Category Archives: Costs

Malaria Affects Agriculture and Food Security

The connections between malaria and food security are recognized in various international health and development frameworks. Below is a look at one side of the equation, how malaria in the household affects food security and agricultural production.

Lewnard and colleagues reported that severe food insecurity was associated with increased risk for positive malaria tests among the Batwa pygmies in Uganda. Also malaria control interventions were associated with decreases in child mortality, accounting for the effect of rainfall and food security in central Tanzania. The authors concluded that achieving targets like the MDGs, “requires the contribution of many health interventions, as well as more general improvements in socio-environmental and nutritional conditions,” i.e. an integrated development approach.

A study in Niger hypothesized that Unconditional Cash Transfers (UCT) would have a positive impact on food security. Two different UTC regimens were tested along with a supplemental food package, but ironically the study found no difference in endline food security between arms. The group felt that the results were possibly driven by increased fever/malaria in children, and thus nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs.

Tusting and co-researchers recognize that agricultural development interventions reduce poverty. They also documented that relative agricultural success was associated with higher socio-economic position, which in turn, was associated with lower human biting rate of malaria-infected mosquitoes. They conclude that “Further interdisplinary research is needed to understand fully the complex pathways between poverty and malaria and to develop strategies for sustainable malaria control.” One possible pathway would be malaria prevention interventions. A study in Ghana reported that, “Children who slept under a bednet were also more likely than those who did not to live in a food secure household.”

Malaria interventions can also affect agricultural productivity. In a Zambian experiment, access to subsidized bed nets was randomly assigned at the community level, and 516 farmers were followed over a one-year farming period. The researchers found “large positive effects of preventative health investment on productivity: among farmers provided with access to free nets, harvest value increased by US$ 76, corresponding to about 14.7% of the average output value.”

Malaria and other endemic diseases affect agricultural productivity, income, and thus quality of housing

Studying the effects of malaria on employees of an oil palm plantation in Papua New Guinea, Pluess and team found that, “on average, an employee sick with malaria was absent for 1.8 days, resulting in a total of 9,313 workdays lost.” This is an indirect influence on a family’s food security.

farming communities often have access only to small medicine shops in the markets

Seeking malaria care can have untoward effects when fees are attached to health services. Johnson and co-researchers report that, “The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances.”

Malaria can deprive the household of funds needed for food. It can also reduce the ability of the family to work and produce or buy food. Such economic, social and nutritional impacts need to be taken into account in developing intersectoral malaria policies.

Multilateral Initiative for Malaria: Posters Range from Prevention to Cost to E-Learning and Beyond

A major feature of all conferences are the poster sessions. These are often overlooked due to timing and placement. Fortunately at the recent 7th Multilateral Initiative for Malaria Conference in Dakar, tea breaks and lunch were made available in the poster tent ensuring more people came to view. Even so some people may have missed the valuable knowledge shared through this medium. We tweeted many of the posters during the event, but below are six posters in more detail.

These range from evaluating a malaria surveillance system to financing systems to sustain malaria drug supplies, including through community pharmacies. The potential of E-Learning for malaria capacity building was explored, and the process pf establishing a national malaria operations research agenda was presented. Several posters examined the seasonal malaria chemoprevention (SMC) program in the Sahel of West Africa including one from Mali as seen below.

Please contact the authors for additional information and updates. Readers who presented a poster at MIM are welcome to share their findings with us.

 

African Leaders Malaria Alliance Recognizes Country Achievements, Adds NTDs to its Scorecard

The 30th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

Malaria Care: Can We Achieve Universal Coverage?

uhc-day-badgeIn New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

  1. A strong, efficient, well-run health system
  2. Affordable care
  3. Accessible care
  4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

DSCN2885aWhile much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Slide1Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Slide2Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.