How precision approaches can boost the effectiveness of our efforts to end malaria

At a time when cuts to global financing for health care in low- and middle-income countries threaten to undo decades of progress towards our global health goals, making health leaders do more with less, Dr. Abdisalan Noor is part of a global cohort of researchers providing a potential pathway forward.

Dr. Noor, the former head of the Strategic Information for Response Unit at the WHO’s Global Malaria Programme, who is also a visiting professor at the Harvard T.H. Chan School of Public Health and Executive Director of AHADI, an Africa-focused organization that works with countries to become self-reliant in the use of data and analytics to solve priority health needs, is working with Exemplars in Global Health to identify lessons on tailoring malaria investments to subnational needs to maximize impact.

Whereas previous approaches to malaria control may have taken a blanket approach to deploying interventions across a country, more tailored approaches use local data to inform local decision-making to ensure the best use of limited resources. This approach is called subnational tailoring (SNT). Subnational tailoring is particularly important for malaria, which varies by geography, seasons, and age, and is influenced by socioeconomic changes. The strategy can help ensure that interventions are targeted to where they’ll have the greatest impact.

“We can no longer afford to use a one-size-fits-all approach for malaria or really any disease management,” said Dr. Noor. “We need to use the best available local data to make the right decisions and optimize our impact – this is especially important as resources become even more limited.”

Exemplars News spoke with Dr. Noor about the research he is leading to examine the success of malaria subnational tailoring in Burkina Faso, Mozambique, Nigeria, Tanzania, and Lao People's Democratic Republic, and what health leaders can learn from these countries.

What is sub-national tailoring?

Dr. Noor: Subnational tailoring is the use of local data to make local decisions. In the case of malaria, subnational tailoring is the use of local data and contextual information to determine the appropriate mixes of strategies and intervention in a specific locality in the country.

The data I am referring to includes ecological data, epidemiological data, and demographic data. You also need data on the distribution and behavior of the mosquito that transmits malaria. And you need data on the type of malaria parasites you're dealing with and the distribution of infection and disease. You need data on the social and behavioral aspects of the community in terms of the way they use malaria interventions such as anti-malaria drugs or bed nets. You need data on any of the biological threats, for example, insecticide and drug resistance that can stymie the effectiveness of our current tools to address malaria. You also need to understand how people access malaria care. Do they have to pay for this access? And if they pay, what does that mean in terms of the overall behaviors around treatment. And you need to understand the interaction between the health services and the patient and what's the quality of care that the patients receive in each community. All of these datasets inform decisions made at the local level to address malaria.

Why is SNT important and what role does it play in addressing malaria?

Dr. Noor: We know that malaria is a disease that varies across ecologies within any given country. It also varies over time as seasons change. Its transmission patterns change due to the effect of the interventions and socioeconomic development. The impact of the disease varies by age and by gender, with young children and pregnant women at the greatest risk. Also, as the mosquito and parasite come into contact with interventions, they adapt and may become less and less susceptible to those interventions. Malaria interventions also interact with each other differently in different settings.

So, the effectiveness of malaria interventions is not uniform. Instead, it is informed by all of these factors. The disease is also concentrated in low-income countries and despite the considerable donor investment in recent years, the demand for interventions remains high and resources are limited. Therefore, you constantly have to innovate the way you prioritize and mix your interventions. Subnational tailoring offers a pathway to do this.

Your teams at AHADI and Harvard are working on a study to identify and surface best practices in SNT. Tell us more about your goal with this work and what findings you expect to see from Exemplar countries.

Dr. Noor: The Exemplars SNT project has identified five countries that are positive outliers when it comes to the implementation of malaria subnational tailoring: Burkina Faso, Mozambique, Nigeria, Tanzania, and the Lao People's Democratic Republic.

The Exemplars SNT project has three objectives. The first one is to understand the processes that each country used to operationalize their malaria SNT strategy and to understand the barriers and facilitators they experienced. The second objective is to identify which best practices and core capacities enable each step of SNT to be successfully operationalized across these five countries. The third objective is to investigate the key decisions that were made because of SNT and how they differed from the business-as-usual approach and what was the impact on the communities where the services were delivered.

Are there any differences that you can already identify, examples of decisions that were very different from business as usual in these countries?

Dr. Noor: The research is in its early stages, but each country has interesting examples of the role subnational tailoring played to improve their malaria response. For example, in Nigeria, the analysis identified geographic areas that were previously not considered eligible for seasonal malaria chemoprevention but could benefit from this approach of providing anti-malarial medicine to young children as a preventative measure during peak malaria season. This led to an additional 12 million children being covered with this intervention. At the same time, the analysis revealed that many urban areas are unlikely to benefit from massive scale up of insecticide-treated nets – an intervention that typically protects populations from being bitten by malaria-transmitting mosquitoes at night. Therefore, the savings made in one area can be deployed in other areas.

Lao PDR represents the other end of the malaria problem, where the disease is concentrated in small areas, where surveillance is nearly real-time, and where we have seen rapid progress towards malaria elimination by targeting not just specific geographies, but also specific populations at risk in a highly mobile, cross-border ecosystem.

What would you say to a health leader who has very limited subnational data?

Dr. Noor: I think the starting point is to shift people away from the thinking that there are places where there's no useful subnational data. This is one of the things that surprised me about my work in subnational tailoring and in our research: just how much data, despite the variable quality, was available in countries and how little of it has been used in the past, particularly at the subnational level.

Almost every single country, regardless of the strength of its health system, has subnational data in one form or another. The main issue really is the completeness of the data and the quality of that data. That has improved over time as countries start to change the way they collect data. With the increased use of digital platforms, there is greater availability of data for decision making.

One thing that is striking is how little of the existing data is in the custody of the national malaria authorities. So, a big part of any subnational tailoring process is to bring all of the data together and to put it under the custody of the national malaria program where it ought to inform decisions.

Now, regardless of the quality of the data you have, you have to make a decision, almost always under resource constrained environments. You need to make the best use of your resources to achieve the best possible impact. That requires using whatever data you have, including sometimes poor-quality data.

There are many approaches that can add value to sparse data, many methods can get you from a place where you think ‘I can’t use this data.’ To a place where you think ‘Yes, I'm dealing with a high level of uncertainty, but I am at a better place than I was without looking and querying my data.’

So, my advice to decision-makers is look at whatever data you have, analyze it in the best possible way, using the right methods, understand the data quality issues better and use this to inform future improvements. This is far better than just doing the same things everywhere across your country, regardless of whether they have impact or not, especially given that you have very limited resources.

That brings us to a very timely issue. We are experiencing an extremely challenging environment for health care funding right now. Can you speak more to how important SNT is given our current climate?

Dr. Noor: External donor financing of malaria control and elimination has delivered one of the best returns on investment. Over the last two decades, billions of cases and millions of deaths have been averted. Malaria is a real public health success story, despite recent challenges. But countries are now faced with a major global health financing crisis. And it's not just in health, but also in development.

The question is: will continuous strengthening of surveillance systems and data analysis and use, which are essential to making informed decisions, become a casualty of the funding crises? Or will we recognize that this is the foundation of all forms of crisis management in health and in any other facet of life, that the right information at the right time of the right quality and at the right level is really essential to responding to crises.

The current crisis presents us with a powerful use case for malaria SNT, as countries must make extremely difficult decisions. The countries that did a good job in malaria SNT are likely to be more resilient and better prepared to respond to the current financing crisis and leverage their limited resources. That’s because they already have the layers of evidence that they needed to help inform their decisions.

My concern is, in the current climate, that the need to make difficult decisions around buying health commodities that will save a life will supersede investment in data and information systems. History has shown that when we relegate such investments to second-tier needs, it degrades our ability to make the right choices and leads to a less effective response.

Is subnational tailoring uniquely important for malaria or should it be used for other health challenges?

Dr. Noor: This isn’t limited to malaria. The principles of using your best possible local data to make the best possible decision is fundamental in public health. Our ability to gain new insights into how to prioritize and optimize our resources increases as data and computational capacities increase. So subnational tailoring, which essentially is the local use of local data to make local decisions, is just as important for any other disease or health problem as it is for malaria.

Is there any place where SNT has been used, but maybe has not been called SNT?

Dr. Noor: In countries with more robust surveillance systems and analytical capacity in relevant institutions this kind of analysis has probably become routine practice. But as far as low-income countries are concerned, the malaria field is a pioneer in using subnational data, geospatial, and modelling techniques to make subnational decisions. However, other disease programs such as those that focus on HIV and neglected tropical diseases have good examples of use of local data. Additionally, during health emergencies, such as Ebola outbreaks, real-time data are a fundamental part of the epidemic response.

What fundamentals do countries need in place to carry out SNT?

Dr. Noor: To engage in subnational tailoring, countries need to have national leadership and partners with a desire for evidence-informed policy making. And this is not something that one should take for granted.

Once countries have that in place, of course, they need diverse data and information of reasonable completeness and quality. They need the basic data infrastructure to manage the data and that's a problem for a number of countries, even when they have data from various sources. It's not easy to bring all of it together in a systematic way that allows for a structured analysis. Each of the five exemplar countries in malaria SNT have structured data repositories of various levels of sophistication. The Gates Foundation, the Global Fund, and WHO have supported the installation of these repositories. And importantly, countries need the capacity to analyze their own data so that they can use it routinely.

This is a space which our organization, AHADI, which stands for Applied Health Analytics for Delivery and Innovation, is very much focused on. We are enabling that capacity so that countries are more self-reliant in analyzing their own data.

Editor's Note: For more information about Malaria Subnational Tailoring, visit Exemplars in Global Health.