THE AMAZON MALARIA INITIATIVE:

Looking Towards the Future

Amazon Malaria Initiative and the following years

AMI began in 2001 as a collaborative effort by the U.S. Agency for International
Development (USAID) Latin American and Caribbean Bureau (USAID/LAC) and the
Pan American Health Organization (PAHO). Since 2008, it has been managed by
USAID Peru as part of the South American Regional Infectious Diseases Program
(SARI). The rationale for AMI was the need to invest in targeted activities to improve
malaria control in countries in the Amazon Basin from where 88% of reported malaria
cases in Latin America and the Caribbean (LAC) originated then, according to PAHO.
Since malaria transmission does not respect political borders, AMI was intended to
complement country specific activities with a regional approach. The same rationale
remains valid in 2011 and indicates the need to work with additional selected countries in
Central America in order to secure progress made in the Amazon Region.

Results expected:

Expected AMI results were formulated as follows in 2001:

Reliable and standardized surveillance information on malaria drug resistance and

vector control used to monitor trends and more effectively target disease control
efforts.
Laboratory diagnosis of malaria improved.
Tools and approaches developed, adapted, tested in local settings and disseminated.

These remain valid and will continue to provide the framework for AMI.

When implementing AMI, USAID developed a novel way of doing business based on a
mix of complementary sources of technical assistance led and coordinated by USAID
through a Steering Committee, which has demonstrated to be more effective and efficient
than more conventional approaches to provide technical assistance. Through a highly
coordinated effort USAID, leads a portfolio implemented through a grant to the Pan
American Health Organization and a task order with Links Media managed from
USAID/Peru, and through the USAID/Washington managed activities Strengthening
Pharmaceutical Systems, Integrated Vector Management Task Order, Promoting the
Quality of Medicines, and an Inter-Agency Agreement with the Centers for Disease
Control and Prevention.

Through AMI, USAID collaborates with a network of national malaria control programs,
addressing issues of real common interest identified based on the analysis of countries
and regional context regarding malaria prevention and control as opposed to imposing
an agenda - essentially through the provision of technical assistance, with a very low
proportion of resources used to provide commodities. USAID also promotes South-to-
South collaboration, sharing of experiences, and working in partnership. As a result,
AMI activities respond to each country (Bolivia, Brazil, Colombia, Ecuador, Guyana,
Peru, Suriname, and selected countries in Central America) and to regional needs; and
their malaria control programs are better able to coordinate between them, and to
leverage technical and financial resources from other agents such as the Global Fund for
the Fight against AIDS, Tuberculosis and Malaria.

USAID/Peru provides AMI strategic guidance that has allowed it to evolve not only to
adapt to current malaria context but also anticipating changes in it as to increase the value
of collaboration in malaria control in the Latin America.

From the beginning, within a comprehensive view of malaria prevention and control,
AMI's initial focus was to build the evidence base to support introduction of ACT
treatment for falciparum malaria implemented in all Amazon basin countries, and to
improve access to and quality of malaria diagnosis. As progress was made in introducing
ACTs (Figure 1), the areas of epidemiological surveillance and vector control received
further attention.

Figure 1. Changes in policies for treatment of non-complicated falciparum malaria in AMI countries. 2000-2006

In the mid-late 2000s, the introduction of ACTs was one of the important changes
regarding malaria in the region. Two other important contextual changes were occurring.

One is that as the incidence of malaria in the region decreased (Figure 2), the region was
becoming a mosaic of areas with moderate-low or low malaria transmission, and areas
with no transmission but at risk of it. Such changes in malaria incidence introduced an
additional challenge in malaria prevention and control, because what is appropriate in
moderate malaria transmission areas is not in an area with no transmission but still at risk
of it.
Figure 2. Evolution of malaria incidence in the Americas 2000-2009 (Graphic prepared by PAHO)

AMI is responding to this change by supporting countries to have strategies for

appropriately addressing each of these epidemiological situations (Figure 3). For that
purpose, we have prepared strategic orientation documents that provide guidance on the
best ways to make combined use of tools available in each area of malaria prevention and
control in different epidemiological situations (See illustrative example for vector
surveillance and control for moderate to low transmission in Figure 4).

Figure 3. AMI. Addressing coexisting high and low malaria transmission areas
Figure 4. Yearly timing of collection of entomological data in moderate to low transmission areas (from
Strategic Orientation Document on Vector Surveillance and Control. Graphic prepared by CDC).

An AMI assessment on the adequacy of implementation of ACTs, indoor residual

spraying, insecticide treated bed nets, and timely diagnosis has showed that only ACTs
have been adequately implemented (See figure 5 for an example comparing adequacy of
implementation of indoor residual spraying and of ACTs in four AMI countries).

Figure 5. Comparison of adequacy of implementation of indoor residual spraying and of ACTs in four AMI
countries (From Flores, W. 2011. Impact of Artemisinin-Based Combined Therapy for Malaria in Various
Countries and Implications for the Countries of the Amazon Basin: Final Report)..

In the epidemiological context described, the adequacy of the implementation of

interventions against malaria is essential from selection through evaluation. Hence,
AMI will support countries to ensure that interventions are adequately implemented in
response to their specific needs.

The other change in context is that all countries in the region have advanced in the
decentralization of their health sector and/or the integration of malaria control programs
to other health activities. Malaria control programs formerly managed with independence
from other programs and health services have lost structure and resources that ensured
the implementation of their activities, particularly at sub-national and local levels; and
increasingly depend on other systems beyond their control (e.g. procurement and human
resources) to have the resources to be effective. In response, AMI is enhancing the health
system perspective in its strategy. An AMI assessment on the impact of health sector
decentralization and of program integration on national malaria control programs is
underway.

AMI contributions to date include:

Acting as a catalyst of malaria prevention and control efforts.
Filling important gaps in the region of global efforts in recent years.
Making possible sustained achievements and providing continuity of efforts in the
Region to reach Roll Back Malaria targets for 2010 (all AMI countries have) and
even several those for 2015.
Helping all AMI countries to introduce artemisinin based combination therapy
(ACT), to monitor its efficacy; and to improve their management as well as
quality assurance and control.
Improving the quality of malaria microscopy diagnosis and the introduction of
rapid diagnostic tests.
Improving malaria surveillance
Profoundly contributing in laying out the foundation for successful malaria
country proposals submitted to the Global Fund to Fight AIDS, Tuberculosis and
Malaria (GFATM). Active GFATM grants worth $56,000,000.
Fostering the implantation of an evidence based public health approach in
National Malaria Control Programs (NMCPs).
Strengthening coordination among malaria control stakeholders within countries,
and between countries. It cannot be overemphasized that RAVREDA, the
network AMI has contributed to build, is arguably the most functional malaria
regional network in the world.
Extending AMI strategies, approaches and tools to countries in Central America.

In more operational terms, AMI has been essential to reach the following:
52% decrease in the number of malaria cases (2000-2009)
Nine out of 21 countries have reached 2015 MDG target for malaria
 13 out of 21 countries have reached or passed the 2010 RBM target
Only 3 countries have reported an increase in the number of malaria cases (the
three NOT AMI countries)
All original AMI target countries implement evidence based ACT treatment and
monitor their efficacy
The number of malaria cases treated with ACTs went from zero to 238,416 (2000-
2009, it was 273,670 in 2008)

AMI is inviting other stakeholders invested in malaria prevention and control in the
Americas to work with RAVREDA or at least use RAVREDA as a reference. This seeks
to support the implementation of the Strategy and Plan of Action for Malaria in the
Americas for 2011-2015 prepared by PAHO (presented in June 2011), as well as
programs and activities developed by countries, and decrease the probability of
duplication of efforts and of projects and activities diverting from such goals.

AMIs extension through 2015 will make it possible to work in conjunction with PAHO
in achieving goals put forward in the Strategy and Plan of Action for Malaria in the
Americas for 2011-2015 prepared by PAHO.

AMI will contribute through high value technical assistance in the following priority
areas for malaria prevention and control in the region:
1. Consolidate and further progress achieved during AMIs first 10 years of work,
providing further attention to vivax malaria and to malaria in populations under
special circumstances.
2. Make RAVREDA activities more independent of AMI contribution.
3. Strengthen the regional approach to malaria prevention and control.
4. Have NMCPs effective and efficient in the context of decentralized health sectors,
and adequately implementing all malaria control strategies they adopt in varied
epidemiological settings.
5. Successfully implement the Strategy and Plan of Action for Malaria in the
Americas for 2011-2015.

Some illustrative actions under these headings are:

1. Consolidate and further progress achieved during AMIs first 10 years of work.
One issue that requires particular attention is how to (further) institutionalize capacities
for performing activities pertaining to malaria prevention and control, this involving
identifying which are to be set at the local and/or subnational, and/or national, and/or
regional level(s). For example, in the early 2000s, consideration was given to
maintaining the capacity to run in vivo efficacy studies at the local level, which does not
seem sensible in todays epidemiological context. Maintaining capacities is, in this and
other cases, becoming more of a regional than a country consideration.
 2. Make RAVREDA activities more dependent of country members (financially and
technically).
RAVREDA activities significantly depend on USAID support. For example, Amazon
countries monitor their stocks of antimalarials and have networked to use the information
to avoid stock outs and loss of drugs due to expiration (figure 6), but this still depends
from technical assistance provided by AMI. We will seek that countries network for this
and other purposes on their own, receiving technical assistance only in case extraordinary
issues arise.

Figure 6. Exchange of antimalarials (November 2010) based on monitoring of stocks supported by AMI
(Graphic prepared by MSH).

3. Strengthen the regional approach to malaria prevention and control.

USAID will promote that Amazon countries transition towards one regional scheme for
treating falciparum malaria (Figure 7) in a technically rigorous and systematic manner,
building on the experience of introducing ACTs and on the existence of an operational
regional network of national malaria control programs. AMI would provide technical
assistance in the implementation of the transition, including aspects pertinent to logistics
and the monitoring of efficacy of the scheme chosen, as well as the study of relevant
issues such as the evolution of resistance to other antimalarials that would not remain in
use.
AMI countries are already received input for considering such transition. Based on
factors including countries information on efficacy of ACTs in use, and the availability of
ACTs formulated as fixed-dose combination, there are essentially two choices:
Artemether + lumefantrine (Coartem) and Artesunate+Mefloquine (AS+MQ).
Figure 7. From several to one ACT scheme in use in the Region.

4. Have NMCPs that are effective and efficient in the context of decentralized health
sectors, and adequately implementing all malaria control strategies they adopt in
varied epidemiological settings, the later including populations living in special
circumstances.
Based on findings of an assessment of the impact of decentralization of health sectors on
national malaria control programs, to be completed during CY2011, AMI will collaborate
with countries to address such impact on their capacity to perform all activities related to
malaria surveillance, prevention and control at national, sub-national, and local levels.
5. Successfully implement the Strategy and Plan of Action for Malaria in the
Americas for 2011-2015.
Through AMI activities, USAID will support PAHO and the countries participating in
AMI in the implementation of the Strategy and Plan of Action for Malaria in the
Americas for 2011-2015. It is appropriate to mention that USAID has participated in the
formulation of this document, and that the objectives set in it are consistent with AMI
objectives.

Additional input for the planning of AMI activities for 2011-2015 will be provided by an
external evaluation of AMI currently underway.