Identifying Opportunities to Address Malaria through Infrastructure Projects

Identifying opportunities to address malaria through infrastructure projects

Workshop Report

World Bank

June 9-10, 1999

Executive Summary

Between the 9th and the 10th of June 1999, the World Bank's Malaria Team, with the support of infrastructure staff within the Bank, hosted a workshop to identify opportunities for addressing malaria through infrastructure projects. The workshop was part of an effort to develop guidance for World Bank infrastructure task teams on whether, when, and how they might incorporate effective malaria interventions, and how they might appraise and evaluate the impact of such interventions. It was anticipated that other partners committed to the aims of Roll Back Malaria might also recognize similar opportunities in their own operations, and thus be interested in a joint consideration of how investments into infrastructure might impact upon the risk of malaria transmission.

The participants represented a wide range of professionals and partner agencies with interest and expertise in environmental health, infrastructure, health economics, entomology and malaria epidemiology. They enthusiastically contributed towards a consideration of whether there is a justification for endeavoring to address malaria through the infrastructure sector; what cost-effective interventions might be integrated into infrastructure operations; in what circumstances/situations such interventions might generally be justified; and how proposed interventions might be appraised, measured and evaluated.

The participants produced a number of recommendations, but the most consequential was that health impact assessment procedures, carried out in conjunction with already existing Environmental Assessments, offer the most cost-effective opportunity to address malaria through infrastructure projects. The participants strongly recommended that Health Impact Assessments (HIAs) should be incorporated into the process of project preparation. The recommendation also implies that health, environment and infrastructure staff within the Bank would assume responsibility for supporting the assessment process, and ensuring the design and implementation of an appropriate response. The workshop concluded that such a response is most likely to emphasize mitigating the increased risk of malaria transmission engendered by infrastructure design and operations, although opportunities to incorporate interventions which might reduce overall malaria transmission were also identified.

The Malaria Team will next review the conclusions of the workshop with a wider range of the Bank's Infrastructure staff, and management in the HNP, Environmental and Infrastructure sectors. They will also work closely with key international partners to initiate and assess approaches to implementing and responding to Health Impact Assessments in malaria-affected countries. Such an integrated approach to addressing malaria, a Bank Corporate Priority, is consistent with the aims of the new Comprehensive Development Framework (CDF). In this new environment, the Malaria Team anticipates that the workshop recommendations could become mainstreamed within World Bank Project Preparation.

Background

The World Bank Malaria Team has been working to define the Bank's institutional comparative advantage within the Roll Back Malaria Partnership. One area which has been identified as a possible comparative advantage are the opportunities to address malaria intersectorally. These opportunities include an area for which the efficacy, cost-effectiveness and affordability is not well established: that of addressing malaria through environmental control interventions incorporated into infrastructure sector operations. The infrastructure sector is recognized as encompassing operations in water, sanitation, transport, housing and urban development, with repercussions in energy, as well as agricultural infrastructure.

Through the workshop, the Team sought input from a range of experts and perspectives into guidance for infrastructure operations on whether, when, and how they might incorporate effective interventions, and how they might appraise and measure the impact of such interventions. Although the role of, and opportunity for, appropriate prevention and care services for affected populations, and communication strategies to encourage personal protection and care seeking were recognized, the potential role for incorporating vector control measures was less well understood. The workshop therefore focused on the potential impact of infrastructure operations on the environmental factors which support malaria transmission.

Workshop Methodology

A World Bank workshop on identifying opportunities to address malaria through infrastructure projects took place between the 9th and 10th June 1999. Participants for the workshop represented a cross-section of World Bank health, environment and infrastructure staff, Roll Back Malaria key partners (WHO, UNICEF, UNDP and USAID), as well as entomologists, epidemiologists, malariologists and economists from academic institutions and the private sector.

In order to foster discussion and debate, the workshop comprised a series of plenary sessions and three separate small team working groups focusing on the following subject areas:

Ø Entomology and Epidemiology

Ø Project Design, Monitoring and Evaluation

Ø Measuring Impact and Assessing Cost-Effectiveness

Several hypotheses had earlier been drafted to guide and provoke discussion, and had been disseminated to the participants. These hypotheses were divided among the three working groups to form the basis for discussions during the workshop. The participants had also been asked in advance to supply a list of resource people who could be included into an inventory of expertise in addressing malaria through infrastructure projects.

By the end of the workshop, each of the 3 working groups had to summarize the findings of their respective group's discussions. These findings, based on each working group, are presented here. It was understood that the three working groups were not mutually exclusive, and many of the issues discussed cut across the three working groups. Therefore, the agenda included opportunities for open discussion in plenary.

FINDINGS OF THE WORKSHOP

Findings of the working group on Entomology and Epidemiology

The working group on entomology and epidemiology acknowledged the need to understand the complexity of variables that determine the interaction between the local vector, community and environment in order to acquire a reasonable estimate of the effect that an infrastructure project might have on breeding sites for anopheline mosquitoes and transmission of malaria to the local resident population. For a given project, a Health Impact Assessment (HIA) 'Health Impact Assessment' as used in this document refers to an assessment of the beneficial or adverse health effects or risks due to an environmental exposure or likely to follow an environmental change. as part of overall Environmental Assessment, offers the best opportunity to address these complexities as they relate to an individual project. The conclusions and recommendations below attempt to generalize these complexities, and are limited to the general picture rather than the specifics of one particular project.

Conclusions:

· Infrastructure projects are an essential element of development and can contribute to the long-term health and well being of beneficiaries.

· Most infrastructure projects undertaken in malaria endemic areas can be expected to adversely affect malaria transmission and disease but in most cases, that effect can be reduced by careful analysis and design.

· Infrastructure projects can exacerbate malaria risk if they have components that include construction of roads, dams, irrigation schemes, pipelines, water supplies and new or upgraded residential sites.

· The health impact of infrastructure projects is most acute when non-immune people become exposed to infection, but also when previously infected people become super-infected.

· Where malaria transmission is unstable (as in urban and peri-urban areas or highland areas in Sub-Saharan Africa), environmental management is most likely to break the cycle of transmission. Where transmission is stable (as in much of rural Sub-Saharan Africa), such efforts may not break the cycle but may still reduce morbidity and mortality and limit the increase in drug resistance.

· Health and infrastructure staff should be working together from the outset of the planning process for an infrastructure project, and cost-benefit analysis conducted for infrastructure projects must incorporate long-term health impacts, including the, often hidden, costs incurred to the health sector.

Recommendations:

· Current global vector control strategies are currently dominated by insecticide treated mosquito nets. Through infrastructure projects, the World Bank is in a position to demonstrate leadership on including environmental management for integrated strategies.

· Bank infrastructure personnel cannot be expected to have all the skills and knowledge to advise upon and/or appraise efforts to mitigate the malaria consequences of infrastructure projects. Rigid (formulaic) approaches to reduce the complexities of malaria control are unlikely to be successful. It is in the Bank's interest to expand existing environmental assessment tools to include an assessment of malaria consequences, and to develop a process by which personnel can access environmental health professionals to assist in developing mitigation plans. World Bank/WHO collaboration within the RBM partnership framework could be highly conducive towards the development of this process.

· More than half a century of experience in development activity by countries and development agencies has produced a wealth of data and guidelines for use in reducing malaria impacts that accompany infrastructure projects. The Bank should make these experiences, data and guidelines accessible to personnel designing infrastructure projects.

· Any project that increases vector abundance or facilitates exposure of non-immune individuals to increased risk of contact with vectors, should include an effective and implementable mitigation plan.

· To facilitate environmental health assessment efforts, the Bank should consider preparing a manual, based on a hypertext database which would assist Bank staff in the design of infrastructure projects that take into consideration the malaria health burden. This system will be valuable if it provides an algorithm of questions to be asked, rather than attempting to make decisions on behalf of the staff.

· The following table could be expanded to include more detailed information on types of risks; options for mitigation and their costs; indicators; references and evidence which exists to support the analysis and recommendations.

Risk of malaria transmission in infrastructure projects

(Rough guide only*)

Type of project Risk of increasing anopheline mosquito breeding sites Malaria transmission risk Ease of implementing effective environmental interventions

Roads High High Easier

Logging High High Difficult

Urbanization Initially high, then low (as breeding sites and contacts with vectors are reduced due to improved infrastructure) Initially high, then low Easier

Irrigation: Rice/sugar High High to low Easy to difficult

Irrigation: Canals/rehab Low to high Low to high Easy to difficult

Energy (dams, pipelines) High High Easy to difficult

Water supply Moderate Low to moderate Easier

* This table does not in any way replace the need for a health impact assessment of an infrastructure project.

Findings of the working group on Project Design, Monitoring and Evaluation

Conclusions:

· The group concluded that health risk management (including HIAs) are an essential element in development projects and should be conducted in the context of the Bank's environmental impact assessments. However, even though infrastructure projects cannot solely assume responsibility for vector control, environmental assessments are rarely conducted in collaboration with health staff. Among health professionals, impact of interventions upon health status is frequently measured using Disability Adjusted Life Years (DALYs). However the concept is unfamiliar to people outside the health sector, and unlikely to be readily adopted by infrastructure staff. There is a need to identify and employ appropriate indicators of incidence and transmission, and modes for measuring them over relatively short time periods. The responsibility for monitoring impact should lie primarily with the health ministry at country level.

· While health risk management and HIAs are important, there is a lack of capacity to conduct them at both the government and donor institutional level. At the government/Ministry of health level there is a need for capacity building in drafting terms of reference, appraising Health Impact Assessments, and managing risks. Improving the capacity to implement Health Impact Assessments by research institutions, private consulting firms and NGOs could expand national capacity to conduct impact assessments, design mitigation plans, and ensure quality of implementation (a recognized weakness in many mitigation efforts).

· The group recognized that a major consideration was how to make health "count" to infrastructure Task Teams. Currently staff from health and infrastructure sectors are not rewarded for efforts to forge inter-sectoral collaboration, even when the need is recognized by the Country Team. Effective implementation of the Bank's new Comprehensive Development Framework implies a change in mandate for sectoral staff, and in how staff performance will be assessed. Realization of the aims of the CDF will also require a change in culture, policy and priorities at the government, in addition to the institutional level. Such changes can be initiated as a top-down approach with directives from the highest levels; or preferably, through developing, rewarding and disseminating the experiences of a few examples of collaboration in country operations.

· The environmental lobby has been more effective than the health lobby in recognizing and promoting the cross-cutting nature of their mandate. There are lessons which proponents of health can learn from the environmental sector regarding the acceptance of a lobbying role, and appreciation of the need to operate "upstream". One such lesson is that learned from the strategic use of public protest (by NGOs and other representatives from civil society) to compel efforts to institutionalize environmental impact assessments and mitigation plans. Along these lines, there is a need to develop an advocacy strategy to increase awareness. Selected examples can demonstrate the added value of including health in infrastructure projects, and the feasibility of affordable and cost-effective mitigation and health-promoting interventions. A strategic alliance between national environment and health authorities and strengthening of environmental health departments in MOH's will contribute substantially towards achieving these goals.

· Information, education and communication(IEC) can readily be incorporated into the design, operation and maintenance of infrastructure projects. However, infrastructure task managers need ready access to resources and tools which can respond to such opportunities.

· The increasing prevalence of Sector Programs expands the scope of influence beyond the donor-financed project to the sector as a whole. It also implies a shift in the approaches taken in the concepts and paradigms regarding the evaluation of success in donor-financed investments; specifically towards a recognition of the comprehensive impact of development programs on the sector as a whole. The Comprehensive Development Framework takes the holistic approach further: recognizing the impact across sectors to the country as a whole. In sectors such as agriculture and roads, this implies a need to include health impact in the economic analysis of projects, and in health projects, suggests that environmental health, because of its multi-sectoral aspects, should receive overdue attention and support. Financing and the monitoring of the health impact of infrastructure projects will need to be a joint effort between infrastructure and health ministries. The environmental health departments of health ministries are, by tradition, conversant with the regulatory roles and responsibilities of the health sector.

Recommendations

· Within the Roll Back Malaria partnership (WHO, UNICEF, World Bank, UNDP) the Bank should recognize its comparative advantage in incorporating malaria interventions into infrastructure projects at the country level.

· Redesign the health component of the existing Environmental Impact Assessment (work currently on-going led by James Listorti).

· Build capacity for intersectoral collaboration by, for example, conducting courses such as the one developed by PEEM Joint WHO/FAO/UNEP/UNCHS Panel of Experts on Environmental Management for Vector Control

, the Danish Bilharziasis Laboratory and the Liverpool School of Tropical Medicine: "Health Opportunities in water resources development". The target audience would be Bank staff as well as clients.

· Include communications for behavior change at project planning, and use RBM to strengthen behavior change strategies. At the community level, communication strategies could be developed by local public health research centers, the national malaria control program, and/or environmental health groups. Consider the role of NGO partnerships in some mitigation activities – e.g., communications, community mobilization.

· Include health costs in the calculation of rate of return of projects, and health impact in economic analyses Some initial estimates of the burden of disease attributable to infrastructure interventions is being done in a pilot study on Ghana under the program "Environment and Health, Bridging the Gaps"..

· Prioritize health risk management in the Environmental Impact Assessment. "Environmental management" should be considered in its broadest sense, certainly far beyond drainage.

· Develop Geographic Information Systems and Remote Sensing as planning tools to support the introduction of Health into Infrastructure Development. This can be assisted by forming alliances with GIS personnel working in the environment sector in order to adapt their work to health uses.

· Compile the state of the knowledge on practical best practices and health risk management.

· Update the following WHO Publications in more user friendly versions: Manual on Environmental Management of Mosquito Control (WHO, 1982) and Review of Cost-Effectiveness of Environmental Management (WHO, 1986).

· Within the Bank, revitalize Environmental Health Affinity group as a cross-sectoral Theme Group or as a sub-group under the Public Health Thematic Group.

Findings of the working group on Measuring Impact and Assessing Cost Effectiveness

Conclusions

· There are recognized opportunities to reduce malaria transmission through infrastructure projects: through reduction of existing breeding sites, such as changes in irrigation techniques, and through reduction of human-vector contact, such as better construction of living spaces, but they are limited. (There also exist some misconceptions about opportunities to reduce transmission, which could channel resources towards ineffective efforts, for example, the belief that open sewage acts as a breeding site for anophelene mosquitoes. As with others sectors, such as education, there are opportunities created by infrastructure projects for reaching populations with communications for behavior change. However, the greatest potential cumulative impact engendered through collaborating with infrastructure sector is in mitigating the risk of infrastructure operations to increase transmission.

· The impact of mitigation efforts are to ensure that incidence/prevalence of disease does not rise to the level projected in the absence of the mitigation plan, rather than reducing incidence below that at the onset of the project.

Effect of mitigation on health risk

· Greater risk is likely to result due to the movement of people (density, exposure, behavior) associated with many infrastructure projects than through increase in vector breeding. (without people, increased vector prevalence would not increase the risk of transmission), but relative risks should be assessed for each project individually.

· Efforts to avoid increased breeding of malaria vectors in any area of active malaria transmission may have the potential to mitigate against increased transmission. Efforts to avoid creating increased breeding sites may even be warranted in holoendemic areas, as reduced frequency of contact may reduce the burden of blood parasites, and of resistance. It would be helpful to further validate the assumptions behind this last statement. The foundation for this hypothesis discussed at the workshop was a) the impact upon mortality demonstrated by the use of bednets in holoendemic areas; and b) suggestions that vector control might contribute towards reducing the development of resistance (Molyneux et al., Parasitology Today, June '99).

· Quality control in infrastructure projects will generally mitigates breeding site creation (although in some circumstances, the engineering techniques are novel, not well appreciated, or need to be more widely incorporated into standard designs). However, the greater challenge is in monitoring, and ensuring that the quality designs are actually implemented and sustained.

· To sustain efforts to mitigate impact, the accountability/responsibility for assessing operations and activities must be established at the country level. Consideration needs to be put on incorporating incentives (economic/political/social) for maintenance, for sustaining efforts under the project, and for appropriate implementation (e.g., project which placed two types of fish in breeding sites – one intended for the community to harvest and one solely to reduce larvae).

Recommendations

· The assessment of population movement is often limited to consideration of migrant workers, but needs to appreciate that workers move with extended families, the influx of informal opportunists who accompany workers, and the movement of people resulting from expansion of roads, new income opportunities, etc.

· Although it is important to ultimately appreciate the malaria transmission attributable risk created by an infrastructure activity, efforts would be more efficiently channeled towards conducting an overall Health Impact Assessment which reviews projects for potential impact upon health status in general, not only malaria or vector-borne disease.

· Projects recognized as creating potential hazards should be assessed for risk of negative impact, and ideally, for possible opportunities to promote health. Mitigation possibilities should then be assessed and considered for incorporation into project design, implementation and monitoring.

· Within HIAs, priority attention should be given to those categories of projects/operations undertaken in those ecological zones which are most likely to create risks. In general, these are operations which have the potential to increase breeding sites and/or facilitate the movement of people into or within malarious areas.

· To assess hazard and potential risk, assessments should be undertaken with the following scope:

Ø Institutions (e.g., local government, and health system) will require a certain level of capacity to detect increased need, and mount an appropriate response.

Ø The environment needs to be well understood to determine whether the ecological setting is conducive for malaria transmission and disease, including an understanding of any seasonal relationships.

Ø The role of people/communities -- with regard to migration, population density, their behavior, beliefs and/or immune status will affect the vulnerability of the population.

· General economic analysis required for project preparation should incorporate such externalities as the negative benefit due to a possible increase of malaria transmission. Analyzing the economic impact is complicated by such complexities as the interaction of incoming earning opportunities and associated increased risk of transmission. There are also issues of the parameters in the local population and time.

Summary Conclusions

The Workshop participants strongly supported the assertion that a comparative advantage of the World Bank within the Roll Back Malaria Partnership lies in its potential to incorporate malaria control into its lending for infrastructure operations, and that Health Impact Assessments (HIAs) – incorporated with appropriate risk management measures -- in infrastructure operations will contribute to achieving the goals of Roll Back Malaria.

The workshop also recognized that a methodology for Health Impact Assessments has been developed and tested, and that the establishment of a supportive environment and clear procedures for the use of HIA in multilateral development banks, bilateral agencies, and national governments is the next critical step.

Incorporation of risk management (i.e. mitigation) measures into the design, operations and maintenance components of infrastructure projects is technically feasible and such measures will have to be assessed for their economic viability on a case by case basis. In some situations (e.g., urban settings) the possibility of incorporating into infrastructure operations strategies which have a primary goal of reducing malaria transmission, would be worth considering.

Such an intersectoral approach, which will require health sector involvement in a regulatory role, with environmental health departments working closely with their colleagues in the malaria control program, would provide a concrete example of the intentions to make the Roll Back Malaria initiative health sector wide, as well as improve cross-sectoral work within the Bank.

Next Steps

Given the conclusion that Health Impact Assessment is the key entry point to addressing malaria through infrastructure projects, the following next steps are proposed for action by World Bank Malaria Team:

1. Disseminate findings of the workshop widely, particularly among infrastructure and health professionals through the World Bank's sector training weeks, and consider additional methods (e.g., a flyer or articles in Bank publications) which will increase staff and management recognition of the HIA section in the Bank's Environmental Assessment Manual. Make available to infrastructure and health staff, the inventory of expertise compiled during the workshop.

2. Meet with management staff in the Health, Nutrition and Population Sector, Environment Sector and Infrastructure Sector to discuss approaches to, and the implications of, institutionalizing Health Impact Assessments. Managers will need to consider the implied additional responsibilities for staff (and the accompanying knowledge management, training and support required), as well as the current lack of incentives for staff to become engaged in cross-sectoral activities.

3. Continue and strengthen contacts with the WHO/FAO/UNDP PEEM Program (which has it secretariat at WHO/Geneva), such as through employing the training course "Health Opportunities in Water Resources Development". Where possible in Country Operations, collaborate with PEEM's efforts to implement an accelerated program of national seminars for senior government officials on the incorporation of health issues into national and sectoral development planning policies. Support PEEM's leadership in updating literature in this area through directing staff to PEEM as an information resource.

4. Support other partners, client countries, WHO, UNICEF, UNDP, bilateral and multi-lateral donors and NGOs in efforts to incorporate malaria into infrastructure operations and/or to inform the efforts of other agencies to do so. This will include exploring the possibility of WHO regional and/or country offices participation in the HIA process.

5. Identify World Bank infrastructure projects currently under preparation in malaria-affected settings which might demonstrate the role of employing HIA, designing health risk management measures, and acting upon opportunities to address malaria through infrastructure projects. Mobilize the RBM partnership, predominantly, PEEM and the World Bank, to collaborate in the assessment, design, documentation and dissemination of experience.

ANNEX 1: Workshop Agenda

Day 1 - Wednesday, June 9

OBJECTIVE: Identify cost-effective and affordable opportunities to address malaria through infrastructure projects.

9:00-9:15 Welcome: C. Lovelace

· Objectives for the Workshop

· Linkages of Infrastructure and Malaria

9:15-10:30 Plenary Session 1: Framing The Issues

Panelists: R. Bos, M. Birley, S. Foster

10:30-10:45 Coffee

10:45-12-30 Small Group Session 1: (Breakout teams meet concurrently)

Entomology and Epidemiology

Lead Resource Person: R.Lennox

Project Design, Monitoring and Evaluation

Lead Resource Person: R. Bos

Measuring Impact and Assessing Cost Effectiveness

Lead Resource Person: M. Birley, S. Foster

12:30-1:30 Lunch: "On Inter-Sectoral Collaboration" Speaker: M. Birley

1:30-3:00 Plenary Session 2:

· Breakout teams report preliminary key issues, most promising brainstorm ideas on cross cutting issues

· Discussion and input from plenary

3:00-4:30 Small Group Session 2

· Breakout teams more sharply define preliminary findings and conclusions)

· Reformulate ideas and revise preliminary conclusions

4:30-5:15 Plenary Session 3: Presentation of Preliminary Findings on Hypotheses

(R. Bos, M. Birley, S. Foster, R. Lennox)

5:15-5:30 Thanks and Review of Agenda for Day 2

O. Pannenborg

5:30 Cocktails

Day 2

Technical Working Groups

9:00-10:30 Plenary Session 4: Panel discussion on the Hypotheses

10:30-12:00 Small Group Session 3: Finalize Group Summaries

· Entomology and Epidemiology

· Project Design, Monitoring and Evaluation

· Measuring Impact and Assessing Cost-Effectiveness

12:00-12:30 Plenary Session 5: Short Summary from Each Working Group

12:30-12:45 Next Steps

O. Pannenborg

ANNEX 2: Hypotheses

1) Infrastructure projects promote development, and this development can occur without increasing malaria transmission and disease.

· How might infrastructure projects increase malaria transmission and disease?

· What type infrastructure projects are most likely to increase malaria transmission and disease?

· What are the minimum requirements to ensure that infrastructure projects do not lead to an increase in malaria transmission and disease?

2) Infrastructure projects promote development, and this development can be made to occur without creating breeding sites for vectors.

· How might infrastructure projects create breeding sites for anopheline mosquitoes?

· What type of infrastructure projects are most likely to create breeding sites for anopheline mosquitoes?

· What are the minimum requirements to ensure that infrastructure projects do not create breeding sites for anopheline mosquitoes?

3) Infrastructure projects, while being able to attract a diverse workforce (both malaria immune and non-immune) can prevent the spread of malaria to non-immune populations, by ensuring availability and utilization of sufficient prevention measures, diagnostic and treatment facilities.

· How would an infrastructure Task Team know the magnitude of the risk of exposing new populations to malaria?

· What would be the necessary requirements for the Task Team to ensure that the project would:

A. prevent the spread of malaria to non-immune populations?

B. Ensure availability and utilization of preventive, diagnostic and treatment services for malaria

4) Infrastructure projects can lead to reduction of malaria in malaria endemic areas if the vector breeding sites can be sufficiently reduced to break the transmission cycle.

· What would it take to "break the transmission cycle"?

· What information is required to know if a reduction in breeding sites could have an impact?

· How can projects monitor the impact of reduction in breeding sites?

· How do they know if a related reduction in transmission is actually occurring?

5) Infrastructure projects offer an entry point for Information, Education, and Communication (Health Promotion and IEC for behavior change) aimed at the reduction of malaria and other vector borne diseases.

· What mechanisms are present within infrastructure projects which make this a plausible "add on"?

· How can IEC efforts be integrated/coordinated with HIV/AIDS, family planning, sanitation, and other communication strategies?

· How does a Task Team Leader know that the IEC approach adapted, has had an impact upon changing knowledge, attitudes and practice towards the reduction of malaria?

6) Indicators can be built into infrastructure projects that can be used to monitor and evaluate the malaria-specific outcomes of the projects.

· Is it possible to identify a generic set of indicators?

· What would they be?

· How easily could they be measured/monitored?

· Is it cost-effective to measure all of them, or can some assumptions of cause and effect be reasonably made?

7) Environmental management projects such as drainage and filling breeding areas provide a cost-effective intervention to reduce malaria transmission.

· Is this a potentially cost-effective approach in rural Sub-Saharan Africa, in the Amazon, in urban areas?

· Is the above valid only to a limited number of water bodies such as canals, rice fields, swamps, etc. ?

· Overall, what general statements can be made regarding the settings/situations in which the above hypothesis is valid and those settings in which it would not be valid?

8) There are established international technical resource centers/individuals that can be called upon to support infrastructure projects to address malaria-specific objectives.

· What types of resources/technical expertise would be required to inform the development and/or monitoring of projects which incorporated malaria interventions?

· Are there Partners from whom this expertise might be accessed at little to no cost?

· Have the workshop participants in the group given input into the inventory of expertise being compiled?

9) There is an economic rational for using infrastructure projects to address malaria specific objectives.

· Is it cost-effective to undertake extensive assessments of the potential impact on malaria during project identification/design? In what circumstances?

· How would one assess the cost-effectiveness of an environmental control measure?

· What is the economic evidence to suggest that incremental interventions (e.g., prioritizing sites in a drainage project with breeding information, ensuring that road construction reduces or avoids producing additional breeding sites, providing messages through existing outreach workers, providing prevention, diagnosis & care for affected populations) could have an impact upon malaria?

10) In predominantly rural holoendemic areas, environmental control measures are unlikely to have a significant impact upon malaria transmission.

· Is the above true for all predominantly rural holoendemic areas?

· Does it make sense to consider environmental malaria control measures in rural holoendemic areas?

11) Infrastructure projects should include malaria/other vector borne diseases prevention elements including baseline study needs, from the earliest planning phase.

· What would this cost?

· Is it cost-effective to do so?

· In what circumstances might it be warranted?

12) Community and health system involvement from the inception of the project can prevent the exacerbation of vector borne diseases in project areas.

· How would a Task Team ensure that the project involved the community and the existing health system?

· What inputs from the Task Team's side would be required to make this happen?

· Is this already happening, and what has been the experience?

13) Infrastructure projects will change the ecology of the area and can adversely affect the local epidemiology of malaria.

· In what circumstances could we generally expect an adverse impact?

· Are such situations common?

· Do existing Environmental Assessments cater for this?

· What mitigating efforts could be justified (would be both cost-effective and affordable?

· What expertise is required?