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African countries must set money aside for malaria vaccines now, and hire business leaders to run control programmes, says Tom Egwang.

Malaria has made life miserable for millions and constrained socio-economic development across Africa. Everyone is waiting eagerly for a vaccine to stem the tide of deaths and the long wait might soon be over, given the significant progress in clinical trials. Africa needs to get ready now.

Poor funding and planning, inadequate infrastructure and logistical problems plague Africa's public health systems. They also constrain the effectiveness of malaria and other disease-control programmes.

Take Apac District, in Northern Uganda, for example. During August 2007 malaria attacked more than 1,500 people a day. Yet tonnes of artemisinin-based combination therapies (ACTs — the only magic bullet against drug-resistant malaria) were rotting away in national medical stores not reaching government health facilities in the region.

The problems are widespread. African children are still dying from measles when an effective vaccine exists. Many parents are still reluctant to accept polio vaccination for their children. And most vulnerable children in the malaria killing fields of Africa still do not sleep under insecticide-impregnated bednets. Yet all three interventions are known to save lives.

So will the malaria vaccine suffer the same fate as ACTs, bednets, and measles and polio vaccines — validated through years of research and development, available in the public or private sector, but unable to reach the target populations? 

Money is a prime concern. The Global Fund, EU, World Bank, USAID and an alphabet soup of other organisations bankroll up to 50% of African health budgets. But, as the global economy teeters on the brink of a recession, donor funds are unlikely to be increased in response to the development of new malaria vaccines. They will probably compete with existing interventions for the same resources. It would be a calamitous blunder if interventions like bednets are neglected because of malaria vaccines.

Faltering vaccinations, struggling finances

The WHO's Expanded Programme on Immunization (EPI) delivers childhood vaccines across Africa. But vaccinations such as BCG (against tuberculosis), polio vaccine, DPT (against diphtheria, whooping cough and tetanus) and measles peaked in the 1980s. Progress has since faltered. During 2000, less than 50 per cent of infants in sub-Saharan Africa received their third required dose of DPT.

The problem is that many communities in Africa do not have access to EPI programmes due to sheer geographical remoteness and poverty. With drugs that don't need to be refrigerated, private drug shops can step in and complete the relay, making medicines available in remote villages. But the private sector in Africa is not yet ready for vaccines.

And public acceptance of a new malaria vaccine must not be taken for granted. A malaria vaccine will probably be based on a recombinant construct. But there is still a strident and hysterical rejection of all things deemed genetically modified in Africa.

Get ready now

One or two malaria vaccines might soon be poised for phase III trials. Assuming that these trials are successful, it might take 4–6 years to license them and scale up production. During this waiting period, each country should start preparing in earnest for their deployment.

Countries should set aside a significant amount of money from tax revenues each year as a reserve for malaria vaccine preparedness. These reserves must take precedence over defence spending. Making peace, not war, should become an important political strategy for national malaria control.

The reserves should ensure that the country can buy and deliver enough doses of approved malaria vaccine to cover all children under 5 years old and all women who are pregnant for the first time.

Governments should give private firms incentives to provide malaria vaccines. The firms could then roll them out to regions not covered by EPI programmes.

Governments must also maintain a robust and vibrant social marketing campaign to increase and sustain acceptance and uptake for malaria vaccines.

Operate like businesses

Above all, malaria control programmes must be rebranded and operated like businesses by a new breed of manager: corporate-style Chief Executive Officers (CEOs). They do not need to be doctors or scientists — rather, they must have strong management and leadership qualifications, and a solid track record of success. Corporate Africa is rich with blue-chip firms led by stellar CEOs. The challenge would be to attract and retain them in the world of medicine.

Such rebranded programmes should be patient-focused, operate to specific measurable and achievable public health targets and strict timelines, and be audited annually. The CEOs should be rewarded with bonuses or laid off, according to performance.

This is a wake-up call for Africa's ministries of health, malaria control programme managers, malaria scientists, policy makers, social scientists and its social marketing experts. Africa is not yet ready for a malaria vaccine. Now is the time to prepare, not simply wait, for the first malaria vaccines to roll off the delivery chain into the EPI.

Tom Egwang is director-general of Medical Biotechnology Laboratories in Kampala, Uganda.

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