Category Archives: Economics

Mis-Use of Insecticide Treated Nets May Actually Be Rational

People have sometimes question whether insecticide treated nets (ITNs) provided for free are valued by the recipients. Although this is not usually a specific question in surveys, researchers found in a review of 14 national household surveys that free nets received through a campaign were six times more likely to be given away than nets obtained through other avenues such as routine health care or purchased from shops.

Giving nets away to other potential users, not hanging nets or not sleeping under nets at least imply that the nets could potentially be used for their intended purpose. What concerns many is that nets may be used for unintended and inappropriate reasons. Often the evidence is anecdotal, but photos from Nigeria and Burkina Faso shown here document cases where nets were found to cover kiosks, make football goalposts, protect vegetable seedlings and fence in livestock.

Newspapers tend to quote horrified health or academic staff when reporting this, such as this statement from Mozambique, “The nets go straight out of the bag into the sea.”  The Times said that net misuse squandered money and lives when they observed that “Malaria nets distributed by the Global Fund have ended up being used for fishing, protecting livestock and to make wedding dresses.”

Two years ago the New York Times reported that, “Across Africa, from the mud flats of Nigeria to the coral reefs off Mozambique, mosquito-net fishing is a growing problem, an unintended consequence of one of the biggest and most celebrated public health campaigns in recent years.”5 Not only were people not being protected from malaria, but the pesticide in these ‘fishing nets’ was causing environmental damage. The article explains that the problem of such misuse may be small, but that survey respondents are very unlikely to admit to alternative uses to interviewers.

Similarly El Pais website featured an article on malaria in Angola this year with a striking lead photo of children fishing in the marshes near their village in Cubal with a LLIN. A video from the New York Times frames this problem in a stark choice: sleep under the nets to prevent malaria or them it to catch fish and prevent starvation.[v]

More recently, researchers who examined net use data from Kenya and Vanuatu found that alternative LLIN use is likely to emerge in impoverished populations where these practices had economic benefits like alternative ITN uses sewing bednets together to create larger fishing nets, drying fish on nets spread along the beach, seedling crop protection, and granary protection. The authors raise the question whether such uses are in fact rational from the perspective of poor people.

An important fact is that not all ovserved ‘mis-use’ of nets is really inappropriate use. A qualitative study in the Kilifi area of coastal Kenya demonstrated local ‘recycling’ of old ineffective nets. The researchers clearly found that in rural, peri-urban and urban settings people adopted innovative and beneficial ways of re-using old, expired nets, and those that were damaged beyond repair. Fencing for livestock, seedlings and crops were the most common uses in this predominantly agricultural area. Other domestic uses were well/water container covers, window screens, and braiding into rope that could be used for making chairs, beds and clotheslines. Recreational uses such as making footballs, football goals and children’s swings were reported

What we have learned here is that we should not jump to conclusions when we observe a LLIN that is set up for another purpose than protecting people from mosquito bites. Alternative uses of newly acquired nets do occur and may seem economically rational to poor communities. At the same time we must ensure that mass campaigns pay more attention to community involvement, culturally appropriate health education and onsite follow-up, especially the involvement of community health workers. Until such time as feasible safe disposal of ‘retired’ nets can be established, it would be good to work with communities to help them repurpose those nets that no longer can protect people from malaria.

Investing in Malaria at the Country Level: removing the financial burden on the poor

wmdlogoWorld Malaria Day 2015 is continuing a 3-year theme of promoting continued financial resource commitment to control and eliminate the disease. Investing in malaria can take many forms, the most obvious of which is the large donor agency grants from the Global Fund (GFATM), the US President’s Malaria Initiative (PMI), DfID, and the World Bank Malaria Booster Program, a name a few. International and local businesses and corporations also provide a share usually through their corporate social responsibility and employee health projects.

Cost recovery systems are not uncommon

Cost recovery systems are not uncommon

The global financial crisis that began in 2008 lingers in many corners of the world, and has caused thoughtful concern since then about how global disease control efforts can be sustained. In relation to malaria, this concern must take account of the fact that when interventions (ITNs, ACTs, RDTs, IPT) are scaled up and sustained, incidence will drop and the nature of programming and financial commitments will change. A greater emphasis on surveillance, identification of hotspots, response to epidemics, and import of cases from neighboring countries will take the foreground. All this will still require financial support, but where will it come from?

Many of the frontline malaria elimination countries in Africa do not receive external financial support but rely on their own national treasury. As incidence in other endemic countries drops, will the same be expected of them? It is important therefore to look at the current pattern on national commitment to funding malaria control and eventual elimination, including whether countries are devoting 15% of their annual budgets to health. Unfortunately in many countries household out-of-pocket expenditures for malaria services form the bulk of national funding for the disease, a major burden in terms of health equity.

medicine shops are a common place for out-of-pocket malaria  expenditures

medicine shops are a common place for out-of-pocket malaria expenditures

Cost recovery schemes have been tried in Burkina Faso. Rwanda has instituted community insurance programs. Yet these efforts still put a major financial burden on the poor. Ironically, while the poor pay more, the rich, both individuals, and corporations (national and multi-national) in malaria endemic countries conduct illicit financial transfers out of the country or evade local taxes.

Ultimately the challenges of political accountability for results and financial management within countries to citizens, domestic civil society and other non-state actors must be resolved if governments are going to take on a growing role for eliminating the malaria burden within their borders. Monetary investments alone cannot eliminate malaria. Political will must also be invested to close financial gaps, mobilize resources from various sectors and create a true partnership to end malaria.

(A longer version of this article will appear in the March 2015 issue of Africa Health.)

Malarious Occupations

Often the focus of malaria case management and malaria prevention is on children under five years of age and pregnant women. Adults generally can be at higher risk for getting malaria because of their occupations, as was seen in two recent publications.

The Asian Scientist reporting on Bangladesh explained that “Slash-and-burn farmers … are exposed to a higher risk of malaria infection.”  The report notes that not only are woodcutters and jhum (slash-and-burn) cultivators at increased risk of being infected by malaria and but they are also endangering their families.

The researchers at the Centre for Vaccine Sciences and the Centre for Population, Urbanisation and Climate Change of the icddr,b, in collaboration with the Johns Hopkins Malaria Research Institute, Baltimore, reported that “jhum cultivators and people living with them had 1.6 times higher odds of being infected with malaria than non-jhum cultivators.”

The study also appeared in the American Journal of tropical Medicine and Hygiene where the authors observed that “Possible mechanisms cited in the study for the observed higher malaria incidence among jhum cultivators include increased exposure to mosquitoes, sleeping away from home unprotected by bed nets and lack of access to health services.”

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Wild cat Gold mining in Burkina Faso also exposes miners to malaria.

Gold mining is another ‘vulnerable occupation, according to a study in Venezuela. Daniel Pardo of BBC News posted photographs that show how mining creates water-filled pits as breeding sites and also the substandard living quarters of the miners where mosquitoes have easy access to victims.

According to the BBC, “Venezuela used to be a world leader in managing malaria, but is now the only country in Latin America where incidence of the disease is increasing. Around 75,000 people were infected last year, and according to government figures, 60% of cases were in Sifontes, a tiny region of the country where gold mining – where workers drill for gold in mosquito-friendly standing water – is booming, and healthcare is scarce. “

These two experiences challenge our ideas of focusing control on only certain groups who are perceived as vulnerable. If we are to eliminate malaria, we need to identify all at risk populations, especially those in rural and hard to reach areas like miners and farmers.

This situation also tells us that much of the occupational risk of malaria is created by humans who overlook health costs in the economic calculations about their work. Clearly we cannot eliminate malaria without collaboration among the health and economic sectors in an effort to promote the overall welfare of populations.

Rural Health and Malaria, a South Africa Example

South Africa’s Rural Health Advocacy Project (RHAP) has released a report or fact sheet on rural health in South African provinces. Of interest is the overlap of rural problems and malaria endemicity.  Three Provinces that border Mozambique are also endemic for malaria – from north to south: Limpopo, Mpumalanga and Kwa Zulu Natal (KZN).

South Africa Provinces and MalariaSeven of the 10 poorest districts in the country fall in two of these endemic provinces, Limpopo and KZN. The two districts with the highest HIV prevalence are in Mpumalanga and KZN, and those two provinces themselves have the highest HIV prevalence among all the provinces.

The fact sheet also reports that, “Poor rural households in a Limpopo District spend up to 80% of monthly income on health expenditure, travel costs being a significant contributor.”

Limpopo and Mpumalanga are among the four provinces with the lowest distribution (or highest shortages) of human resources for health. Concerning maternal mortality, the fact sheet notes that, “Each year an estimated 4300 mothers die. KZN most affected.”

While one cannot say the exact role malaria plays in rural poverty and rural health disparities, it is important to note that interventions to control and eliminate the disease must have a strong rural focus. Hopefully there will be economic benefits to such interventions.

Household cost of treating fevers in Ghana

Researchers at the Dodowa Health Research Center and the other centers affiliated with Ghana’s Ministry of Health/Ghana Health Service have shared with us their findings and concerns about the costs of treating malaria and febrile illness in Ghana.  We can see that despite efforts to reduce costs through such efforts as the Affordable Medicines Facility malaria (AMFm), households are burdened when malaria strikes.  Alexander A. A. Nartey, Patricia Akweongo, Elizabeth Awini1, Maxwell Darlaba, Theresa Tawiah, Jonas Akpakli, Doris Sarpong, Christine Clerk, Martin Adjuik, Moses Aikins, Fred Binka and Margaret Gyapong explain in more detail below.

AMFm certified quality drugs available in Chemical Seller Shops in Ghana

AMFm certified quality drugs available in Chemical Seller Shops in Ghana

The burden of malaria seems to be reducing globally but sub-Saharan African countries continue to bear the greater burden of the disease considering the economic burden on the households. Malaria continues to be the number one cause of morbidity and mortality in Ghana. The household cost burden of malaria is both direct and indirect costs.

The study was a cross sectional cost-of-illness design. The study used self-reported fever as an indicator of malaria. The study household sample was drawn from the entire Health and Demographic Surveillance System (HDSS) databases of the Dangme West, Kintampo (North and South) and Kassena-Nankana (East and West) districts. All patients from such households that have a history of fever in the previous two weeks were interviewed on their care seeking, health providers used, treatment received and the related costs.

The average direct OPD cost of treating fevers was GH¢16.54 (US$11.25) and the average cost of self-treatment was 5 times less than seeking care at health facilities OPDs  in Ghana. A household in Ghana was likely to pay GH¢31.43 (US$ 21.38) as direct cost per episode of fever treatment which was equivalent to 32.7% of monthly minimum income in Ghana.

Government of Ghana in its effort to keep the direct cost of treating fever relatively low through the provision of Health Insurance Scheme and the introduction of a subsidized AMFm drugs, the overall lost of productivity to the patient play a significant role especially when there are multiple fever cases within households in a year.