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The Millennium Villages project is led and executed by the communities on the ground in Africa. Throughout the continent, more than 400,000 people are leading this bold initiative, giving their time, skills, and resources to make the project a success and one that is relevant to local conditions. Because Millennium Villages are an investment toward a sustainable end to extreme poverty, Millennium Village communities strengthen their local governments and institutions and certify the preparation and implementation of the interventions in their community. This is necessary to ensure that their development will become sustainable and self-sufficient.
The Millennium Village project is based on the findings of the UN Millennium Project and is led by the science, policy and planning teams at The Earth Institute, Millennium Promise and the United Nations Development Programme. The Millennium Villages project offers a bold, innovative model for helping rural African communities lift themselves out of extreme poverty. The Millennium Villages are proving that by fighting poverty at the village level through community-led development, rural Africa can achieve the Millennium Development Goals — global targets for reducing extreme poverty and hunger by half and improving education, health, gender equality and environmental sustainability — by 2015, and escape the extreme poverty that traps hundreds of millions of people throughout the continent.
With the help of new advances in science and technology, project personnel work with villages to create and facilitate sustainable, community-led action plans that are tailored to the villages’ specific needs and designed to achieve the Millennium Development Goals. With regard to malaria, significant progress has been seen after the provision of long-lasting insecticidal bednets (LLINs) for every sleeping site was introduced. Three years later, there is a seven-fold increase in bednet utilization rates and a 60% reduction in malaria prevalence on average across the sites. The Center for National Health Development in Ethiopia (CNHDE) developed the strategy for malaria control in the MVP based on universal coverage of the population at risk with preventive and therapeutic measures; with free, mass distribution of Long-lasting Insecticidal Nets (LLIN); together with availability of free treatment with Artemisinin-based Combination Therapies (ACT), implemented by governmental health facilities. In areas of high transmission, Intermittent Preventive Therapy (IPT) is administered by local health resources to pregnant women as part of antenatal care. Community Health Workers, trained to diagnose with Rapid Diagnostic Tests (RDTs) and treat with ACTs, support community-based case management. Through the use of innovative technologies (RDTs, mHealth/ChildCount+) and training the MVP has brought the diagnosis and treatment of malaria down to the household level, thereby allowing diagnosis and treatment to happen earlier. With RDT segregating febrile cases, doctors can now more accurately diagnose non-malarial causes of fever such as pneumonia and meningitis, and refer these cases to the apropriate treatment center. Diagnosing malaria accurately at the household level allows the visiting community health worker to better engage in the preventive or promotive discussion of bed nets and mosquito larva breeding sites since CHW can observe directly the situation at the household where malaria case occured.
Additionally, simple solutions like providing high-yield seeds, fertilizers, medicines, drinking wells, and materials to build school rooms and clinics are effectively combating extreme poverty and nourishing communities into a new age of health and opportunity. Improved science and technology such as agroforestry, antiretroviral drugs, the Internet, remote sensing, and geographic information systems enriches this progress. Over a 10-year period spanning two five-year phases, community committees and local governments build capacity to continue these initiatives and develop a solid foundation for sustainable growth.
Currently 80 Millennium Villages are clustered into 14 different sites in 10 countries. Each cluster site is located in a distinct agro-ecological zone which together, represent the farming systems used by 90% of the agricultural population and 93% of the agricultural land area of sub-Saharan Africa. The sites range from slash-and-burn in rainforest margins to pastoralism in deserts and represent different situations of population density, soils, climate, water access, disease complexes and burdens, environmental degradation, market access, education levels, cultures, religions, and gender issues.
The main goal of the Tropical Laboratory Initiative is to combine and simplify the latest technology for diagnostics at the point-of-care to reduce the number of missed and misdiagnosed cases, to provide an entry point into clinical care, and to significantly reduce morbidity and mortality associated with malaria, HIV/AIDS, tuberculosis, neglected tropical diseases (NTDs), and pregnancy-related complications.
In 2005 the UN endorsed quick wins as critical for accelerating progress towards the Millennium Development Goals. The Quick Impact Initiative on malaria was a response to the UN Millennium Project Task Force on malaria, which recommended a rapid scale up of malaria control to achieve a quick impact in MDG 6: combat HIV/AIDS, malaria and other diseases.
The Quick Impact Initiative on Malaria (QII) of the Earth Institute was designed to provide extensive technical support to endemic countries to address the bottlenecks that were preventing malaria control efforts from being successful. It has played a major role in mobilizing resources for the scale-up of malaria control in Africa. With malaria experts based in Bamako and Addis Ababa, to support West and East Africa respectively, the QII provided on-site, hands-on support to national malaria control programs in fourteen countries for assessing needs, planning and budgeting comprehensive malaria control, securing funding from international donors, planning and supporting program implementation and identifying bottlenecks to successful malaria control. Internationally, it has advocated for increased funding, policy change and harmonized work that leads to greater efficiencies.
QII has supported Ethiopia, Djibouti, Liberia, Madagascar, Nigeria, Sao Tome e Principe, Senegal, Mali, Ghana, Kenya, Tanzania, Uganda, Malawi and Madagascar in applying to the Global Fund for funding for malaria control in rounds 7, 8, 9 and 10. It has helped these countries to mobilize close to US$1.3 billion for scaling up malaria control interventions.
The malaria program has advocated for a policy environment that enables the management of malaria in the community, as close to the household level as possible, where most of the patients are cared for. Since 2009, community health workers of the Millennium Villages in Nigeria, Ghana, Senegal, Mali, Malawi, Kenya, Tanzania, Uganda, Ethiopia, and Rwanda are diagnosing malaria with Rapid Diagnostic Tests (RDTs) and treating it with Artemisinin-based combination therapy (ACTs).
The experience of the Millennium Villages with community-based management of malaria is helping to inform malaria treatment policies in Africa. The Earth Institute has worked closely with the Mali National Malaria Control Program to promote community based management of malaria as a viable and cost-effective strategy, and the country’s malaria strategy has been revised accordingly. RDTs are changing the way in which malaria is seen and managed in Africa, and as such, continued training, re-training and supportive supervision, quality assurance mechanisms as well as a solid system for documenting impact are needed to adopt new guidelines for diagnosing and treating malaria.
In 2007, Legatum provided funding - through Geneva Global - to the Global Network for a three-year initiative dedicated to NTD control in Rwanda. In collaboration with the Earth Institute, Columbia University, the Access Project has built a strong foundation for sustainable NTD control through partnership development, training of health professionals and teachers, and mapping and baseline surveys.
In the past three years the Access Project, in close partnership with the Rwandan Ministry of Health, provided over 17 million deworming treatment to Rwandans. In one recent campaign in October of 2009, 4 million children and 500,000 post-partum mothers were treated. In schistosomiasis-endemic areas, the Rwanda NTD Control Program has also treated nearly 600,000 individuals. The Rwanda NTD Control Program has made remarkable progress in cultivating leadership, building capacity, strengthening health systems, and generating program efficiency. Through strong collaboration with the government, non-governmental organizations (NGOs) and other partners, the program has leveraged monetary support from partners such as Feed the Children International, Food for the Hungry, UNICEF, and the World Health Organization (WHO), and treated millions. The NTD program has built promising health infrastructures founded upon human capital, prevention efforts, and strong partnerships that have the potential to support many more years of deworming campaigns.
In 2005, the Government of India launched the National Rural Health Mission (NRHM) to commit increased health spending with the aim to improve the quality of health care for people in rural areas, especially the poor, women, and children. At the request of the Government of India, the Earth Institute, Columbia University, has been convening an International Advisory Panel (IAP) that meets biannually to review NRHM operations, assess progress, conduct evaluations, and make policy recommendations. The Model Districts project was created to implement the recommendations from the mid-term evaluation of NRHM, conducted by the Earth Institute. The Model Districts project originated from recommendations made to the government at meetings with the IAP in India in 2009. Through this project the Earth Institute aims to demonstrate that with a small level of additional resources put into targeted areas of the existing NRHM program and by strengthening the NRHM's management structure, the Millennium Development Goals and universal primary healthcare access can be achieved. These programs are based out of the Columbia Global Center South Asia.
The malaria team at the Earth Institute was part of an advisory commission to Sao Tome and Principe in 2004. As part of a blueprint for development, EI supported the Ministry of Health in the design of a comprehensive malaria control strategy that entailed scaling-up preventive strategies including Indoor Residual Spraying (IRS), long-lasting insecticidal nets (LLINs), intermittent preventive therapy (IPT) and early diagnosis and prompt treatment with artemisinin-based combination therapy (ACTs). It was designed to achieve the MDGs for malaria and promote social and economic development in the country. After three years of implementation, there was a dramatic decrease in morbidity and mortality due to malaria: consultations decreased by 85%, hospitalizations by 80% and deaths by 95%. In 2007, EI supported a Sao Tome and Principe application to the Global Fund to sustain the gains achieved so far.
Nigeria is the most populous country in Africa and bears the highest malaria burden in the world, with 25% of all malaria cases in the continent. Malaria is responsible for 60% of outpatient visits in health facilities and 30% of hospitalizations, the worst hit being children under five and pregnant women. Nigeria has recently started an ambitious scale-up of malaria control nationwide.
The scaling-up of malaria control requires the rapid implementation of a package of preventive and therapeutic interventions in an integrated fashion. It requires the rapid and simultaneous implementation of vector control measures such as Long Lasting Insecticidal Nets (LLINs) Indoor Residual Spraying (IRS), Intermittent Preventive Treatment of pregnant women (IPT) and prompt diagnosis and treatment of malaria to cover the entire population at risk. Cross cutting activities such as Monitoring and Evaluation (M&E) and BCC/IEC are critical strategies that would complement the above interventions.
The National Malaria Control Program (NMCP) in consultation with the malaria team of the Earth Institute, Columbia University, conducted a needs assessment for the scale-up of malaria control in 113 LGAs selected for the Millennium Development Goals (MDGs) scale-up project at the request of the Office of the Senior Special Adviser to the President on MGDs (OSSAP/MDG). Prior to the roll out of implementation of the project, the NMCP and EI will conduct a baseline malaria and anemia prevalence survey to assess impact and monitor progress as the project implementation commence. This local survey will also enable us to gain a detailed understanding of the evolution of malaria epidemiology at the local level.
The HEP is the flagship program of the Ethiopian Ministry of Health. It was initiated in 2004 to scale-up access to preventive and basic health care among the country’s rural population. 15,000 health posts were built across the country, each one of them to be staffed by two Health Extension Workers (HEWs). HEWs are young women with a high school education who undergo a year-long training in a curriculum designed specifically for the program; they are originally from the rural areas where they will be deployed after training. Primary Health Care is at the center of the HEP, as well as task-shifting, or assigning some curative interventions to less specialized health workers as way to address the constraint of human resources in the health system. The HEP represents a significant economic and political commitment of the Ethiopian government and it is being followed with interest by the international public health community. The successful delivery of health interventions through the HEP could have an enormous impact in childhood mortality in the country and beyond, since Ethiopia is one of the six countries were half of worldwide childhood deaths occur.
In relation to malaria, Health Extension Program workers are trained to educate communities on the modes of malaria transmission and to promote malaria control activities according to the principles of the Global Malaria Control strategy and national strategic plan. They also mobilize communities to identify and clean up mosquito breeding sites, conduct indoor residual house spraying, and promote use of insecticide treated mosquito nets. These workers will also be trained to provide prompt clinical diagnosis and treatment with effective first line antimalarial drugs for uncomplicated malaria.
The EI, through the Center for National Health Development in Ethiopia, has supported the HEP since its inception and serves as its external evaluator. The malaria team at EI has worked with the Ministry of Health in Ethiopia developing the strategy for malaria control through community-based management of malaria by HEWs, trained to diagnose malaria with Rapid Diagnostic Tests and treat it with appropriate medicines. It has also supported the National Malaria Control Program in applying for funding from the Global Fund, which has enabled Ethiopia to rapidly scale up malaria prevention and treatment.
The Ministerial Working Group on Scaling up of Health Systems grew out of a meeting in Addis Ababa in July 2009, when the Ministers of Health from China, India, Nigeria, Ethiopia and Kenya met to discuss concrete ways to support health scale-up initiatives in low- and middle-income settings. This meeting also provided an opportunity for these countries, the core members of the Working Group, to present and reflect on their countries’ experiences. Despite many differences, participants found they share several goals and challenges, which can be better addressed though the sharing of best practices and lessons learned. The conception, design and successful implementation of health system scale ups promises to greatly improve the health care of millions, reduce extreme poverty and further economic growth.
The key objective of establishing the Ministerial Working Group on Scaling up of Health Systems is to provide a rich information flow to assist each country in the design and implementation of health-systems scale up. By engaging in systematic comparison of the respective countries’ national scale up plans and initiatives, by sharing the lessons learned and best practices in support of primary health systems, and by collecting information on the recent experience of other countries, the Ministers and their technical experts will have an opportunity to strengthen and, if required, correct and refine the new initiatives and programs under implementation. The project should contribute to the successful achievement of the MDGs in all participating countries.