 Okay, we've got a full panel today so I think we'll start now and people will join us as they come in. My name is Jennifer Cook. I'm director of the Africa program here at CSIS and we're here on World Malaria Day to talk about a particular project on malaria that's taking place in Equatorial Guinea. This year's theme of World Malaria Day is achieving progress and impact. There are promising signs in the fight against malaria worldwide. The trend lines are moving downwards, albeit slowly and there's still a great deal more to do. In 2000 an estimated 350 to 500 million people, there were 350 to 500 million clinical cases of malaria worldwide with more than a million people dying from the disease. By 2009 there's about 225 million cases and malaria deaths are down to 781,000 in 2009. Of course we still have a long way to go but I think this year's theme of assessing progress and impact is there's a lot of positive stories to tell. Almost 90% of deaths due to malaria occur in Africa and some of the decreases of the past decade have occurred with the greatest decline in much of Africa. Malaria Day was instituted by the World Health Assembly in 2007 and was set apart as a day to recognize the global effort to provide effective control of malaria. It's an opportunity for countries in affected regions to share experiences and support each other's efforts, for new donors to join a global partnership against malaria, for research and academic institutions to flag their scientific advances to experts in the general public and for international partners, companies and foundations to showcase their efforts and reflect on how to scale up what has worked. So in this case we have I think a very good example of a new kind of partnership between Marathon Oil, the government of Equatorial Guinea and the Medical Care Development International working in Equatorial Guinea since in the last three years on kind of an innovative public-private partnership. Equatorial Guinea obviously has many challenges in terms of governance and human rights but in this instance I think we'll hear a little bit about how that government is engaging with Marathon Oil and the partnership to reduce and really achieve some pretty significant results on the ground in terms of reducing malaria health-wise and environmentally. We're delighted to co-sponsor this event with E.G. Justice and I'm going to ask Joe Kraus to come up and just say a word about the mission of E.G. Justice and thank you to you and to Tutu Alicante for co-hosting this with us and bringing us this great team of panelists. So why don't you come up, say a few words and then we'll move right to our panel. Great. Thank you CSIS. Thank you Jennifer Koch for agreeing to moderate today. Thank you for the panelists. Thank you for Brian Kennedy for helping set everything up and thank you especially to you all for coming inside today to listen to this interesting talk. E.G. Justice really briefly we focus on promoting human rights, rule of law, transparency and civic participation in Equatorial Guinea with the end goal of improving lives of ordinary Equatorianians. We do that in a number of ways. We focus on advocacy. We do independent research and analysis. We just published recently a report on civil society and participation in Equatorial Guinea. A handful of copies located outside on the table also on our website. Next week we'll be launching a brand new website that we'll have amongst other things an information center where eventually it will become a primary source of information for all things Equatorial Guinea. And then one of the other things that we do is we do events like this. We host E.G. Policy Roundtables where we try to create a forum, a neutral space for a number of different stakeholders, companies like today, health experts, education experts, academics, government officials, civil society representatives to have a space where they can come and discuss ways to improve the lives of those people living inside of Equatorial Guinea. So we are very pleased to have the topic today which is focusing on some of the positive things that have gone on in Equatorial Guinea, in this case Malaria. So we'll turn it over to Adele Shouche who will start our discussion. Thank you. Maybe I should introduce our panelists. Sorry about that. Okay. Yes. Well, thank you to you all for joining us. We've really got a terrific panel today that's been deeply involved in this. We have first Adele Shouche who's Director of Corporate Social Responsibility with Marathon Oil. He's led the development of the company's social responsibility strategy in Central Africa including this Bioko Island and EG partnership. Adele is going to speak, I think, to the genesis, the structure, the goals, kind of the overall context of the partnership. Next we'll have Christopher Schwabe who is a health and public finance economist with Medical Care Development International. He directs the Bioko Island Control Project and the Sister Nationwide EG Malaria Control Initiative. He's going to speak really to the implementation of the program and progress on the ground. Michelle Slotman is Assistant Professor in the Department of Entomology at Texas and A&M. Michelle will speak to the entomological results and impact of the project and the kind of operation research that his university is engaged on and kind of maybe what this model teaches us more broadly. And finally also with MCDI we have Luis Benavente who is Director of Improving Malaria Diagnostics Projects who will talk about really the health impacts versus the entomological impacts, kind of the health and human welfare impacts of it. And then we'll come back. It's a big panel but we'll try to leave ample time for question and discussion. So thank you all for joining and Adele, the floor is yours. Well thank you Jennifer for the introduction and also thank you for hosting us here at the center. Good afternoon everybody and I can see several familiar faces. Hi to those who are here we know. Also I want to thank EG Justice for actually approaching us to speak about the subject. Joe mentioned that they do other fora on each and specifically is going to address the subject of malaria control in Ecuador, Guinea specifically on Bioquo Island. Jennifer mentioned earlier this is of course April 25th, April 25th is celebrated as Africa Malaria Day. So we are here to celebrate results around the world specifically in EG but also we're here to reflect on the challenges that are facing us in this particular country but also some of the challenges are actually reflected in much of what we see happening in Africa. Very briefly before I start into the genesis of the project I thought I'd spend maybe just a few minutes explaining who marathon is for those who are not familiar with us, talk about our general approach to CSR because definitely this is CSR project then go into why we're doing this project, you know how we're doing it and what we think has worked. Of course if I mentioned you know the other elements that my colleagues from MCDI from A&M and Luis of course on behalf of the London School is also presenting on behalf of the McLean Schmidt we're going to more the details of initiatives some of the results and some of what we see in terms of path forward including the challenges we've seen so far. Very briefly here you can see on the map you see a marathon we've been actually in business for 120 years we are among the Fortune 100 companies we are the fourth largest oil and gas company in the U.S. I won't worry with all the numbers you have them there one thing I want to mention here we have roughly 2,000 almost 30,000 employees here but we are in the process actually of sparing off marathon in two companies and that would happen actually on June 30th we'll have a company that will address the upstream business and the downstream business will be a separate one. I mentioned that it will actually define our path forward and how we do our business specifically the malaria project will continue with the upstream which we'll talk about a little more. You can see our footprint here we are in some specific areas what we call core areas and certainly the Gulf of Guinea where EGE is one of our core areas. I thought I'd share with you our approach to CSR I know we we have a philosophy around CSR it's based on nine elements and these nine elements are on the foundation of the company which is the values and the code of our business conduct. The nine elements are in three categories that defines how we behave, where we invest in and what we can influence or promote. So it's basically at high level the nine elements. Certainly the malaria project touches the number of those elements and I come back to that in a second. Going more into the strategy marathon actually sorry I went too fast we look at our social investment you know with with a very defined lens which is this triangle here. Number of our projects are the top tier which means actually in terms of volume and also from our commitment are philanthropic commitments which means sometimes we don't look at the result but the majority of our projects are sustainable projects that are linked to our business case and we look at them as investments in terms of return for the communities as well as our our commitment to our presence in certain communities. So we look at them during our presence but also we look at them beyond our presence in case we have to leave. In many cases and we are in extractive industries we hear for a short period of time and we leave you want to make sure that we leave the communities and at least same or at least better shape than they were before we came in. How we see this of course we are an online gas company so we need to get help we need to get help from implementing partners in general the NGOs non-governmental organizations we partner with them to make sure we bring the right expertise on the right subjects whatever is the issue we have to address. In this case we're going to talk about it's going to be health so we have a number of experts in health and of course wherever we are whether it's a local or national or federal government so we we partner with the government to make sure they're part of the solution and make sure they are actually enabling us enabling themselves to move along and find a sustainable solution. Very quickly here these are the nine elements you show in our policy here so I wanted to show you here a portfolio of activities that we have around the world. I'm not going to go one by one until you can have that look at it probably you can have it on the website I'll have to reload it but one thing I want to mention Equatoria Guinea which is the place when I talk about for malaria is probably the only country we have all the nine elements fully engaged of our policy where every single one of them has a project or combination of projects and we feel this is a country that needed strong commitment from our end because of the frontier setting and we have committed fully including the malaria control projects that I'm going to talk in a minute and you can see them here in the top corner on the right and their community developments. Well I know it's a long introduction so let me jump into the meat of the subject let's talk about Equatoria Guinea or to give you the sense of place here that's where EG is and Central Africa sometimes they reference it as West Africa but technically Central Africa it's a country that has setting as an island but also as there's a continental portion of the country we're going to talk about the project here at a high level combining both the continental as well as the island portion of the country but before I do that I want to mention very quickly how we got into EG we came in actually in 2002 we came in through the acquisition of a current asset and we saw there's a vision for us to be there for a long term when I say long term we're talking about 20 years maybe 40 years with the intent that we will have a long presence and we will create maybe a regional hub for us to do our business but by doing that of course we had to look much deeper into the issues that we are faced in the country and there's a list of them here as a number of challenges a small population uh so we've had issues around education so forth but but the most important and the biggest challenge we've seen actually is health challenge and that challenge is malaria one element before I jump into the malaria situation I thought I'll give you a sense of our business in the country when we entered into Equatoria Guinea through that acquisition I mentioned 2002 and again without going through the technicalities of the business you know we we had a business that produced 34 000 barrels of equivalent per day and was mostly condensate which is a light crude you think about just like like a regular oil liquid petroleum gas and methanol methanol is actually liquid that used the pharmaceutical products and actually plywood glue what we've done it's what I mentioned long-term vision is to to grow our business there and we had the number of incremental steps to increase our presence and you can see the the projects without going through a lot of details either the projects we expanded or we added the last one was an energy plant an energy plant here that was probably done the fastest ever in terms of projects anywhere in the world in less than seven years in terms of bringing a project from development into production that took us from 34 000 barrels to 175 000 barrels though the interesting part about that here by doing this we became the single largest private sector employer on the island and certainly in the country so our footprint became very large our connections with the country now became very strong particularly the communities where we are so now that I said a tone on the business side let's come back and talk about the issue of malaria in Africa and EG Jennifer mentioned some statistics I want to repeat them we talked about the heavy burden there a couple elements I want to add here the and you can see here on this map the burden is mostly in sub-Saharan Africa and you can see it on the map with the the very dark brown trace along Africa and certainly EG is right in the middle of that heavy endemic area we talk about the number of around million deaths per year mostly children and these deaths are all happening you know in sub-Saharan Africa we also talk about the fact that these deaths are mostly impacting children under the age of five for one important piece because children at the age of five have not fully developed you know the immunity so they are those at the highest risk of actually succumbing to the disease or becoming no severely ill. Maka Ali's will talk in great depth EG actually has a very specific type of malaria which is cerebral malaria so it's the most dangerous and most deadly form of malaria of any form you can find around the world a couple of elements I want to mention you know to you in the context of EG and you have here the numbers I want to mention that here I believe EG was the most endemic country of Africa before the program was started in 2003-2004 one last element about the context I want to talk about the economic side these numbers are a little old but however they reflect the burden that malaria has imposed this is a financial burden and there are a number of calculations that show it's in the billions I think people need to remember that it's in terms of lost productivity because people are sick they cannot go to work or they have to care for their dependents children as spouses or because the country cannot attract foreign investment because foreign investors are skeptical about investing because they they fear the additional risk and additional costs to bring in a business into a country that's highly endemic so that's a combination of of what it is to the entire continent you can look at that at the context of of a household and these numbers hold true in the context of EG that would be the same margin you can see the number of that burden on Equatorial Guinea before the interventionary she's around $15 million a year that's a cost that the country actually subject to what I want to do here is talk about the various initiatives we have around malaria my colleague is going to spend the bulk of their time talking about the commitment we have on Buick Island which is where we are as a business but I'm going to very briefly talk about what we have done in terms of connections to make this program not only on the island but also nationwide including the continental portion and what we have done in terms of promoting some of these findings to the rest of the continent through the Corporate Alliance on Malaria for Africa so what is this project here clearly when we came in 2002 I mentioned we we found out this is the biggest challenge for our employees and also for the communities where we are so we thought we need to design a program that can significantly reduce or eliminate the burden of malaria on Buick Island and the intent is to improve that for our employees for the communities where we are and specifically focus on this burden on children for the simple reason as I mentioned earlier children are the ones who get hit the hardest because the immune system has not built up that what we've done we've done a two-phase approach we've done a commitment of five years and two tranches the first one started in 2003 going 2008 and we just now renewed the second phase of our commitment going all the way 2013 the total commitment between us and private sector partners as well as the government is now $44 million that's over the period of 10 years and the project is basically focused on five major components vector control which is mostly spraying case management which has been provision of medical supplies but also improving the health system in the country to find better diagnosis of these cases information education and communication is a very important piece because we have spraying and we have to enter homes it's a very invasive process so to achieve that we have to have a strong communication so the communities understand the benefit that we are providing to them for this initiative monitoring valuation of course you know we want to make sure the project brings results so we have to monitor if it's progressing according to the metrics we set up last but not the least we feel that this project has to be owned by the host country so we have spent significant interest and significant resources to make a lot of effort around capacity building and this is towards our counterparts in the ministry and within the program so at some point in time we're going to hand over the project to the ministry of health let me share with you here a little bit more more detail about how it works I mentioned the first phase in between the first and the second phase what we've done we approached the global fund and I'm sure a lot of you are familiar with the global fund which is almost like a bank the only difference is they don't give loans they give grants so when you get it here you don't have to pay it back as long as you spend the money in a way that is according to their principles the global fund focuses on three diseases tuberculosis HIV AIDS and malaria so we work with them with the intent that we can leverage the success we've seen on Bucco Island and take that to the mainland so through a commitment on the technical side with our government and NGO partners we scaled up the project with a grant from us as well as from the global fund for another 27 million dollars so bringing the commitment between us the government and global fund to 71 million dollars over a period of 10 years to have this probably where it is the only country in sub-Saharan Africa that has a nationwide fully integrated program to to eliminate malaria some of the metrics I mentioned earlier there so let's talk about the model from our perspective clearly I mentioned that our experience is in extracting oil on a gas so we have to surround ourselves with people that can help us execute on the strategy for a health public health program so the first step is to partner with the the government itself to have access to policies as well actually access to to the workings of the nation so the ministry of health and social well-being social welfare here is our partner along the ministry of mines and country and collectively they represent the interest of the nation in terms of the implementation we have a number of partners of course one of them is here MCDI it's the implementing NGO working on the ground but we have a number of technical expert organizations academic institutions and others we call them the technically technical advisory group and you have a list of them you can see them there on the screen going from Harvard to Yale and so forth and the intent of having that group is to bring the set of the art knowledge to this project here from all the research we done around the world and bring that to help our team and ourselves to make the right decisions so we are always on the forefront of knowledge and and development so we are further pushing the developments and the goals of this project the tripartite partnership you know works fairly well the intent is for us to always bring skills that are complementary so we we bring from our side some of our project management as well access skills and I mentioned the other level of skills we get from the other partners. Christy is going to spend some time presenting some of the attributes as well as the challenges of this partnership here looking at it from an implementing NGO angle. In closing here I mentioned the commitment we had on Bioko Island I also mentioned the commitment that we we have created with the global fund by scaling up from an island to the context of a nation and going to the continent we thought we need to do something at the level of the continent so we created the corporate alliance on Malaria for Africa this is a group of private sector companies that is right now managed or secretaried by the global business coalition and the intent of this group here is is very simple is to become a focal point for the corporate sector there's a lot of stuff happening in specific countries you take the case of the quarter organized a number of companies working there so we have to work hand in hand together so we do not waste the resources duplicate efforts and basically dilute the interest of the communities also in a number of countries there's a lot of grants coming through the global fund or the PMI or other international organizations so the intent is to leverage some of the skills of the private sector and have those brought in to support some of the activities there so we are fully I would say optimized at the level of a country so the intent of this alliance is to share the best practice and knowledge we can have and making sure there's advantage in bringing that knowledge when a company wants to have a business in a specific country with that I want to close and ask my colleague to come and talk more specifically but the the five elements of the initiative give me a second here to switch okay thanks everybody for for being here I'll try to be brief we've got a lot to cover I'm going to go very very quickly through the interventions which Adele already has given us an introduction to talk a little bit about some of the implementation results then I'm going to turn the floor over to Dr. Slotman who will talk about some of the entomological impact Luis who will talk about the human health impact then I'll come back and talk about the economic impact on welfare of the Aquado Guineans a brief look at the future optic because as you saw from Adele's presentation there marathon has a long-term vision of what it's doing there in Equatorial Guinea and that provides a very unique framework for an implementing organization to work within in terms of combating something like malaria and then I'll end with a PBO perspective on this partnership which we think is really quite unique the interventions as Adele indicated were vector control malaria case management behavior change communications monitoring evaluation human resources let me just touch on a few of those briefly here indoor residual spraying as you can see from the image here involves putting a odorless and colorless insecticide product a product that lasts about six months on the walls on the inner walls of all houses or other buildings where people congregate in peak biting periods which are in the early evening we've been doing this since 2004 it works because in context where vector species have a propensity to bite indoors and rest indoors after biting they're looking for a vertical resting space to land on they find the insecticide interrupts the transmission process so it's it's not a mosquito killing venture it's a it's a malaria interruption process in addition to IRS which was introduced in 2004 in 2007 we distributed and hung long-lasting insecticide treated nets in all of the houses and one per sleeping area on the on the island we use two different chemical products two different insecticides and so we've actually got a rotational insecticide management strategy going on because if the mosquito is not getting killed by one insecticide on the net he's getting killed we hope by the other insecticide on the wall in addition to these core interventions we're also looking at some other options the the transmission characteristics on the island have changed substantially since we started and as a result we see quite a heterogeneous transmission characteristic that differ from different localities as such we're looking at a number of different options to address and try to bring down malaria in the areas that have been most intransigent and we're looking for solutions that may be a little bit more easy to implement than indoor residual spraying which is an incredibly labor-intensive and demanding venture one of those new products is this zero vector durable wall lining which is featured up here the blue stuff which we've done some studies on acceptability and equatorial guinea and there's a high degree of receptiveness to this product in particularly in the traditional housing that's that's made of wooden clavards and so this kind of serves as a screen but it also has a five-year lasting at least we're told insecticide product on it and our initial three-year evidence on on actual kill rates is that it does last for three years at least so and we're continuing to evaluate that in addition for focal supplementary control measures dependent on the area and the transmission characteristics we're looking at introducing screening of homes particularly the eaves where mosquitoes come into the house we're looking at the use of repellents we're looking at larvasciting and environmental management but these are adjuncts to the core strategies that we're that we're implementing the second major component is improved diagnostics and treatment and that's involved the replacement of monotherapies largely based on chloroquine with artemisin and combination therapy this was done in 2005 we've improved diagnostics of malaria introducing rapid diagnostic tests for free at all facilities that don't have a laboratory those that do have a laboratory we've strengthened the microscopy in those places and on an annual basis we recycle all of the providers and all the diagnosticians through regular training to try to improve that and in starting in 2010 the government has committed itself to a primary health care initiative that has moved this down now to the community level we had previously been operating at the hospital and health center level one of the new innovations and something we're very proud of is that we've been participant in developing the first african malaria slide archive which is used for quality assurance and accreditation and this involves setting up replicates of individual um slides from from people that have different species of malaria and different densities of malaria and so these slides can then be matched or put in different combinations and you can test microscopists all of these slides have been validated by a group of WHO certified experts around the world so we have the we have we have a gold standard we have true you know cases that can either positive or negative that can be evaluated and from that we can actually test and improve the quality of diagnostics we put a lot of effort into improving intermittent preventive therapy for pregnant women and in particular ensuring that they have a dose of this in the second and third trimester of their pregnancy and through that in order to do that have strengthened anti-natal care services as well the third major component is behavioral change communications based on a national communication strategy that tries to get out some key behaviors that we're changing which include early care seeking for children the acceptance of irs twice a year which is a very invasive process and people need to be available to do that use of nets by under 15 year olds and pregnant women the use of IPTP and intermittent preventive therapy as I just mentioned and advocacy for decision makers so that we have the collaboration of government at the central and local levels in the country this is done through a series of communication strategies including community outreach the picture in the upper right is a brigade of people that go out with each spray around literally visit every house twice a year with a multi-dimensional series of messages and if the people can't hear them they get a blowhorn right in the right in the ear but no this is actually a very effective way of communicating not not the megaphone per se but that group they also link up with community leaders who are very actively involved through the Ministry of Interior and actually competing with each district competing against each other to try to have the best coverage rates in addition in the bottom here we have a lot of activities that are on communication at the health facility level both through the provider and for patients and caregivers that are there mass media through television and radio and print media and then advocacy events including workshops symposia and other advocacy events for government the fourth major component and really a very very important part of this and I think a unique element of this about 15 percent of the total budget goes into monitoring and evaluation it's an unprecedented monitoring and evaluation system it gives us probably I would say modestly the best data set on malaria in the world rivals for people that know the garky project and that that data set this is the new garky right here and it will be used I'm sure for many years to come to analyze the effectiveness of malaria it's a comprehensive system that we make all decisions based on we have information in all areas it's based on a set of indicators that have been agreed to nationally and with WHO that monitor progress and impact and there's a dashboard that they can follow in the government and we follow on a monthly basis to see where we are with this a key element of this is a sentinel site surveillance system that operates out in 19 sites around the island that are geographically representative of the malaria dispersion it monitors vector transmission and currently that's done through light traps and human landing catches but it also monitors the prevalence of disease the core element of that is an annual malaria indicator survey which looks at parasite infection rates hemoglobin for anemia illness history and care seeking behavior knowledge attitude and practice related to malaria a lot of information on economics which will present a little bit of here today each five years including before we started an assessment questions to look at under five mortality which we'll also present here and on two events looking at serology to look to look at whether or not there are antibodies for malaria and how that has changed over time as a metric for evaluating the force of transmission and the impact of the project we are have done quite a bit with geo referencing but we're doing a heck of a lot more with it now all houses are actually in the process of being geo referenced on the island so that we can plan and monitor activities on a household basis that's either being done using satellite imagery or we're creating maps based on gpsing of the houses we're also mapping the transmission characteristics of the island and looking at risks of transmission and risks of importation and characterizing the island because we do have a very heterogeneous transmission phenomenon going on and then we see this as being a core element of the future elimination strategy once we get levels down to very low levels of incidents where we're actually going to be tracking individual cases and having focal response to that because equatorial guinea is probably one of the least developed government systems that i've ever seen in africa and i've worked in southern chad and southern sudan and southern madagascar it's surprising i mean but it's not surprising given its history a lot is changing but a lot needed to change and so when we came in there was no national health information system so a project that was supposed to do malaria soon found that needed to set up a health information system for the country which is far more than malaria so we've done that and worked and we now for the last two years have i think the first two years of reliable data out of that system nationwide computerized semi-computerized drug information system and pda-based sprayer and productivity and quality systems that allow us to track not only what we're doing but how we're doing it as a del mentioned a huge part of the last phase of this in fact 10 percent of that 27 million dollars is going into human resources development coming into this second phase 97 percent of the people that worked on this were kwadogunayin but that was operational the people that managed the project were still foreigners and so the the emphasis of this last of this round now is to systematically go through a process of transferring responsibility to this group of individuals here who are the next generation of malaria people for the country who are currently in peru being educated they'll be back in June we'll go through a benchmark systematic handover over the period of about a year and a half we anticipate that they will actually run the program underfunding from marathon in the final year of the project and we'll talk about the future after that so this is a very big commitment on that so let me briefly touch on some of the operational results before looking at some of the impact we've achieved greater than 80 coverage in all but two rounds of spraying we had some real difficulties when we started up the second phase including the fact that there's a housing boom going on on the island and we lost track of how many houses that it's literally grown at about 20 per year that's new houses and houses building and we we got down to a period where we actually had about less than 60 coverage so we've now got that under control and we're and so we're doing that that's about 36 000 houses or about 200 000 rooms that are sprayed twice a year we started originally with a pyrethroid insecticide and found that there was resistance to that product and so switched at great cost to marathon which i'll explain again later to a carbamate which required two rounds of spraying per year and so one of the big cut preoccupations with the project is looking at insecticide resistance and michel and his group at texas a&m and the ivcc at liverpool are working with us to help make sure that that insecticide resistance plan is up to date one of the one of the outputs of the project in terms of understanding malaria control and the impact of these interventions is that we've got very good evidence that if you can get 80 percent coverage of irs not only the houses that are sprayed protected but anybody that's living in a house that's not sprayed in that same community through a communal effect is protected and so that's one of the lessons that's been learned with the data from bioco as i said in 2007 we distributed and hung one net per sleeping area in the whole island we achieved the highest coverage rate on among under five year olds at the time over 75 percent of those children were sleeping under a net the night prior to the interview but unfortunately because this wasn't done on a nationwide level and all aquado guineans have relatives living on the mainland there was a phenomenal leakage of nets very quickly out from the island a year later we were down to 35 coverage and a year later we were down to five percent coverage so in three years we went from the highest level in africa to less than when we started and that was really troubling it wasn't what we expected but we've responded to that among pregnant women that was a little better because we have a keep-up program that goes through the ANC clinics but evidently it wasn't good enough the government has committed to a new round of distribution nationwide with its own resource through something it calls the social development fund and we anticipate that that will happen in the latter part of this year early next year that's important because one of the other lessons that we've learned from the OCO experience is that there's a great deal of synergy between those two interventions together and it's so it's good to do IRS it's probably equally as good to do bed nets alone but it's even better to do them together so in terms of the houses that have both of those interventions have by far the lowest level of parasitemia on the island in the case management area we've had 100% of the government facility supplying drugs and treatment we've had no stock outs if you can believe that and we have an increasing proportion of women taking IPT that's still only about a third of the women but fortunately 90% of women in equatorial Guinea go at least for one ANC visit so we feel that we can make some headway there in terms of knowledge we've made some progress the percentage of respondents who knew that mosquitoes transmit malaria has gone up knowing that not all mosquitoes are responsible for that an important message also has gone up but not quite as much knowing that that ITNs or bed nets and even IRS are effective means of controlling malaria that's very high and has gone up and that in fact services like this are free of charge that's also a important piece of information that they need to know so with that I will turn the floor over to Michelle to tell you a little bit about the entomological impact of the project all right as Chris mentioned this BIMCP has quite an extensive vector and monitoring evaluation program and one of the key forms of entomological monitoring is keeping track of mosquito abundance and this allows us to know if our vector control activities actually have an impact on the mosquitoes that may transmit malaria so initially we did this using window traps and they collect mosquitoes that try to exit the house through windows and it was quite effective early on early on in the BIMCP when vector abundance was quite high what we've done here is we've plotted the abundance of enoughless finestus and enoughless gambi which are two of the primary malaria vectors on Bioko Island before the control started and we plotted over a five four-year period of the BIMCP and as you can see after the first IRS round in which barifroid was sprayed there was a remarkable drop in the number of finestus mosquitoes in fact finestus was virtually eliminated from the island however we didn't see the same thing in enoughless gambi and only after we switched to carbamate insecticide in spray round two we saw a huge drop in ofless gambi as well so anti vector interventions do not only reduce vector abundance they can also change the composition of vectors in various locations so here we have some composition information for various species we see that finestus went from 45 percent to virtual elimination but another vector on the island enoughless malas also declined in abundance going from 10 to 3 percent now even though enoughless malas is declined in frequency on the island in some of the locations it's still the most abundant vector present for example in the southwest area here which is called luba we see that there are 86 percent enoughless malas mosquitoes and this kind of evidence is important for vector control strategies because these vectors all have different characteristics for example enoughless malas doesn't have the gene that confers resistance against barifroid insecticides that were used in the first spray round and whereas this the frequency of this gene went up in an awful as a gambi also an awful as malas is traditionally thought of to be a more outdoor feeding species so wouldn't be targeted as much by indoor based vector interventions so you know the bmcp's anti vector interventions have been indoor based so far irs and itn's and there's some evidence to suggest that this has actually led to a change in the vector biting behavior of enoughless gambi so that's the major vector on the island right now and in the literature is generally described as being an indoor feeding species so here we have mapped the the sort of the number of outdoor and indoor feeding enoughless gambi over 12 hour periods starting in the early evening until the early morning and what you can see here is that the outdoor number of the number of outdoor feeding mosquitoes are as high or even higher than the indoor feeding and that they peak at around 10 to 11 in the evening so just finding that outdoor biting occurs during a time when human adults are likely to be active outside as huge implications for for vector control basically that underscores the importance of having an important or an extensive vector monitoring system in place but also to have a basically malaria control program that can adapt to these changes in entomological characteristic and switch tactics and that is something that Dr. Schwab will address later on when he will talk more about the nature of the funding and the public private partnership that exists in the Imbioko island. So really what we're aiming for is a reduction in the force of transmission and the way we measure that is by looking at the EIR is the entomological inoculation rate and that's basically the number of infective bites that a person receives on average in a single year and there are two components to this first is the number of mosquitoes and the second is the proportion of mosquitoes that are capable of transmitting malaria. Ideally you'd like to reduce both but even if you reduce one year you can still reduce the EIR. So this graph shows that the BIMCP had really quite a substantial impact on reducing the force of transmission going from the EIR of close to 600 in 2004 to about 100 in 2010 so that's from going from approximately two infective bites a night to you know one infective bites every fourth night or so. This has already led to a quite an important reduction in malaria on the island something that Dr. Beneventi will talk about in a few minutes but if we want to move towards eliminating malaria from the island we really need to reduce the EIR to zero. An important part of vector control consists of insecticide resistant management of course and for this we need information on what kind of resistance is present we do that in several different ways first we monitor the frequency of genes that confer resistance against insecticides we also expose live mosquitoes to insecticides by exposing them to a specific amount for a specific amount of time and that gives us a pretty good idea of you know how effective an insecticide or various insecticides actually are at killing live mosquitoes. Now there's also a thing called metabolic resistance and in this case there are enzymes that break down the insecticide inside the mosquito and they're present at higher levels and we have colleagues at the tropical school of medicine in Liverpool England that are investigating this issue. So switching or rotating between insecticide classes is usually a recommended practice to prevent the emergence of insecticide resistance and the way that basically works is you hit a mosquito population with an insecticide in one class that works in one particular way and then a little bit later you hit it with an insecticide that belongs to a different class of insecticides and has a completely different mode of action. So in addition to these monitoring and evaluation efforts the BIMCP also supports more basic scientific research that will have implications for future control as the island moves toward elimination. There's research done by my team at Texas A&M and also we have colleagues at Yale University and of course Personnel from MCDI and the Ministry of Health of Ecuador Guinea are involved as well. And there are several components. The first one is looking at vector migration. We have a project looking at mosquito population size and then our colleagues at Yale are doing a modeling study of insecticide resistance. So the migration study really the question we're trying to answer is you know what's the level of migration from the mainland to Bioko Island and this critically important question when we're talking about moving towards eliminating malaria as the re-importation of mosquitoes is in a potentially an important source of reintroduction of malaria to the island. So basically the way we do this is we look at genetic variation in populations on Bioko Island and on the mainland and try to see how much of that variation is shared or if these mosquito are genetically distinct. And this will answer several questions for example you know what's the probability of this species reinvesting Bioko after elimination or also even other questions such as you know what are the chances of insecticide resistant genes moving from the mainland to Bioko Island. So I won't go into too much detail but we do have some preliminary results. So here I present a tree in which each gene from a specific individuals represented by one of these round dots or squares and they are clustered based on how similar they are to each other. So all the individuals here are very close to each other and they're quite different from the ones that are in different clusters. Okay so all these clusters over here okay that's all enophilus mellus and all the ones in here are enophilus gambi from Bioko and the mainland. So there's two observations first of all there's quite a lot of very different clusters in enophilus mellus suggesting that in fact there may be multiple previously underscribed species within this this taxon but more importantly down here okay we have all the Bioko individuals okay of enophilus mellus and they're all very different from all the mainland enophilus mellus and they do not share any of the genes with the mainland population so that indicates that enophilus mellus is completely isolated on Bioko from the mainland population but if we look at enophilus gambi the situation is completely different and in fact all those samples from the Bioko and the mainland are intertwined and there is no genetic differentiation between the mainland and Bioko suggesting there's quite a lot of migration within this species from the mainland to Bioko and so that's very important knowledge of course if you ever talk about you know moving towards elimination then really we need to think about introducing new methods that prevent the re-importation of mosquitoes from the mainland. So another study we are doing is looking at mosquito population size and we're using genetic methods for this. Previously I've shown your reduction in abundance based on window traps and now we use human landing catches and light traps which show a reduction in abundance as well but they might not be simply measuring how many mosquitoes are out there but also behavioral changes for example mosquitoes may be learning to avoid us. So by using genetic methods we can get some data that we cannot get at by using these collection methods. So basically we want to know how big an impact are we actually making on the size of mosquito populations by using these control methods and you know did the mosquito population size decline after we started to control? Is there a continual decline or moving back up with resistance etc and also you know do IRS and and bed nets affect mosquito sizes differently? And finally you know is there a difference in response between different species? So this work is in the process of being completed but right now I'm showing you some data from the part of the island with the highest level of transmission that's Mongola and there we estimated the ancestral mosquito population size that's before the control started was around 20,000 in this particular area and that it has been reduced to about 3000 okay so that's quite remarkable reduction in mosquito population size and that's about a seven-fold reduction and we also estimated the time at which this occurred. Now the signal in the data for this for this is not very strong meaning that we cannot pinpoint the time of the reduction very accurately but it does correspond very nicely to the initiation of the BIMCP and since we don't really have any other explanations for why we would have had such a huge reduction in population sizes safe to assume that this was due to the BIMCP control measures. Now it does seem that these the start of the IRS programs had an initially large impact on mosquito population sizes but we don't really see a strong signal for a strong decline after that. So after that mosquito populations either remain constant or a slow decline and this is one of the reasons why the BIMCP is also looking at alternative or additional control methods and it does also suggest that IRS by itself is not capable of eliminating mosquitoes from Biocup. Finally our colleagues at Yale are doing an insecticide resistance modelling study and basically the question here is you know at what insecticide frequency does the efficacy of control reduce to such a point that we really need to think about switching to another insecticide. And this information is crucial for determining when changes in insecticide need to be made or how often we need to rotate between different insecticides not only to prevent the emergence of resistance but also to ensure that we have effective control measures and so the models are still a work in progress although some preliminary results show that insecticide resistance actually has a very large impact on on EIR the force of transmission showing that in the presence of insecticide resistance the EIR can be increased by about 50 percent. And here I show some data from the EG mainland in which it shows that resistance frequency of a gene or the frequency of the gene that provides resistance against birefroid insecticide is actually quite high in the mainland before the control started already. The control was done by the Global Fund project that Dr. Xiaouz mentioned earlier and that used by birefroid insecticides and after this spraying was initiated actually the frequency of this gene went up quite dramatically almost reaching fixation. And the project didn't really have the financial flexibility to switch to carbamates as was done on Bioco and that's something that Dr. Schwabi will talk about again later as well. So all these findings kind of demonstrate how critically important it is to have an effective monitoring system in place but also to have a malaria control project that's flexible enough to be able to adapt to these changing entomological characteristics and adapt the vector control strategy. And that wasn't possible on the mainland but it has been possible on Bioco. And this slide it just summarizes some of the results from the modeling study and we actually decided to skip this in the interest of time. So with that I will pass it on to Dr. Buena Vente. We did our baseline in 2004 and in this group children between two and five years of age the proportion with malaria parasites was 42%. As you can see over the time the level of the project so far we have decreased 55% the proportion with malaria parasitemia. We have not eliminated transmission as Michael said and this reduction is comparable with similar programs doing indoor spraying in Limpopo and Mozambique and the northern part of South Africa. We are not monitoring only children under five. We are doing also school children pregnant women and in selected sites the general population. What you can see in this slide is that there is a significant variation between different regions between subdivisions of the southern. This is an island that is only 70 miles long but fairly heterogeneous. It has swamps, it has mountains, forests, etc. So as you can see the blue means that parasitemia decreased significantly and red that got worse during the life of the project compared in 2004 and 2009. You can see there are still areas of persistent parasitemia particularly in the northwest quadrant. This map shows you the reduction in the proportion of individuals with antibodies against malaria parasites. Why we added this essentially is because parasitemia is a little unstable. Malaria parasitemia may vary seasonally even in the same season may vary between locations. So this is a more stable indicator. As you can see the reduction was significant and as expected the lowest in the northwest quadrant there is flat, swampy area. This is the proportion of the children with marked severe anemia hemoglobin under eight grams per deciliter and this mirrors very closely the proportion of pregnant women with marked severe anemia that came down from 14% in 2006 to 3% in 2009. So this is very encouraging. The reduction in total anemia wasn't as significant but we believe that most of the anemones caused by notational causes very, very poor diets and what is the malaria control program essentially reduces is the proportion with marked severe anemia. What I'm going to present now is the way we measure child mortality rate. Essentially we collected with a module based similar to the demographic and health surveys reproductive histories and then expressed the number of deaths per a thousand live birds. As you can see after the project conducted malaria vector control there was a significant decline almost two-thirds in the proportion of the rate of under five deaths. It's not just infant is under five because there was no evidence of other substantial improvements in disease control efforts such as immunization, sanitation. We conclude that the high coverage of effective malaria control interventions is the likely cause of this reduction and it's not only malaria specific deaths that we are reducing but also causes of death that are indirectly associated with malaria such as pneumonia anemia and malnutrition. In the Umbioco island as well as in the continental part of Icoteal Guinea HIV prevalence is very low less than 1% of the children so we don't think this is a confounder. In summary malaria was the most frequent cause of child death in Icoteal Guinea. There's evidence that high coverage with the effective malaria control interventions are associated with decline significant decline in mortality and this is associated with simultaneous decline in malaria. The prevalence of infection anemia fever and the number of infectious mosquitoes as Michael presented no other changes in health interventions targeted to children and this is associated with economic development explaining observed mortality reduction. Thank you. I'm sorry this is lengthy but hopefully of some interest. We've got some evidence on welfare implications that are generally not available for programs like this. We've done detailed household expenditure assessments at various points in the in the work and we've estimated income based on household expenditures savings and borrowing. We've annualized the use of the cost of assets imputed missing values and done some other tricky things basically to come up with a measure of what we consider an annualized value of net worth of each of the families not a measure of income but from this evidence we've been able to look at what the changes in the economic situation in Bioko have been over the first five years. This is a Lorenz curve that looks at income inequality in the country. The two curves of particular interest are the blue and the black. The others are sort of rural Africa and urban Africa comparators. What you see is that the line has shifted down from blue to black and the further it gets away from that midline it means that there's greater inequality in income distribution. In particular you can see down at the bottom that the share of total income in the country earned by the poorest 20% of the income distribution has dropped from 7% in 2004 down to 1% of total income in 2009 so the share of income owned by the poor has reduced. A similar reduction however is observed in the top 20% which has dropped from 47 to 43% which means that there's been a growing middle class that's gone on that is now accounting for more of the income in the in the country so there's a trickle down occurring. Economic growth has led to poverty reduction fairly unambiguously on the island. This is looking at the percentage of individual of houses that live on two dollars or less a day these are individuals has dropped down from 40% to 15% in the four in the five years and the percentage living on a dollar or less a day which is the millennium development goal metric has dropped down from 15% to 5% so in this five-year period Equatorial Guinea has met and surpassed the millennium development goal which is to have the number of individuals living on a dollar or less a day so there's a lot of money in the country and there's a lot of wealth but you know there is some good things happening on on this side. Looked at in terms of purchasing power this is a equivalent kind of measure and looking at being able to buy 2,300 calories of goods and services plus basic needs and you see a similar decline those in relative poverty can buy that basic needs good package of goods has dropped down from 30% to 15% while those who can only afford the 2,300 calories has remained constant so fewer are living on less than a dollar a day but the cost of living has gone up so these people that's still 10% of the population that can only afford that basket of that that food and minimal caloric requirements the project itself has had a very substantial impact on on the welfare of the population the cost of malaria care has been reduced by about half this has benefited the whole population as a whole but it's benefited the poor particularly when expressed as a proportion of their income and you can see that on the right the poor the poorest 10% of the population the cost of reducing malaria care this is just the treatment costs of malaria care has come down represents a savings of about 24% or about a quarter of their income so it's it's like the equivalent of giving them a cash grant of an increase in their salaries or their income by about a quarter whereas for the richest it's been about 5% so everybody has benefited from the reduced cost of treatment and certainly the rich on an absolute level have benefited more but on a proportionate level the poor have so it's been a very pro-poor intervention so we conclude I think fairly unambiguously that maryllaria control is a very effective adjunct to economic growth for poverty alleviation and it's a highly effective way of redistributing oil revenue to the poor so with that let's take a quick look at the future malaria malaria bioko as scribes and it's committed to the global malaria action plan seeking if possible to eliminate malaria from from bioko we recognize this is an enormous challenge and that we're a long way from getting there but there's a commitment on the part of marathon and this group to get there if at all possible we are probably we're at the point now of sustained control for those that know this so we've scaled up all of the interventions to have impact we've seen a result of that impact we're struggling now to keep that impact that that scale up going and to bring to bring the incidence of malaria down to get to pre-elimination we're looking at one or two cases per thousand we're substantially higher than that now so we've got a long-term perspective so we've gone the first two phases have gotten us to sustain control the third phase is we hope looking at pre-elimination but I think marathon has a long term as Adele said extractive horizon we're talking 20 to 40 years we've talked about five we've talked about 10 of those years here we're already contemplating potentially a third phase here for pre-elimination marathon and its partners are prepared to stay and see that see this out through the course it's an unprecedented level of commitment so I think it's interesting to have a perspective I hope you find it interesting from a pvo about what it's like to work with this this group both with the government and and the private partners here this partnership is without question the reason this thing has been successful as Michelle Michelle indicated we have two models in Equatorial Guinea we have the global fund model and we have the marathon government of Equatorial Guinea model and we're we've been locked into a fixed funding stream and a fixed program stream that on the on the mainland that was designed two years before we went in there and really didn't know that much about what was going on on the mainland we've been stuck there and even though we can we can show evidence that we need to change in a traditional very traditional funding arrangement that frankly AID and everybody else will do you're stuck you've got to stay with it okay so you live with what you've got on Bioko we've changed dramatically as a result of information sometimes in a matter of two weeks when we first had insecticide resistance which cost us the cost marathon about four million dollars that decision was literally made in a week provide the evidence substantiated discuss the implications go back to the corporate heads and make a decision and like that we switched and that's extremely unprecedented I think most would concur so what are the assets that each bring in it's it it works because we can leverage what the government brings to the table which is obviously the legal and statutory framework some they contribute a third of the financing of the project and there's an infrastructure and human resource base that's ultimately as I said 97 of what we've done is done by Equatoria and so we anticipate that 100% of it will be done within the next five the next few years here the oil companies bring in this financial wherewithal financial flexibility a results oriented frankly engineering view of the issue show me the problem there's no problem that can't be solved with good information and a good engineered solution an enormous logistics base we'd still be offloading the first truck out of the port if it was MCDI's responsibility these guys can make things move all right government relations when we have a problem with the minister of health this goes right to the top you know there is just there is nothing that stops this train from moving and it's in large part because of that ability to do it and this very unusual long-term commitment to be involved in an entity in an engagement investment where you can see a 15 20 year horizon I mean that's sustainability I don't know what people's definition of sustainability is but if you can guarantee that you got flexible funding for 20 years that's a pretty enviable situation the non-profit MCDI in this case we hope brings in knowledge on health and development and the social sector and we're a non-profit so I'm gonna say by default we're cost effective so we bring in the research institutions as you've seen for Michelle and others bring in specialized state-of-the-art knowledge scientific rigor education and very important to send information dissemination which has brought a lot of attention to this effort and the community organizations bring in the local knowledge acts access and credibility and obviously a long-term commitment I just want to speak a little bit more about marathon here and what they do they're this the project is successful because they have supported rapid startup and achievement they you know they provide customs clearance support as I mentioned the infrastructural support they directly participate in decision making with us we meet with them weekly they know what's going on and they participate on that they are they're interested in interventions that have bring the greatest bang for the buck so they're looking for new innovations new technologies new answers and they're always willing to go where frankly other institutions might be more scared to go so IRS was a good example when we started in 2004 RBM there was one paragraph in the world malaria report made about one page on IRS well the Harvard's expert said no IRS can work it worked in the 1950s it can work again in sub-Saharan Africa and so they invested in that and and Bioko in large parts showed that and the PMI's use of it and now RBM's adoption of it is not is related to what had happened here on Bioko so it's they're they're committed on a long term to it I'm going to skip ahead but this is you know I think that that engagement by marathon has been critical in the process at the same time we're all we all have our frailties we all bring limitations to the table the government in spite of a really considerable effort for it is an extremely weak has extremely weak public administration a weak health sector and so that's part of the struggle here you turn every corner and it's well this system doesn't exist in the ministry so we're going to have to help build that one and so it literally almost becomes a health sector development program there's also frankly been variable political will here depending on which minister has been there and some have been highly supportive and some less and so it's taken some of the advocacy in order to be able to move us forward at various times and this this very innovative social development fund which they've set up which has funded primary health care and a number of initiatives and it currently has an 80 million dollar malaria control fund set up for the for continuing the global fund project which is now no longer going to take place because Equatorial Guinea has disqualified itself from global fund resources because the per capita income is so high that is to be picked up by the social development fund but teaching the government and the ministry how to account for those resources so that they can actually get those 80 million dollars that's proved to be a challenge so that's a work in progress right there the the oil companies are great they've pushed us very hard but sometimes they push almost too hard and their agenda is not totally aligned always with the the timeline for social sector change and so trying to get things done and being willing to bypass even the minister of health at times when that's been necessary well that puts I'll tell you that puts MCDI in a very strange position where it's actually got it's got to work with that minister of health sometimes so you know that that's one of the downsides but frankly if that's what we have to deal with we've been pretty pretty happy that that's our our problem but it has led to a certain amount of confusion and distrust within the health sector at times we are a small entity we are dependent on a few individuals so we're subject to those limitations and our management systems frankly have had to ramp up in order to be capable to to report to the corporate donor here in a way that even is more demanding than a id which which is already fairly demanding the research institutions sometimes find it hard to focus on what's operationally significant and are thinking about more esoteric research they often have time difficulty making a definitive recommendation there's so many what ifs out there well if this happens well then we would say that but but this could prevail and so we're not going to say that so and they're not really always willing to accept the second best decision here so we have to work with them on that but again they bring a lot more to the table than they than they when they're detracting elements and the community organizations and Equatorial Guinea are nascent they're they're the Red Cross has been a very big part of our program particularly for bed net distributions but it's unlike most African countries NGOs are few and far between on the island and so that's been a limiting factor this is just the story that I think is unprecedented in terms of funding we've gone through changes that have been led by a number of structural factors you know when we started out certainly marathon wasn't expecting that this was going to cost what it did certainly from a management perspective we don't want to hang our hats on the fact that we've cost them to have to ratchet up their budget every every year but the fact is that under the conditions prevailing in the country conditions related to this housing boom 20 percent average annual growth unprecedented no one foresaw it so we're we're spraying houses you gotta spray more houses that's going to cost a lot more money uh entomological conditions changing Michelle has talked about resistance we didn't we the literature didn't suggest this resistance existed it did it doubled the cost of the IRS program overnight outdoor biting which is now making our indoor activities less less effective that's going to require a change in strategy so that's that's a change thing I'm changing in understanding about control interventions you know the using outdoor strategies the need for focal interventions and finally economic conditions changing inflation uh currency appreciation which has caused local costs to go up all of those things have led at various times to structure need for structural change in the budget and unlike any other development project that i'm aware of and certainly that mcdi has ever been funded by we've gone through what is that five a year every year we've gone through an adjustment in that first phase now that's a little bit embarrassing but it's what has made this thing actually work that we are continuing to fight it aggressively is because of that flexibility so very briefly conclusions we've got way way beyond where we should have here we've reduced the force of transmission we've reduced the prevalence of infection we've reduced we've achieved the millennium dome element goal for under five mortality the country has achieved the mdg for poverty eradication and and certainly this project has had a big impact on helping that we've I think shown the demonstrated the need for a strong m&e system that allows you to be adaptive and change the results speak to that we've confirmed the need for scaling up and keeping scale up we've we've lost progress at times where we haven't been able to maintain that scale up and we've demonstrated I think the effect of the effectiveness of this kind of public-private partnership so with that long thing thank you very much for your patience thank you really thank the panel I know I was very adamant early to leave ample time for discussion but I really think it was very useful to have such a kind of in-depth comprehensive look at the kind of many spin-off effects of this and kind of looking at the project from different directions from so I want to thank you all for that we'll open up for 15 maybe 20 minutes of discussion I I'd like to start I mean there's so many interesting things that come out of this kind of the impact on the health system more broadly and how perhaps marathon and future will will leverage that but we'll open it up let me just start with the government responsibility I know we in in this you said they're funding a third of this and they're stepping in now to take over the global fund programming is that is that correct one of the trends in in us pet fire assistance is moving towards this kind of partnership framework agreement where the responsibilities of the government are outlined as well as those of the implementing and or the funding partner and I wonder how you know maybe Chris or Adele you might I mean how do you see this translating in terms of kind of pushing the government to take up a little bit more as as we all know Equatorial Guinea is not lacking for for money it's lacking for capacities yes but I wonder how do you see the private sectors role in in terms of pushing them that direction we'll start with that and then go for a round of questions thanks I was expecting actually this question Jennifer so we're prepared I think before I answer the the path forward let's look at to the history of this when we started the project in 2003 at that time there was not strong capacity need actually where the financing in the country so they actually there we started at the base where 90% of the project was funded by the private sector mostly by us now partners so the government actually had a 10% commitment to take I think if you look at that we also looked at the structure of the ministry of health which is basically ministry for whom we were doing this work the this is the most endemic country in Africa the department that is handling this project which is the national program had three full-time people in the most endemic country so clearly you cannot count on infrastructure to basically deliver on a very large scale project or even manage it financially here so so what you've done over the first five years and Chris mentioned that one of the biggest pieces is as we developing the the five elements one of them is always being sustainability which is trying to create an environment where the ministry and the government actually have bigger role as we move forward the second phase we did two things the financial share was proportionate you know with the increase into the the structure of the project so they are going to one third of the cost of the project but at the same time we have made some key metric adjustments where Chris mentioned one of them here 97 percent of the operating team is national employees which is very large actually for if you can look at a number of health initiatives public sector health programs it's a very large number and we have made a commitment to actually have the government involved in the management this is including the financial administrative and technical management so the team that Chris mentioned is being trained now in Peru before that in Mexico is going to be the next generation of leaders to take this project forward everything has its own time and its own format so clearly the government is having more revenues now we're building the capacity if we do move or when we move into phase three we will see them involved at a much higher level in terms of financial commitment we will also see them much more involved in terms of executing on the project so I think this is also very good project if we miss in terms of executing on our strategy we have the high risk of reverting all the gains we've done in this country and basically far into the same situation happened in Satome and Precipio where she's on basically the decided to stop we don't want to have that we don't want to actually after all this gain start all over again so we have to be very careful on how we do the transition so we see it taking more place towards the the end of this phase and the third phase with a high finished commitment from the government and higher commitment in terms of technical and manager oversight so we'll take a few at a time Deirdre here and there's a mike and if you could introduce yourself my name is Deirdre Lapin I'm affiliated with the African Study Center at the University of Pennsylvania thank you very much all of you for a fascinating presentation because I have a background both in health and corporate social responsibility was fascinating I want to address a couple of questions to Adele or anyone else who wants to pitch in my first question is this how do you as a company describe to yourselves the benefit of this project to you and your bottom line I mean it's obviously beneficial to people but how do you as a company view it as beneficial and secondly expanding a little bit on Jennifer's question how do you as a company see the potential of making a change in that genie coefficient the Lawrence curve that you showed how could you somehow through the EITI or other mechanisms expand that middle class because we know that one of the major determinants of health is increased income and and wealth great yes have mics coming hi this is Margaret Reeves from CSIS and I was just curious I think you said that in equatorial sorry equatorial Guinea marathon was one of the largest private employer so it is still surprising that marathons put such a big investment into this kind of work in that area but it obviously you know if that's your workforce you want to keep them healthy and it makes sense but I'm curious in terms of your programs if you have them I'm assuming marathon has social responsibility programs around the world and I'm curious how this has translated in those settings where maybe you're not you know in in equatorial Guinea you're really going to be benefiting from this because you're sort of the big gun so I'm wondering how that works in your other programs yes you're in the middle and then we'll come to the front hi I'm Sarah I'm an associate with Pahef I'm a student at George Washington University my question is more on a micro level I actually had this question when you guys were talking about implementation as a community and I wanted to know how accessible is your health information system and is it more than just internet and brochures what exactly are you guys doing to make sure that the people know what they can do to better protect themselves also my second question is how's the trust between a marathon and the community being built up and how is that being sustained as you guys transition from marathon management to population management in equatorial Guinea thank you stick one last in this round sorry to load you up up in the front thanks I'm Lisa I'm so with Human Rights Watch I want to come back to an underlying theme which was raised about the government's role and and ask you to expand on political commitment dimension and starting with the origin of this project and you've noted that the government's financial commitment at least theoretically is is increasing but I'd like to hear how it came about and what the government's role was then and in terms of financial commitment to break down what has been the actual versus promised commitment because the social development fund as was hinted at is in theory very interesting but hasn't really delivered dollars to date as a country that's very wealthy and got these high levels of malaria incidents because of a lack of investment in its people so I'd like to hear more about that and and really tease out what the outlook is for the future which is the third component kind of over time how do you see the political will as a factor in malaria control in the country great where should we start do you do you want to start to let me cover some of the three questions all dealing with the government particularly will marathon versus CSR strategy and so forth so maybe they can lump them up all together here and Chris if you don't mind covering the community piece and so forth Lisa to your question here I think the level of activity in the country here and not to defend EG or not or or or else I mean it's when we came in it was endemic it's been endemic for a long time so basically we came in a time where they were peaking and we came in at a time so in terms of the political commitment you asked about the financial support first phase 10% this is not theoretical actually they paid their bills you know we collected on their bills the second phase which is 30% we're collecting as we speak literally every month we're collecting so they are physically paying their share of the program so it's not theoretical this is something that it was one of the conditions for us to continue on the second phase if they didn't have a financial commitment in the game we would not be involved as a matter of fact both financial commitments you know were negotiated at the highest level in the government beyond actually the ministry of health was done at the level of the presidential office so the commitment is at the highest level for the intent of the benefitting communities and we see that moving forward again the proportion should evolve in the third phase to where they're taking the lead role and the companies actually are supporting now coming back to the question about how does it play to the bottom line and its impact on the middle class for those who've been following EG actually if you go and have a look right now there is an immediate impact if you look at the current Chris showed and of course Chris is an economist efficient economy you can explain to you how a middle class created it shows definitely that you have migrations from the basically top earning classes and the the poorest of the poor and you see a bigger middle class being created we see that happening with an even hour workforce so we are creating the the middle class we see them they're able to have a much higher person in power we know the salaries you know what they are doing we we see their evolving habits so middle class has been created as we speak I can't tell you how large it is we can just see some of the metrics around that and of course as being the largest employer in the private sector it does have a multiplier effect because middle class would actually start spending there in terms of the question around the benefits of the bottom line I'm sure you're asking okay we are spending 27 million dollars on that phase 16 another one and so forth I think we have to we usually look at our portfolio of activities in a given country I showed specifically I made the introduction to show how our strategies and CSR how we look at the distribution between philanthropy versus sustainable development and certainly this project is not something we qualify as a philanthropic project this is a sustainable development projects it was driven by a business case we entered a country it was highly endemic it was very endemic for our employees our expat as well as our national employees so we thought let's do something about it not only for the employees but also for their families if you take when we got in you take one cycle of malaria it takes 21 days in general of a person's life that is down they can't do anything here actually Dr. Beneventi mapped in one of our businesses the number of lost productivity days just from the impact of this project and show the impact of an implementation of large scale initiative to to our business because when you have a lost time it's for the earning person but also when they have a sick child or sick spouse they can't come to work they have to attend for those this is not even counting the cost involved in spending on actually on treatment so there is a multiplier effect and it does have a benefit to that I think when you look at our portfolio of programs around the world I specifically show those clearly the portfolio is tailored to the issues in the country is tailored to the investment that we have in the country so of course if we are in an exploration phase we would have a lot less spending on CSR versus if we are in a production phase or actually we are exiting a specific country so at that time when we had EG was one of our largest investment assets in Africa and one of the most challenging socially so there is a strong link to the commitment financially and the size of the project to the size of our presence and the size of the challenge we're facing there right and let me I'll just speak a little bit more to the the communication strategy and and and how we're trying to get the message across about health prevention and so we as I talked to we we have a community outreach program so we not only send these teams out twice a year they go literally to every house and talk to them I don't know what in a sort of comprehensive integrated set of messages that that you know is a five to ten minute session with a householder twice a year which is a fairly intensive engagement there's a lot of community education meetings that are organized there are there's street theater groups that go out there's a there's a range of different community outreach activities that are done including working through the the red cross of Equatorial Guinea to get out everybody that comes to a health center is going to be presented with information on the wall they're going we've worked with providers to try to be better educators to the patient and we have there are dedicated Ministry of Health IEC staff who are in each one of these facilities and and when groups of women or caregivers or patients are congregated they talk to them and you know their audio their visual aids that are there and it actually I mean I've been out it actually it actually takes place and it's pretty it's pretty remarkable there is mass media and and you know that that does play a role I don't in terms of behavior change I'm not sure it's you know the key role but things like you know for instance when the government switched its policy to allowing universal free distribution of drugs it was very important that this information get out to everybody that in an otherwise cost recovery oriented health system where they are going to pay for just about everything else you know malaria care is free and getting that message across so that there aren't under the table payments and other things that are going on was an important thing that was done through mass media and then there's a lot of advocacy events working with community leaders it's taken us you know frankly it took us about five years to get the Ministry of Interior to bring its you know district presidents to the table this is a country that has a very strong capability to control its its political hierarchy right and so it was always distressing to us that we couldn't get them to actually leverage this but we do have them doing this now and and they're proud of it I mean just attended I was there two weeks ago attended the first award ceremony where you know a district president you know proudly received a certificate for having had the highest spray coverage in its district you know and so slowly but surely and and in a place like this where you can actually get a government to make a decision that's going to do something it's amazing what they what they can do they they're there and they can have an impact so I don't know if that answered your question but I wonder we go for another round but I wonder now that if the global fund is now moving away from the mainland how is kind of what how what's going to be your relationship to what happens on the mainland one of the things that struck me was kind of the amount of operational research that you're doing and how that that then that feeds back and you're able to change things up which I think is as you said is missing from a lot of the US and kind of large large donor and it's kind of a special asset that the private sector has but so is that also is that model going to get kind of replicated on on the mainland I don't know what how large of a role you'll have within that mainland effort that's going to be largely up to the government of Equatorial Guinea to determine they we were involved with them in laying out this 80 million dollar investment strategy which is a five-year strategy among the things that happen on the global fund project is that we weren't able given global fund resources to actually do IRS and ITNs together so the two provinces with the highest population density got IRS and the lower population density areas got ITNs the evidence shows real synergies between this and in fact given the problems on the mainland of bringing malaria down it's really critical that they actually do these together so the project foresees this but you know the the release of these funds is still still waiting and that has largely to do with public accountability the government the ministry of health's ability to account for the resources that they've gotten from the social development fund and they have gotten resources I mean they're this whole community health network thing has been completely funded through that and you know the government has approved the the social development fund board has approved this 80 million dollar investment it's literally sitting there waiting because the auditors have shown that you know the ministry has not accounted accurately and well enough for the for the monies that it's had so they're they're working with trying to get that and once that's done we're told that this money is going to come forward once that happens Bioko will continue to have a role to play the national health information system it's in our interest to know what's going on on the mainland in terms of cases and so we're going to continue to support that entomological monitoring we can support that from the technical people that we have on the on the island so we you know we've invested five years in on the mainland we're not going to walk away from it obviously our capacity to do things will be will be more limited but part of the social development fund project depending on how the government wants to do this has the ability to hire technical assistance whether they choose to go with mcdi or a different model or different organization is really up to them but finances are not going to be their limiting factor it's going to be human resources and that's the real challenge and I'll say that the global fund when we originally started with them made a very strong case that if this was a a rated project that you know they there was like there was a prevailing mechanism for non-competitive rollover and that you know that they saw it as a long-term commitment but you know their own rules ultimately equatorial guineas wealth disqualified them and you know actually marathon and others tried to advocate with the board at the global fund to to give a particular dispensation for equatorial guinea but they you know they they didn't do that in the end so you know I don't know exactly what is going to play out I it's it's unfortunate you know what what's happened but I think if there's any country that actually could put the resources on the table to do it it's equatorial guinea and and they and it's designed it's there just needs to be released yeah well thank you very much Marcus Guino um with the State Department um USAID was mentioned a couple of times and and I was curious of what degree of cooperation you have with USAID what kinds of programs they have that you you kind of compliment uh and in my my other question is I understand that there's there's a small group of peace corps volunteers uh in equatorial guinea and again just curious whether you have any interaction with them whether they assist you in any way thank you thanks Marcus actually uh USAID has a very unique situation in EG most in most cases USAID receives money from the US government throughout taxpayer's money to spend in development programs this is the only project USAID actually is receiving money from a country which is EG the first installment was done the four years ago it was seven million dollars I had another million eight million and the US actually USAID became almost the administrator of the set of four areas of priorities health education environment and women's affairs and which led to the creation to what Chris mentioned earlier the social development fund so the project for malaria that 80 million dollar proposal was developed you know by USAID working with the MCDI and the Ministry of Health and so forth and a number of other projects were developed and it's a mechanism the intent for USAID is to become almost like a broker making sure the mechanism are in place and making sure there's also a mechanism to spend the money in a in a very um I would say a structured way so yes we worked very closely with the USAID certainly in a completely different format what we've done in the past where usually we worked on execution projects uh the peace corps um is no longer there actually the peace corps was there until I believe the early 90s what is meant election we had a couple of peace corps guys coming and work with us in the early project I do not believe the peace corps would be reintroduced in EG for a number of reasons one of them at EG is not in the same scale as it was when the peace corps was there just because it became a high earner at least on a GDP basis um thank you very much my name is Swamaka Oparji I'm a graduate student of community public health and global health from University of Maryland Baltimore and um my first question is about um I wanted to find out if there was any environmental hazards that are to humans associated with the ICP that you use for the eradication of the vectors and um my other question is about the I was listening to Michelle when you were talking about the number of um measuring the number of infective um bites per year and I wanted to find out how did you measure that all right let me first let's let's take a couple more but that's a good question that I was wondering as well gentlemen the bites yeah it's human baiting it's anyway um my name's phil coin I'm at uniform service university I just have a question about other vector-borne diseases uh in Bioko I know that in the past the APOC program the anko program actually was spraying for anko sarciasis there but I don't know what the current status is and of course I think there's lymphatic filariasis there as well which is another mosquito-borne disease so I'm just wondering if there's been any attempt to measure some of your collateral benefits of this program in the context of other vector-borne diseases hi Nicholas Cook from the congressional research service um given the small scale of a equator guinea and this top-down political support for the program and the can-do attitude of marathon uh as as described earlier uh these seem to have facilitated this program and but what impact how would you compare the scalability uh to other countries or the replicability to other countries I mean these these were kind of unique factors in a much bigger country with less centralized top-down control what would be different all right let me say a little bit about that the public health um dangers of spraying um insecticide um in terms of IRS and bed nets um any study that I'm aware of hasn't shown any effect on on human health whatsoever the amounts of insecticide used are really um quite quite small compared to um some of the users in in agriculture for example and exposure to humans is extremely limited and the benefit surely of of spraying is much larger than you know than than the potential danger in terms of the human landing catches they they are basically um human volunteers that um sit with their legs exposed with an aspirator and they collect mosquitoes that land on their legs um and these are human these are natives of um ectoregini they have um acquired immunity um there is a doctor involved that provides treatment if needed and um these treatments or these catches have been approved by the the ethics committee um of course of the ectoregini government but also of the London School of Tropical Medicine and Health so it's a it's a fairly widely used collection method actually we hire volunteers by the way have a list I'm sure you'll get a long line on that one there is some cosercosis in umbioco and vector control and mass drug administration we we haven't worked closely with them but uh we we intend to because um mass drug administration is fairly similar to active case detection in the case of malaria and particularly for school children and certain populations can be done in their schools the last question on replicability and the unit I'll address that one if you don't mind um you do mention there are two key attributes yes the the geopolitical situation clearly on island setting is much more favorable than than within the middle of a continent uh the the approach we have taken yes there were very strong attributes what we've done in the past a few years we've done a lot of benchmark in other projects done in partnership by the private sector and governments we looked at activities in Angola we looked at South Africa we looked at Ghana recently actually Chris and I and others were there recently so clearly you know there's a ring fencing situation when you are in open land trying to define the parameters there that are fairly challenging but however I would I would say it's not all it's not all rosy here the fact that we have very strong issues around the resistance we've seen you know DNA mutations so forth it is not straightforward so what we gain on a geopolitical side here we might be challenged on another side so I would say it's even here so it's capability and replicability here will vary greatly for each country could I just add to that I think one of the real limiting factors and it's surprising I mean we've had colleagues who've worked you know 25 years in Africa and they've come to EG and we said you know you're going to be surprised and they say oh no I've we've been here and a month after they're there they say I I've never seen anything like this and it's it's hard to describe but the human resource capacity is their huge this is their big challenge I mean they they've had no educational base and so they're they're they're they're scurrying now to build that human resource base you compare that with a place like Nigeria or Ghana or I mean anywhere in Francophone West Africa where you've just got a much stronger human resource base so in some ways the replicability and the scalability is easier in another context than it is in Equatorial Guinea no question the scale is advantageous and the fact that it's on an island is advantageous but you know you can sort of look at this as sort of a district-based activity in another country and well okay so there's a decentralization in other countries and I mean that's something that's only nascent in Equatorial Guinea they've district health management teams don't exist and they're just being conceived of so you know in countries where you have a more decentralized framework the issue the challenge of course is you know is some of the the mix of interventions like IRS I mean that durable lining is a very attractive proposition if resistance phenomenon don't prevent it from being used because putting something in a house that last five years versus going in twice a year to try to spray you know that's that's a really fantastic thing I think the other thing and part of what for us is interesting about the Bioko experience and partnering with Marathon is that we're looking down the road at you know maybe these silver bullets out there but looking at you know at vaccines down the road or other interventions there you know whatever is coming down the pike one of the benefits of having a tremendous monitoring and evaluation system is that anybody that's developing any kind of new strategy has an interest in coming in and showing being able to show an impact so you know that's that's part of it I think the answer for Africa is economic development and you know some of the the changes that are going to occur in housing and and the ability to prevent these things through that economic development and and hopefully down the pike if we can make an impact and sustain an impact for you know a decade or more you know some other approach like a vaccine is ultimately what's I think going to be required to eliminate the real money the mainland yeah still open questions right but there I mean there's a good example of the replicability I mean we went in we used the Bioko model we implemented we have not had the same degree of success and I think actually and I think it's going to be one of the things that for the literature is going to be very important that we can show why we haven't had success and it and it has been the fact that we've been trapped in a pair you know in a you know in the original proposal which simply has not been able to respond to the change what we've learned and the changing circumstances you know and the data that Michelle put up there about resistance phenomenon I mean going from you know 64 percent to 84 percent of the mosquitoes having that gene you know and well you can't use pyrethroids there so what are you going to do and the fact that you don't have a program that can adjust to that so replicability has also to do not just with the context but with the donor and what are they going to do and allow you to do to change so again equatorial guineas in a very enviable position that 80 million dollar assuming that the social development fund allowed doesn't micromanage that and and actually I've seen the the work plan for this it's it's a horrific thing that looks about that thick you know which purports to to micromanage this thing all the way assuming they don't do that the resources are there to be able to adapt and and maybe they have a shot at it I wanted to acknowledge the support from USAID through PMI and the technical support from CDC for this section on monitoring and evaluation these those resources allow us to purchase computer to train develop the health information system and train the health workers that are in charge of managing the statistics yeah that's very important we were the one of the first PMI recipients before the big launching of the whole thing and and it was formative and so yeah very very important yeah I want to thank the panel again this is really being really excellent in-depth look I think one of the things we'll look forward to kind of updates on your program but I think also importantly the SDF implementation by the equatorial guinea will be government will be something to to watch for as well I want to thank you I want to thank EG justice once again and Tutu Alacante and Joe thanks very much and to our panelists for really great presentations thanks so much