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.
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.
Case Study: Training in TanzaniaIn Tanzania and in many other African countries, since the 1960s, malaria assistants, malariologists, entomologists, and engineers have not been trained in large enough numbers to deal effectively with the growing problem. In response to this need, one participant's paper describes training programs recently developed in Tanzania to redress the shortages of health personnel and to update and enrich the curricula of the actual training programs for malaria prevention and control:
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.
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:
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
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 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:
Other Center Functions
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.
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:
The technical coordinating unit of the network will:
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.
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.
These funds would: