Behavior Change for Malaria: Are We Focusing on the Right ‘Targets’

Two articles caught my attention this morning. One reviewed the merits of improved social and behavior change communication (BCC) for the evolving malaria landscape. The other addressed the damage institutional corruption is doing in Africa. And yes, there is a connection.

When I was trained as a community or public health educator in the MPH program at UNC Chapel Hill, the term BCC had not yet been coined. We were clearly focused on human behavior and health.  What was especially interesting about the emphasis of that program was the need to cast a wide net on the human beings whose behaviors influence health.

DSCN7742 CHW flipchart

BCC of individuals and communities may not be enough

While the authors in Malaria Journal state that, “The purpose of this commentary is to highlight the benefits and value for money that BCC brings to all aspects of malaria control, and to discuss areas of operations research needed as transmission dynamics change,” a closer look shows that the behaviors of interest are those of individuals and communities who do not consistently use bed nets, delay in seeking effective treatment, and do not take advantage of the the distribution of intermittent preventive therapy (IPTp) during pregnancy. The shortfalls in the behavior of other humans is lies in not “fully explaining” these interventions to community members.

The health education (behavior change, communications, etc. etc.) program at Chapel Hill taught us that a comprehensive intervention included not only means and media for reaching the community, but also processes to train health workers to perform more effectively, to advocate with policy makers to adopt and fund health programs, and intervene in the work environment using organizational change strategies to ensure programs actually reached people whose adoption of our interventions (nets, medicines) could improve their health.

At UNC we tried to focus change on all humans in the process from health staff to policy makers to ensure that we would not be blaming the community for failing to adopt programs that were not made appropriately accessible and available to them. We did not call it a systems approach then, but clearly it was.

This brings me back to the article on corruption. Let’s compare these two quotes from the IRIN article …

  • The region accounts for 11 percent of the world’s population, but carries 24 percent of the global disease burden. It also bears a heavy burden of HIV/AIDS, tuberculosis and malaria but lacks the resources to provide even basic health services.
  • Poor public services in many West African countries, with already dire human development indicators, are under constant pressure from pervasive corruption. Observers say graft is corroding proper governance and causing growing numbers of people to sink into poverty.

Illicit cash transfers out of countries and bribery of civil servants, including health workers, are manifestations of the same problem at different ends of the spectrum resulting in less access to basic services and health commodities.  Continued national Demographic and Health Surveys show that well beyond 2010 when the original Roll Back Malaria Partnership coverage targets of 80% were supposed to have been achieved, we see few malaria endemic countries have achieved the basics, and some have regressed. Everyone is bemoaning the lack of adequate international funding for malaria (and HIV and TB and NTDs), but what has happened with the money already spent?

Without a systems approach to health behavior and efforts by development partners to hold all those involved accountable, we cannot expect that the behavior of individuals and communities will win the war against malaria.

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