages. The messages disseminated and the methods used will be determined (respectively) by what is appropriate to the target population, given a community's needs and structure, and by the community's access to high-technology media: Radio and television can be used, where feasible, to reach a large portion of a population. However, centers will also be prepared to disseminate such information using "lower technology" where more effective, such as posters and booklets for non-literates.

Expected Outcomes

The expected outcomes of establishing such centers will be a general reduction of malaria transmission associated with development, through the creation in Africa of integrated control strategies appropriate to the various regions and ecological zones of malaria transmission. The centers will support the application, by these resident specialists, of the latest advances in an African context. The centers will also foster the training of a cadre of African experts, who will be linked in an Africa-wide network of malaria research and training centers, with close ties to leading malaria centers worldwide. An important aim of the centers is to reduce "brain drain" by providing an environment within Africa that is stimulating for African scientists.

Option 2: Network of Specialists

This approach will allow intersectoral, intra-African, and intercontinental cooperation to be implemented without the delays and the burdens of substantial inputs that institution-building may entail. The network will also permit the most direct manner of collaboration among overseas and African scientists.

The network will comprise:

• a designated center that will operate as the coordinating unit, and which may be an existing research institution or university; and
• other existing centers in Africa that will work to complement each other to conduct pre-project planning and regular monitoring and evaluation to ensure that the linkages between malaria and development are understood, anticipated, and controlled for.

The technical coordinating unit of the network will:

• identify African scientists who will participate in the network and promote communications among them;
• facilitate and coordinate research among network participants;
• work with African scientists in the network to
  • plan and carry out Malaria Impact Statements
  • plan, implement, and monitor safeguards proposed to reduce malaria transmission
  • prepare guidelines for malaria reduction during project development
  • organize and carry out short training programs at various locations
• seek and channel funds to strengthen the participating centers as may be necessary to enable scientists to function within the network.

Option 3: Malaria Institute

Structure and function

This institute will maintain a database of relevant scientific literature on malaria, including the less widely available journals -- especially those published in developing nations in Africa and elsewhere. The malaria literature will therefore be available in a central location in Africa for all scientists and others on the continent interested in problems of malaria. Electronic transfer of requested information will provide academic and governmental agencies ready access to the world's records of malaria-related research findings.

The center will collect not only written data, but specimens of malaria vectors, maintained in an up-to-date insectary for studies on vector biology, insecticide resistance, etc. It is proposed that rather than being a broad-based, high-technology center focused on vector biology, the institute concentrate on applied problems related to malaria vector control strategies specific to Africa and be a resource for other research laboratories throughout Africa and elsewhere in the world. Museum-type collections of vectors will be maintained for teaching purposes. Regarding the vectors, malaria parasites could also be collected throughout Africa and, although some strains might be maintained in culture, a comprehensive collection, stored in liquid N2, could provide materials upon request to research institutions worldwide. Thus, the institute will not only provide malaria parasite strains for research purposes but could conduct limited investigations on drug resistance and other practical issues related to control and treatment of malaria. These activities could include studies on bed nets, insect repellents, and new insecticides.

In addition to acquiring literature related to malaria and collecting malaria vectors and parasites, the institute could actively accumulate data on malaria epidemiology, monitoring changes and the spread of parasite drug resistance and insecticide resistance throughout the region. These data will reflect changes in malaria endemicity -- especially those related to development projects, urbanization, demographics, etc.

Dissemination of information on malaria will be one of the principal tasks of the institute. Since the focus of the institute will be malaria control, workshops on malaria control techniques will be held on a regular schedule. These will be aimed at training individuals and national teams interested in malaria control. These workshops will outline the organizational infrastructures necessary for malaria control programs as well as the management training required to ensure results. In addition to providing "in-house" training, the institute will maintain teams of extension agents that will offer technical advice and evaluation of local programs and problems related to malaria control demonstration sites located near the institute could be used for teaching proper use of developed technologies. The center will also produce and disseminate videos and written instructional media related to malaria control.

The institute will become a valuable resource to assist international agencies interested in development projects to conduct appropriate environmental and health impact assessments related to malaria. Post-project monitoring of changes in malaria endemicity would provide useful experience to direct future development efforts.

The center will maintain a permanent staff with guidance from an international board of directors selected from African member states and international development agencies.

A single institute is recommended, the focus of which is principally the reduction of morbidity and mortality of malaria through the appropriate application of the best available technologies and methods. Its mission is chiefly one of training and service, with research activities limited to the evaluation of malaria control-related activities and issues related to drug resistance, insecticide use and resistance, management of development schemes, education and media campaigns, etc. Its mission should not be competitive with existing institutions, the principal aims of which are basic research related to malaria. The proposed institute will be bilingual and viewed as a resource center dedicated to problems of malaria control in Africa.

Funding Alternatives

There are several possible means for funding any of the above-recommended options. Because development itself has the capacity to influence malaria, control should be the responsibility of those most directly responsible for supoprting the development scheme -- the appropriate national agency and donors. It therefore would be reasonable to expect the donor agencies to play a role in supporting the infrastructure necessary to address the linkage between malaria and development.

This support could come form an annual assessment levied on all development schemes scheduled for Africa. Funds would be provided by the donor at the start of the fiscal year and be based on the total development budget. A flat rate of one percent might be recommended. Or the percentage to be contributed might be determined based on the potential adverse impact of each project being reviewed by objective center/institute staff. Moreoever, some mechanism for enforcing payment of a tax must be established, e.g., access to center/institute/network resources will be contingent on payment of fee.

• Additional revenue could be provided by international development agencies and NGOs interested in development in Africa.
• Donations might come from African member states independent of the required percentage of all development projects where EIAs suggest potential or real impacts on malaria endemicity.
• Fees from workshops and other services provided for users would also help to offset the cost of operation of the institute/centers/network.

These funds would:

• support the regional centers/network/institute and their research training functions;
• support the preliminary malaria impact studies;
• support the monitoring programs of the implementation and operational phase of the development schemes; and
• place centers/network/institute in a position to provide advice and pilot experience to development schemes and national malaria control programs.