Silvio Martinelli, the Global Fund’s Regional Manager for Latin America and the Caribbean, provides an overview of the Mesoamerica and Hispaniola Regional Initiative.

Friends: To begin, can you provide an overview of the Mesoamerica and Hispaniola Regional Initiative?

Silvio: The objective of the Global Fund’s Mesoamerica and Hispaniola Initiative is to help eliminate malaria in this region by 2020 — and to certify it as “malaria free” by 2025 — by bolstering and rewarding effective malaria programs.

The region, which includes Belize, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Panama, Mexico, Haiti and the Dominican Republic, has already made stunning progress in fighting malaria. All across Latin America, in fact, malaria rates have been falling, often dramatically.

The Global Fund, which currently supports country-specific malaria grants in the Dominican Republic, Guatemala, Haiti, Honduras and Nicaragua, has set aside an additional $10.2 million for the initiative to leverage activities already taking place in the countries and regionally. While this is a relatively modest amount of money, it is intended to catalyze malaria efforts in these 10 countries, helping to drive the entire region toward elimination.

This initiative was also an early part of the Global Fund’s new funding model, which aims to approach to investments more strategically and for greater impact.

Friends: You mentioned that this region has seen great progress with respect to malaria. Can you give us a bit of background on that?

Silvio: Much of the region has already met the Millennium Development Goal of reducing the number of diagnosed cases by 75 percent. Three countries — Costa Rica, El Salvador and Mexico — are in the pre-elimination phase. The remaining seven countries are in the control phase, with some nearing pre-elimination.

Narrowing the focus to one community, we can see the astonishing level of impact. For example, by implementing comprehensive interventions, the Wampusirpi municipality in Honduras reduced the number of reported malaria cases from 700 in 2010 to fewer than 10 in 2011 and 2012.[1]

Of course, in some areas, there is still a long way to go. But for many countries in this region, malaria elimination is within reach.

Friends: How is the regional initiative intended to help support rapid impact? Are there particular challenges that the Global Fund is addressing through the regional initiative that will help drive success?

Silvio: We are so close to achieving malaria elimination in this region. To the best of our collective ability, we want to ameliorate the obstacles that remain. In essence, this is what the regional initiative is intended to help do.

For example, many of the countries in this region already have strategic malaria plans in place or are in the process of updating or developing one. However, a recent evaluation conducted by the Pan American Health Organization (PAHO) and the World Health Organization (WHO) identified that the pre-existing frameworks were largely focused on controlling the disease rather than on elimination. According to the PAHO/WHO assessment, even those countries in the sub-region that are in the pre-elimination phase and complying with the established criteria could use targeted improvements. In other words, though progress is being made, there is a need to optimize efforts to reach elimination. This is an area where the regional grant can help.

And, of course, funding is a challenge. Countries in this region rely mainly on domestic funds; external aid beyond that from the Global Fund is scarce. As with other diseases, finding and treating the last cases is always more expensive.

We do not want these challenges to prevent us from reaching elimination. The Global Fund sees an opportunity to help drive the region toward this final goal by building on the impressive reduction in malaria already achieved, and by supporting the use of the latest existing epidemiological evidence and lessons learned to accelerate impact.

Friends: You mentioned that the Global Fund also funds country-specific malaria grants in this region. What is the level of funding for these country grants?

Silvio: Out of the 10 countries included in the regional initiative, the Global Fund has individual malaria grants with the Dominican Republic, Guatemala, Haiti, Honduras and Nicaragua. The total invested for malaria programs in these countries since 2002 is about $119 million, 80 percent of which has already been disbursed. Haiti has the largest share — about $36.8 million — followed by Guatemala with about $18.5 million.

Friends: Can you explain why the Global Fund decided to create the regional initiative rather than simply allocate the $10.2 million across the country grants?

Silvio: Mesoamerica is made up of countries that share land, customs and high rates of population migration as well as malaria-causing parasites that are sensitive to the same medicines. Regional coordination with cross-border management, therefore, is needed to address risks, make surveillance and case tracking more flexible, and improve logistical programming. If “business as usual” is applied in this region, malaria elimination may unnecessarily take longer and many more lives will be impacted by or lost to the disease.

Already, agreements have been established between Honduras and Nicaragua; Costa Rica and Panama; and Guatemala and Mexico. Building on these coordination efforts will help to ensure that interventions are sustainable, progress can be maintained, and that malaria-free areas remain malaria-free.

Importantly, the regional initiative will help to facilitate the exchange of information, experience and lessons learned across the entire region, providing an opportunity for the countries to create a more harmonized approach and reach the collective goal of elimination.

Friends: Can you provide an example of how coordination between and among these countries will drive increased effectiveness?

Silvio: Certainly — let’s look at Haiti and the Dominican Republic. Frequent migration occurs between these countries, which are co-located on one island. So there is a high risk of continuous malaria parasite transfer. Combined with the fact that the disease is concentrated in remote and hard-to-reach areas, tracking patients becomes quite challenging. In addition, treatment approaches differ in each country, making it difficult to control malaria in border areas and among the migrant populations.

This is where this regional initiative can add value. It offers an opportunity to help standardize national policies and rules, which will facilitate malaria elimination.

Friends: How will impact be measured?

Silvio: The Global Fund, participating countries, and partners have all agreed to use a performance-based, “Cash on Delivery” financing mechanism to increase efficiency in the use of available funding. The reduction of the number of local malaria cases is the single indicator that will trigger a financial reward mechanism. Independent verification of the reduction in cases will be needed to release this monetary reward, which will be highly flexible, with few limitations, allowing countries to invest it at their discretion in the strengthening of core health systems.

This type of performance-based reward mechanism is intended to intensify the focus on impact, rather than only inputs or outputs. It encourages the use of high-impact interventions that will most quickly lead to a decrease in local malaria cases. Finally, it creates a powerful incentive to improve a program’s surveillance system, so that countries are able to demonstrate a decrease in local cases and receive a corresponding financial reward.

As part of the national grants and programs, all countries also will measure other indicators, such as coverage with vector control interventions and the number of locations that exist by epidemic classification (e.g. high transmission area, low transmission area, etc.) as outlined in the WHO Manual on Disease Surveillance for Malaria Elimination.

Friends: Will the entire $10.2 million, then, be used for the performance-based financing mechanism?

Silvio: The largest portion of the grant — $7 million — will be allocated to the Cash on Delivery reward mechanism. However, the rest will be used in other areas such as:

  • External verification of target achievement, which is a critical component of this approach;
  • Regional lines of work, which will not duplicate in-country interventions;
  • Start-up funding for countries that do not have, or are not eligible for, Global Fund country grants; and
  • Principal Recipient support. Population Services International will perform this important coordinating role for the regional grant.

Friends: What is the current state of the initiative? What are the short- and long-term goals?

Silvio: The long-term goal of this initiative is to reach elimination of malaria in this region. In addition to working toward zero local cases of malaria by 2020, we aim to certify regional elimination by 2025. Toward this end, the government of Costa Rica hosted a meeting in June of 2013 with all malaria programs, key technical counterparts and partners involved in the initiative. At this meeting, the Council of Ministers of Health of Central America (COMISCA), as well as the governments of Haiti and Mexico, committed through a declaration to reach zero cases of malaria by 2020, and to align efforts for the acceleration of elimination in Mesoamerica and Hispaniola.

Under the leadership of the Regional Coordinating Mechanism, the countries began negotiations for a concept note for a Global Fund grant, which was signed in March 2014. $200,000 in startup funds are now being disbursed to six countries. These countries will present their results in early 2015 so that a disease baseline can be confirmed. In the first quarter of 2016, funding based on the 2015 results will then be awarded.

This post was originally published in August 2014.

Footnotes

[1] Banegas E. I., Mejia R. E., Singh P., Burgos E., Aguilar J., Calderón K., Montalvan W. and Talabera M. P. An integral intervention for malaria control in the municipality of Wampusirpi, Gracias a Dios. Poster session presented at: Research Without Borders. 6th Biennial NeTropica Meeting; (2012) 25–27 Jul; Copán, Honduras.