Posts or Comments 20 July 2024

Monthly Archive for "August 2008"

Coordination Bill Brieger | 31 Aug 2008

Limpopo – another river to cross in controlling malaria

limpopo-river-crosses-4-countries.jpgThe countries of southern Africa are more often known for their HIV problems than for malaria, but as Korenromp and colleagues point out, “… in Botswana, Zimbabwe, Swaziland, South Africa, and Namibia, the incidence of clinical malaria increased by < 28% (95% confidence interval [CI] 14%–47%) and death increased by < 114% (95% CI 37%–188%) … due to high HIV-1 prevalence in rural areas and the locally unstable nature of malaria transmission that results in a high proportion of adult cases.” Three of these countries, South Africa, Botswana and Zimbabwe, along with Mozambique, lie along the course of the Limpopo River, where malaria is seasonal but endemic.

Interest in another larger river, the Zambezi, this year has drawn attention to the cross-border challenges to malaria control.  The Limpopo provides another key example of the disease that knows no borders.

limpopo-river-sm.gifThe Global Fund malaria overviews of these four Limpopo countries varies widely from 13,400 and 22,400 annual cases in South Africa and Botswana to 1.3m and 5m cases in Zimbabwe and Mozambique.  The latter two countries of course share the malaria endemic Zambezi watershed, while the former two do not even have a malaria grant from the Global Fund. And yet, malaria is endemic along two-thirds of its 1,750 kilometer long arc of a course that starts in South Africa, heads north, then northeast, east and finally south to empty into the Indian Ocean in Mozambique (as seen in the map from Encarta).

A recent study examining malaria in South Africa’s Limpopo Province found that the three eastern districts had the highest incidence over a ten-year period, and although the incidence appeared to be reducing, the authors cautioned that more understanding is needed about the nature of malaria in seasonal and epidemic-prone areas (Gerritson et al., 2007). They quote Cox et al., in calling for better estimates for malaria disease burden in countries where malaria epidemics occur to aid in better policy formulation, strategic planning and early warning measures.

The Limpopo experience stresses the importance of understanding both the epidemic nature of the disease and its interactions with HIV. Each river in malaria endemic regions may have its own lessons to teach, and we should be ready to learn.

Funding &Peace/Conflict &Performance Bill Brieger | 30 Aug 2008

Controlling malaria during political turmoil

Simbarashe Musiyiwa of The Herald of Harare, Zimbabwe focused on HIV/AIDS in critiquing the slow progress being made in accessing money for two rounds of Global Fund projects in the country. “The Global Fund for HIV/Aids, Tuberculosis and Malaria has been challenged to stop politicising HIV and Aids funding and distribute the amount due to Zimbabwe in time as is has done for other countries in the region. Since Zimbabwe’s standoff with London began at the turn of the millennium, the illegal Western sanctions have been used to have the fund either deny Zimbabwe assistance for flimsy reasons or allot it amounts far below what other African countries get.”

The recently completed Zambezi Expedition passed through Zimbabwe and noted that, “Ongoing economic difficulties are obstructing malaria control efforts in a country which had historically made much progress in the fight against the disease.”

zimbabwe-malaria-grant-targets2.jpgIn addition to HIV, Zimbabwe has two malaria grants from the Global Fund, and a review of the progress reports on the Round 1 and 5 grants is instructive.  The most recent progress report (October 2007) on the Round 1 Grant shows that 70% of the &8.5 million project has been disbursed. The grant currently has an overall rating of B1, which is quite good. Progress has been made on some indicators as seen in the attached chart.

Furthermore the Global Fund has praised the CCM of Zimbabwe. “The CCM in Zimbabwe is considered one of the model functioning oversight structures within the region and is supported by a Secretariat with a full-time Co-ordinator.” In addition the Principal Recipient (PR), the Ministry of Health, is said to be performing adequately. “Overall, the Principal Recipient has demonstrated satisfactory management of the Round 1 Malaria grant. Technical assistance provided by WHO including the assignment of experts to the Principal Recipient, has contributed to the efficient management and oversight of imported commodities.”

This does not mean that there are no problems. One of the biggest concerns is inflation. In fact hyperinflation with rates exceeding 1000% mean that once money is received and exchanged into local currency it quickly looses value unless spent in a relatively speedy and efficient manner – a challenge to PRs in any country. Fortunately the Global Fund has means of buying commodities directly if countries request in order to avoid inflationary effects.

Round 5 Malaria Grant did start late – in October 2007 – but 24% of $28.5 million has been disbursed as of May 2008.  At least for malaria, the picture of disbursement and utilization of funds to achieve targets may not be as dire as the Herald implies for HIV grants. The Herald does report that an auditing team from the Global Fund is due in Zimbabwe soon. Hopefully this team will ensure that the fight against malaria does not stop even amidst the political and economic turmoil in the country.

ITNs Bill Brieger | 28 Aug 2008

Mosquito Net Usage – a fish story

People are creative. People designed and produced a bednet that was impregnated with insecticides in order to prevent malaria. Other people look at these nets and think of their own ‘creative’ ways to deploy them.

llins-for-fishing-sm.jpgA case in point was just published in Malaria Journal. Minikawa and colleagues visited the shorelines of Lake Victoria in Kenya and found that LLINs and non-treated nets were being used to catch and dry fish.  They provided pictorial evidence as seen at the right. Specifically at seven villages 283 nets were being used to dry fish and 72 were used for fishing.  Most of these nets (84.5%) had been obtained free or at subsidized rates from health centers and NGOs, while the remainder were bought in the market. These nets accounted for 44.4% of the area of drying sheets spread in these villages. Fishing nets and papyrus mats made up the rest of the drying surfaces.

The three most popular reasons for using bednets to dry fish were: fish dry faster on these nets, they don’t stick and not surprisingly, these nets are cheaper.

A total of 220 nets, both LLIN and not, were found in the 111 houses of these seven villages. In contrast to the bednets used for fishing/drying, most (60%) of these had been purchased in the market. The total bednets found in homes were almost enough to meet coverage targets of two per household, and the 145 LLINs were definitely enough for use by the 70 children under five and estimated 20 pregnant women in these villages. But this still does not resolve the ethical issue of providing free or low cost nets to communities only to find them diverted.

Net stories include use for fishing in Zambia, as bridal veils in Zambia and other countries and trapping edible ants in Uganda. These problems arise when LLIN distribution programs focus on the wrong numbers. It is not enough to say how many hundreds of nets have been distributed in a community. The real concern is whether they are used correctly and for the intended purpose.  Maybe in the Kenyan case there were too many LLINs given without attention to actual population.

More than likely the bednets for villages along Lake Victoria were distributed without community involvement and follow-up.  Local leaders and volunteers should take part in the process so they can remind people about appropriate use, help people install the bednets correctly in their homes and monitor actual bednet use.

Community &IPTp &Malaria in Pregnancy Bill Brieger | 24 Aug 2008

Malaria in Pregnancy – reaching into the community

Jhpiego’s Malaria in Pregnancy (MIP) project in Akwa Ibom State, Nigeria flagged off its community component in July.  Prior to that primary health clinic (PHC) staff at 15 local government facilities had been trained in focused antenatal care, malaria in pregnancy and community directed intervention. These staff in turn recruited and trained 734 volunteer community directed distributors (CDDs) who represent 459 kindreds in the 87 communities surrounding the PHCs.

cdds-visit-nurse-in-charge-of-nearest-clinic.jpgField monitoring is underway to document the first month’s activities. This includes attending the monthly meetings that CDDs have with their nearby health facility staff and review of both CDD and ANC clinic registers. CDDs are expected to provide health education on MIP prevention, provide the first does of IPTp if appropriate and refer pregnant women to ANC clinic. Baseline assessments showed that women were not utilizing ANC at local government facilities, so Jhpiego has started working with staff on quality improvement so that referred women will want to use the services.

ANC attendance has increased. Review of the registers in three small clinics showed a total of 8 ANC clients in April, 7 in May and 2 in June. This rose to 44 in July and 25 for the first half of August for the three clinics combined. Before one starts to get excited, one must look at the work of CDDs in distributing sulfadoxine-pyrimethamine for IPTp.  For example, at one of the large operational base clinics, 84 women attended ANC in July. Only 24 of 44 CDD/kindred records for July had been collected by the staff, but these showed that the CDDs had seen 670 pregnant women. A similar pattern emerged at all facilities.

CDDs were interviewed individually and during their group meetings. They said that it has been so long since women utilized the local government clinics that it was difficult to convince them to be referred.  Some women preferred checking in with TBAs near the time of delivery, while others relied on their churches for prenatal supervision and delivery.  There were concerns about poor state of the infrastructure. Many complained of fees for registration, cards and medicines (although IPTp is free). Nurses often turn back those who cannot pay instead of at least providing them the free services that exist.

While free services such as blood pressure monitoring and tetanus toxoid immunization are free, the various fees and charges can amount to US $4.50 or more assuming a woman makes up to four ANC visits. This may sound inexpensive, but for people living on the proverbial dollar a day, it is a major cash outlay.

Advocacy visits are underway to local government chairpersons and supervisory councilors for health to encourage them to make all aspects of ANC free and improve the health facilities.  While the CDDs are starting to reach pregnant women earlier with IPTp, their job is not done until the women attend ANC and get the full range of services intended to protect their pregnancy.

Health Systems &HIV Bill Brieger | 23 Aug 2008

Health Systems: malaria and HIV

Major new funding for HIV and Malaria has been coming in over the past eight years. The question is how that funding has not only impacted on the two diseases, but what has it done to the health systems that are expected to deliver disease control services?

From the beginning of RBM, partners and planners has stressed that malaria cannot be rolled back outside the context of health sector reforms and improvements.  Except for the possibility of ITN distribution campaigns, malaria control activities such as case management with ACTs and delivery of IPTp via directly observed treatment, require a strong, accessible and affordable primary health care system.  The issue of home management is tackled in the context of the health system training, supplying and supervising community volunteers. Even campaigns are run from a base in the district health department and linked with child immunization activities.

To some extent we have seen negative effects on the health system with new malaria funding when there is donor pressure to achieve and report quickly on performance – parallel procurement and distribution systems have been set up as well as parallel monitoring and evaluation processes, but ultimately the delivery of malaria control services requires that primary health services – facilities and staff – function on the ground.

seizing-the-opportunity-p1-sm.jpgIn contrast critics have pointed to HIV/AIDS programming as creating its own structures resulting in internal brain drain within countries – pulling staff and resources away from the basic health system in order to reach treatment and coverage targets. A recent publication, Seizing the Opportunity of AIDS and Health Systems, explores this issue through three country examples. The report focuses on health information, supply chain and human resources in Mozambique, Uganda and Zambia. Concerning information system the report summarizes the situation thus:

In each of the three countries donors draw information from parts of the health information system and from national monitoring and evaluation systems. Meanwhile, all three donors have their own donor-specific reporting requirements in all three countries. The proliferation of information systems results partly from donors’ own priorities and accountability requirements. But it also reflects weak government coordinating structures for health information system management. And it reflects the ill-equipped, underfinanced state of national AIDS councils.

There is evidence of functional antiretroviral supply chains, but not a strengthening of the overall supply chain within countries. “In all three countries, the Global Fund, PEPFAR, and the MAP have worked with governments to develop supply chains for antiretroviral drugs. The supply chains are still fairly small, however, often serving 300 facilities or fewer. They rely largely on public structures. Yet they generally function more smoothly than the much larger government-managed supply chains for other essential medicines.”

In addressing human resources the report says that donors have focused more on in-service training of existing workers than on helping enlarge the pool of health staff. Because of better salaries and benefits in donor-supported programs, health staff have been pulled away from the public sector, thus weakening the health system. The report concludes by saying …

As PEPFAR, the Global Fund, and the MAP work to extend the reach and effectiveness of their HIV/AIDS programs, they will continue to find that country health system weaknesses create barriers to program expansion. To surmount those barriers they should finance programs in ways that increase the abilities of country health systems to provide broad quality health services, while doing the least possible harm to those systems. But to create greater incentives for donors to seize this opportunity, actions by country governments are also urgently needed. Earmarked funding for HIV/AIDS is evidently here to stay. The approach recommended here will ensure that donor funds bring the greatest possible benefits to country health systems while also achieving desired AIDS-specific outcomes.

We might add that benefits to the country health systems will ultimately also benefit efforts to control malaria.

Anemia &Integration &Malaria in Pregnancy Bill Brieger | 09 Aug 2008

Anemia: another place to focus on integration within antenatal care

Anemia in pregnancy is responsible not only for threats to a woman’s health, but ultimately the survival of the child. Hotez and Molyneux in a PLoS Neglected Tropical Diseases editorial explain that …

“… most of the 7.5 million pregnant women infected with hookworm likely live in areas of sub-Saharan Africa that place them at risk for malaria. At the same time, malaria control and NTD control have each been shown to reduce anemia both in children and in pregnant women. Therefore, combining malaria and NTD control practices in a unified anemia framework affords one of the best opportunities to reduce the huge burden of morbidity and mortality that results from anemia in sub-Saharan Africa.”

detect-and-prevent-anemia-in-pregnancy2.jpgEach disease presents its own challenges. Guyatt and Snow report that, “Although the vast majority of women with malaria infections during pregnancy remain asymptomatic, infection increases the risk of maternal anemia and delivering a low-birth-weight (LBW) baby.” Furthermore, “It is estimated that in areas where malaria is endemic, around 19% of infant LBWs are due to malaria and 6% of infant deaths are due to LBW caused by malaria. These estimates imply that around 100,000 infant deaths each year could be due to LBW caused by malaria during pregnancy in areas of malaria endemicity in Africa.”

Addressing hookworm during pregnancy in Peru, Larocque and colleagues found that pregnant women, “infected with moderate and heavy intensities of hookworm infection and those with moderate and heavy intensities of both hookworm and Trichuris infections were more likely to suffer from anemia than women having no or light intensities. These results support routine anthelminthic treatment within prenatal care programs in highly endemic areas.”

Positive experiences on anthelminthic control were also reported from Nepal in the Lancet. During prenatal care  “… women received albendazole twice during pregnancy. Women given albendazole in the second trimester of pregnancy had a lower rate of severe anaemia during the third trimester. Birthweight of infants of women who had received two doses of albendazole rose by 59 g , and infant mortality at 6 months fell by 41%. Antenatal anthelmintics could be effective in reducing maternal anaemia and improving birthweight and infant survival in hookworm-endemic regions.”

We reported from Mozambique that PMTCT and IPTp for malaria in pregnancy control are integrated into antenatal care in many clinics.  One can see metronidazole in addition to SP and AZT in the picture among the preventive medicines available for pregnant women. Countries can make their choices of anthelminthics, including albendazole, but the meassage that Hotez and Molyneux convey is the need to control NTDs like soil transmitted helminths should be an integral part of services for pregnant women.

HIV &Integration Bill Brieger | 05 Aug 2008

Malaria at the XVII International HIV conference

Malaria is estimated to kill over 1 million people a year, mostly children, while the annual death toll from HIV/AIDS approaches 2 million. Where these diseases overlap, “Malaria contributes synergistically with HIV/AIDS to morbidity and mortality in areas where both infections are highly prevalent, such as in Africa south of the Sahara. In addition to providing immediate health benefits, prevention and treatment of malaria may lessen transient increases in HIV viral load during malaria episodes and thus help limit the progression,” according to the World Malaria Report.

iasmexico_banner.gifWith the clear public health links between the two diseases, one would have expected to see more reports about malaria in HIV within the XVII International AIDS Conference in Mexico. Search at the conference website on malaria as a key word turned up only four abstracts or session outlines that actually addressed malaria, not just presentations that happened to spell out the full title of the Global Fund, and thus inadvertently mentioned malaria.

An abstract by Imani et al. reported that, “HIV infection was significantly associated with cerebral malaria in children admitted to Mulago Hospital and the prevalence of HIV infection among those with cerebral malaria was 9%.
Recommendation: Malaria prevention should be an important component of education and counselling of HIV infected children and their caretakers. A large study is recommended to establish whether there is a correlation between the level of HIV immunosuppression and cerebral malaria.”

Oloo and colleagues presented on “Strengthening HIV/AIDS programs for transport sector workers through a regional trade union approach in East and Central Africa.” Among their recommendations was the importance of providing “integrated reproductive health, malaria and family planning services to transport workers through the resource centers.”

A workshop is being organized on, “Uniting and Empowering Civil Society on CCMs: How AIDS, TB, and Malaria Organizations Can Work Together on CCMs and in GFATM Advocacy,” and is crosscutting on the three diseases.

Finally, Raposo et al., presented the topic, “Counseling and testing in health: a public health approach to increase access to health promotion in Mozambique.”  They stressed the need for linkages with other health services. A model for better integrated services was described that included, “Additional counseling is provided for malaria prevention, environmental health, uptake of antenatal care during early pregnancy, and institutional delivery.”

Better integration of disease control and prevention efforts is needed to better serve those in endemic communities. Integration should also be evident in advocacy efforts such as international conferences. We can’t afford the medical model that looks at diseases only, not the people who suffer from multiple problems.

Advocacy &Partnership Bill Brieger | 04 Aug 2008

Zambezi Expedition – the journey is not over

In March of this year the Zambezi Expedition set out on a three-month quest to rally political support for the fight against malaria and demonstrate the need for coordinated cross-border action by navigating three thousand kilometers through Angola, Namibia, Botswana, Zambia, Zimbabwe and Mozambique. The Roll Back Malaria-sponsored Expedition spread awareness of malaria with the help of NGOs like Nets For Life and corporations like ExxonMobil. In fact the ExxonMobil press release observed that exactly 150 years after the Scottish missionary David Livingstone embarked on a historic journey along the Zambezi River, malaria remains a problem for the people along its shores.

The Mail and Guardian reported that, “Expedition members said many villagers along the river must travel long distances to the nearest medical post. Limited access to medical care and a lack of regional cooperation are hindering malaria prevention, group members said. ‘There are no borders for malaria,’ expedition manager Herve Verhoosel said. ‘Mosquitoes don’t get their passports stamped at the other side of the border.'”  A Reuters television news clip available on the Expedition’s website quotes one of the travelers talking about the challenge of community members trekking 70 kilometeres to a health facility to get malaria treatment in Angola.

In June as a follow-up the Zambezi Expedition was featured during a panel at the World Economic Forum. The Expedition website noted that, “Panelists Prof. Awa Coll-Seck, Executive Director of the Roll Back Malaria Partnership (RBM) and Sipho Mseleku, CEO of the Association of SADC Chambers of Commerce and Industry (ASCCI) underlined the critical importance of political commitment in fighting diseases of poverty such as malaria. They called for increased multi-country collaboration with specific attention to strengthening community engagement against poverty and disease. ‘Malaria knows no borders and the Roll Back Malaria Zambezi Expedition is a model for multi-country cooperation,’ said Prof Coll-Seck, ‘We hope that countries in other sub-regions will collaborate in this way because they have similar problems.'”

end-of-zambezi-expedition-in-mozambique_.jpgNow more than two months after the Expedition reached its end at the Indian Ocean [see photo by Marcus Bleasdale], malaria and mosquitoes still cross the Zambezi and the borders of countries along its shores.  As stated in the theme of the expedition and the first World Malaria Day, which was celebrated along the journey, malaria is a disease without borders – the journey of collaboration among countries and partners in the region should not stop just because the boats have reached their destination.

Treatment Bill Brieger | 02 Aug 2008

Turmeric – a role in malaria treatment?

tumeric-b-sm.JPGFrom time to time news stories appear that stress the healing powers of common herbs and spices. The value of turmeric (curcumin), the yellow powder used in many Indian dishes, has again been promoted on the web.We have talked about the importance of continued research for new malaria drugs. PubMed offers some studies that have looked at the effect of turmeric on malaria.

In 2005 Reddy and colleagues showed that, “curcumin, a polyphenolic organic molecule derived from turmeric, inhibits chloroquine-resistant Plasmodium falciparum growth in culture in a dose dependent manner … Additionally, oral administration of curcumin to mice infected with malaria parasite (Plasmodium berghei) reduces blood parasitemia by 80-90% and enhances their survival significantly. Thus, curcumin may represent a novel treatment for malarial infection.”

Nandakumar et al. (2006) reported that, “Artemisinin and curcumin show an additive interaction in killing Plasmodium falciparum in culture. In vivo, 3 oral doses of curcumin following a single injection of alpha,beta-arteether to Plasmodium berghei-infected mice are able to prevent recrudescence due to alpha,beta-arteether monotherapy and ensure almost 100% survival of the animals.”

Concern about multi-drug resistant parasites led Cui et al. (2007) to explore the effects of curcumin on malaria. Observing from previous research that, “Among its antiprotozoan activities, curcumin was potent against both chloroquine-sensitive and -resistant Plasmodium falciparum strains,” these authors found curcumin displaying cytotoxicity for malaria parasites.

The most recently reported research by Martinelli and colleagues (2008) put something of a damper on the subject. They report that, “Recent studies have proposed curcumin as a potential partner for artemisinin in artemisinin combination therapies to treat malaria infections. The efficacy of curcumin alone and in combination with artemisinin was evaluated on a clone of Plasmodium chabaudi selected for artemisinin resistance in vivo. The addition of piperine as an enhancer of curcumin activity was also tested. Results indicated that curcumin, both alone and in combination with piperine had only a modest antimalarial effect and was not able to reverse the artemisinin-resistant phenotype or significantly affect growth of the tested clone when used in combination with artemisinin. This is in contrast with previous in vivo work and calls for further experimental evaluation of the antimalarial potential of curcumin.”

Their call for further research should be heeded … and funded.

  • Cui L, Miao J, Cui L. Cytotoxic effect of curcumin on malaria parasite Plasmodium falciparum: inhibition of histone acetylation and generation of reactive oxygen species. Antimicrob Agents Chemother. 2007 Feb;51(2):488-94. Epub 2006 Dec 4.
  • Martinelli A, Rodrigues LA, Cravo P. Plasmodium chabaudi: efficacy of artemisinin + curcumin combination treatment on a clone selected for artemisinin resistance in mice. Exp Parasitol. 2008 Jun;119(2):304-7. Epub 2008 Mar 7.
  • Nandakumar DN, Nagaraj VA, Vathsala PG, Rangarajan P, Padmanaban G.. Curcumin-artemisinin combination therapy for malaria. Antimicrob Agents Chemother. 2006 May;50(5):1859-60.
  • Reddy RC, Vatsala PG, Keshamouni VG, Padmanaban G, Rangarajan PN. Curcumin for malaria therapy. Biochem Biophys Res Commun. 2005 Jan 14;326(2):472-4.

HIV &Integration &Malaria in Pregnancy Bill Brieger | 01 Aug 2008

Malaria, HIV – integration into Antenatal Care in Mozambique

Infectious diseases during pregnancy put both the mother and the unborn child at risk.  According to WHO’s Global Malaria Program, co-infections with HIV and malaria put pregnant women at special risk. WHO is also concerned that opportunities to address infectious diseases like HIV and malaria are often missed during antenatal care (ANC).  WHO therefore recommends a minimum 4-visit focused ANC package as follows:

For antenatal care to be effective, all pregnant women need a minimum of four visits, at specific times and with evidence-based content. Care for women during pregnancy improves health by preventive measures, and by prompt detection and management of complications. Essential components of a focused antenatal-care package include screening for and treatment of disorders (such as anaemia, abnormal lie, hypertension, diabetes, syphilis, tuberculosis, and malaria); provision of preventive interventions (such as tetanus immunisation and insecticide-treated bednets); and counselling about diet, hygiene, HIV status, birth, emergency preparedness, and care and feeding of babies. Since antenatal care has good coverage, it provides a platform to increase the interventions provided during antenatal visits, including HIV care for the mother, prevention of maternal to child transmission (PMTCT) of HIV, and support for feeding choices. However, this opportunity must be weighed against the risk of overloading services that are already stretched.


It is encouraging to see that the Ministry of Health in Mozambique is taking the integration of malaria control and PMTCT into its antenatal care services.  The picture above shows an ANC nurse’s desk in one of the more that 500 health facilities that offer PMTCT. There is almost what one could call a one-stop-shop for pregnant women in terms of getting their preventive medicines – sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (IPT), and AZT and neviraprine for PMTCT prophylaxis, among others.

Some challenges to this integration remain.  The policy for IPT was adopted only in 2006 after pilot testing in two provinces, and needs to be disseminated more fully. PMTCT is presently offered in only about one-half to one-third of health facilities where ANC is offered. ITNs are not yet available in all routine service points, but there is a strong commitment to contiunue work toward integration.

The Round Six Global Fund application for Mozambique summarizes the vision of integration: “The HIV/AIDS component supports provision of comprehensive antenatal care (ANC) to pregnant women, consisting of provision of anaemia, syphilis and HIV tests; iron, folic acid and vitamin A supplementation; Intermittent Preventive Tretament (IPT) of malaria in pregnant women; de-worming, health education & counselling on breastfeeding , nutrition, HIV and hygiene. The delivery by the malaria component of ITNs through routine ANC will reinforce this comprehensive care. Early data from applying the model in Inhambane Province has also shown increased use of ANC when ITNs are made available; this will enhance uptake of the other services.”

We hope other countries take this as a model of ANC integration to emulate.