Plus

Plus

A tangled web they weave
Is the massive grant for malaria in jeopardy? Kumudini Hettiarachchi investigates
A major foreign-funded project, amounting to millions of rupees, to distribute mosquito nets to the poorest of the poor in the northeast and bordering areas, has run into a storm in a tangle of claims of non-transparency, arbitrary decisions and allegations of pay-offs.

The key players in this tragic drama, which would ultimately affect the thousands of men, women and children in malaria-prone areas, are the Health Ministry, the Anti-Malaria Campaign (AMC), Sarvodaya, the World Health Organization (WHO) and the Lions Club.

The project to distribute "long-lasting insecticidal nets" as the mosquito nets are dubbed involves big money from the Global Fund to Fight AIDS, TB and Malaria and comes in the form of a grant in addition to other funding for several more activities. The Global Fund has allocated US$ 3.8 million (over Rs. 380 million) for the distribution of 320,000 nets to marginalized people in the two years -- 2003 and 2004.

Although the mosquito net project has been plagued by problems since its inception in 2003, by the beginning of this year (2004), 97,000 nets had been distributed. However, major concerns and contradictions have become evident with regard to the second lot of 223,000 nets to be purchased right now under an allocation of around US$ 2.6 million. (See box for project details)

Among the web of issues the project is enmeshed in, one crucial question seems to have been tucked away conveniently without a thought. Will the humble people such as farmers, fishermen, pregnant mothers, small children and also refugees in malarial areas, who are supposed to be the beneficiaries get the best product? Or are arbitrary and uninformed decisions being made to foist on these people who have no voice, any product that the so-called decision-makers think they should use? Could this be for reasons varying from utter callousness, indifference, inefficiency to corruption?

These are the vital issues in this complex matter that demand the immediate attention of the government. Most of the mosquito nets would be distributed among people in the northeast, areas that have been, until recently, inaccessible to malaria-control programmes. No one knows the outcome of the peace talks and how long accessibility will remain.

"Isn't it only logical, therefore, to provide them with the best possible option, in the form of long lasting mosquito nets, to protect them against malaria?" ask experts, while an investigation by The Sunday Times finds that the cheaper product is to be bought, without consideration for the "long-lasting quality" that malaria experts are stressing on.

What of the reality with regard to the project itself?
Two international companies have so far been "recommended" by the WHO Pesticide Evaluation Scheme (WHOPES) for "long lasting insecticidal nets" in malarial areas. The 'Olyset Net' produced by Sumitomo Corporation of Japan comes with a "full recommendation" while PermaNet 2 produced by Vestergaard Frandsen of Denmark comes with an "interim recommendation". The Sumitomo Corporation is represented by Colombo Liaison Representative with offices at the World Trade Centre and Vestergaard by Hummingbird Trading Co. Pvt. Ltd. at Narahenpita. Vestergaard also has a branch in India.

The WHOPES recommendations follow extensive field studies on the netting material and the chemical used to impregnate the net to prevent and control malaria.

The WHO website is very specific about the two types of nets. It states: "Olyset is effective in providing personal protection against malaria vectors for at least five years.” With regard to PermaNet 2.0 "considering the safety, efficacy and wash resistance of PermaNet 2.0, interim recommendation is given for its use in the prevention and control of malaria. WHO should support and facilitate large-scale field studies to confirm long-lasting efficacy for malaria and other vector-borne diseases".

The picture gets clearer - for 'long-lasting efficacy', WHOPES guarantees Olyset but 'large-scale field studies' need to be done, it says, to confirm this with regard to PermaNet 2. Another factor that becomes apparent is that PermaNet 1, the first product of Vestergaard was found to be effective only for two years.

This is also what the Technical Evaluation Committee appointed by the CCM (Country Coordinating Mechanism) itself has gone by and persistently recommended. Even at a meeting on November 16, this is what the Technical Committee has stressed. The committee comprises Health Ministry Secretary Dr. Athula Kahandaliyanage; Health Ministry Consultant Dr. Punsiri Fernando (Vector-borne Disease Control and GFATM); and Anti-Malaria Campaign's Acting Director Dr. Lakshman Siyambalagoda and Consultant Community Physicians Dr. Rabin Abeyasinghe and Dr. Gowrie Galappaththy.

The Technical Committee has also raised a point over the "ambiguous situation" created by two communications fromWHOPES/Geneva and the WHO local office.

We want the best and the most long-lasting net to protect the people for as many years as possible, the AMC emphasises.

Strangely, without clarifying this "ambiguous situation" the CCM has decided at a meeting on November 16 to get the "cheaper" one of the two, as opposed to the best one suitable. Ironically, two members of the Technical Committee who are also on the CCM - Dr. Punsiri Fernando and Dr. Lakshman Siyambalagoda have agreed to one recommendation at the Technical Committee but to a completely contradictory decision at the CCM.

The Sunday Times reliably learns that despite a clear indication from the Technical Committee, Sarvodaya has now been issued instructions to order 223,000 PermaNet 2 nets. When contacted by The Sunday Times Dr. Fernando said both nets were recommended by the WHO.

Retired and re-employed ministry Consultant Dr. Fernando, based at the AMC office, explaining that he read out the Technical Committee's report at the CCM, claimed that the CCM decision was based on the price factor, as the PermaNet 2 was cheaper and also because there has been much delay. “There is a fear of the Global Fund cancelling the project,” he said.

Vestergaard nets are being offered at US$ 4.9 per net (cone-shaped) and US$ 4.3 per net (rectangular-shaped), while the Olyset family net is available at US$ 7.6 per net.

Dr. Siyambalagoda said his major concern was the delay.
However CCM sources said the body which was supposed to be apolitical had political involvement and many members were afraid to speak up.
Sarvodaya which is in the midst of the net issue has a major grievance. "We are being used as a cat's- paw. We sought the help of the Anti-Malaria Campaign as we didn't have the necessary technical expertise. Now we find the AMC itself is in the dark about technical matters but dominating Sarvodaya. The AMC is using us to achieve their end. It is not the entire AMC consultants but a few who think they are the last word in malaria," says Dr. L.P. Chandradasa, the GF Project Director of Sarvodaya handling the mosquito nets issue.

All these crises and problems that have been dogging the project, says Dr. Chandradasa, have compelled Sarvodaya to pull out at the end of Phase I in May 2005 and not be a partner in Phase II.

His other grievance is the 'price factor'. "We bought the first set of Olyset family-size rectangular nets at US$ 7.6 per net but now for the second set, a quotation of US$ 5.1 per net has been given. How has the price come down suddenly?"

Documents in the possession of The Sunday Times reveal that the price change has not been informed to the CCM on one hand and that a letter sent by the WHO to Dr. Fernando on the fact that it cannot guarantee the prices until the time of actual purchase had not been presented to the CCM. Dr. Fernando, when asked denies he received such a letter, though The Sunday Times has a copy.

In view of these problems and controversies dogging the mosquito net project, the government at the highest level, needs to set up an independent body to check out the following:

Is the best net, suitable and also long-lasting, being imported under this project?
What is the most suitable shape - rectangular or cone?
What is the role of the WHO local office in all this confusion?

If the net project is veering off course, Sri Lanka, specifically the Health Ministry needs to take firm decisions to set it right quickly. Funds coming in with no strings attached should not be allowed to go down the drain but to the target group - the marginalized people in malarial areas. If not, the final consequence may even be the Global Fund stopping these funds.

What is the project?
Sri Lanka, with specific reference to malaria, had requested major funding in 2002 from the Global Fund based in Geneva for "intensive malaria control among the hitherto marginalized populations in conflict-affected districts in Sri Lanka who are presently afflicted with a very high malaria burden".

The total funding -- provided by GFATM which specifies a private-public partnership for project implementation -- is US$ 8.34 million and is to be disbursed over a five-year period, under Phase I (covering the first two years) and Phase II (covering the next three years). For the first two years a sum of US$ 4.46 million has already been disbursed. However, the funding for the Phase II is conditional on the performance and success of Phase I.

According to the procedure required, the country requesting the funding, in this case Sri Lanka, has to send the project proposal through a mechanism set up specifically for this purpose called the Country Coordinating Mechanism (CCM). In this project, the fund recipients are the Health Ministry (Principal Recipient 1) and Sarvodaya (Principal Recipient 2).

The major components to be handled by the private sector or non-governmental organization (NGO) in this case -- PR2 or Sarvodaya - are:

health education in the community
promotion of the use of locally available mosquito repellents, spraying and use of treated bed nets
distribution of larvivorous fish to the communities to prevent breeding of mosquitoes

Under Sarvodaya (PR 2), comes the sub-recipients, Lions Club, Sarvodaya Community Health Unit, Colombo University and Independent Medical Practitioners' Association (IMPA). With regard to the mosquito net issue the grassroots level sub-recipients are Lions Club and Sarvodaya Community Health Unit assigned to distribute the nets to the needy.

A major portion of the US$ 4.46 million for the first two years, US$ 3.8 million, is for the procurement and distribution of mosquito nets. Meanwhile, the local fund agent representing the Global Fund is PricewaterhouseCoopers based at Braybrooke Place, Colombo 2.

According to the overall project documents, the "anticipated result" of the project, including both the government (Health Ministry) and NGO (Sarvodaya) input is the reduction of malaria incidence in the North-East Province to 2 per 1,000 population, from the current figures of 15.8 per 1,000 population.

Back to Plus