Category Archives: Equity

Equity in Malaria Programming, the example of bednets

The WHO defines Equity as “the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification. ‘Health equity’ or ‘equity in health’ implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.”

WHO goes on to say that, “Countries and programs need to disaggregate selected health indicators by key stratifiers including demographic characteristics (gender, age), place of residence (urban/rural, subnational), socioeconomic status (wealth, education), as well as other characteristics (migrant/minority status etc.).”

Writing for the Tropical Disease Research Program, H. Kristian Heggenhougen, Veronica Hackethal, and Pramila Vivek in the publication, The behavioural and social aspects of malaria and its control, say that …

“What must now be clear is our conviction that any review of factors for world-wide malaria control must give specific attention to issues of socio-economic inequity and disease epidemiology.” Malaria is not an equal opportunity killer, but disproportionately affects certain segments of the population. Heggenhougen et al. continue that, “while we argue for a focused attack on malaria, we cannot avoid noting that without attention to these larger matters – inequity and marginalization – any improvement in health, including malaria, may be short-lived.”

The Demographic and Health Survey (DHS) and its Malaria Indicator Survey (MIS) provide an important snapshot on equity issues in the rollout and coverage of major malaria.   In particular, we look at the issue of long lasting insecticide-treated nets in two countries, Ghana (2016 MIS) and Liberia (2016 MIS), to demonstrate how equity issues can be seen. Two three measures are considered, wealth quintile, location (urban/rural) and gender/sex.

In Ghana we see that having at least one net for the household is more common in lower income groups. These groups are more vulnerable. Although not specifically shown in the MIS, one might assume that people in the higher income groups have better quality housing that provides less opportunity for mosquito entry. Likewise households in rural areas, where anopheles are more likely to breed, have a higher proportion of nets. So while nets are not ‘equally distributed by these characteristics, they are more favorably available in those households that may be more vulnerable to malaria.

When we look at the indicator of universal coverage where it is expected that there should be one net for every two household members, the proportion meeting that goal is much lower than simply having a net in the household for all groups.  That said the pattern of higher proportions among rural and lower income groups remains. Within households, the Ghana MIS a nearly equal proportion of female (43%) and male (41%) had slept under a net the night prior to the survey.

Overall, Liberia has much lower LLIN coverage than Ghana. The pattern for location is similar to that of Ghana, but for wealth, the poorest group (Q1) have lower coverage that wealth quintile groups 2-4. Also as in Ghana the Female (40%) and male (38%) are very similar.

We encourage readers to review the recent MIS and/or DHS reports from the countries where they work and look for differences in net availability as well as uptake of other malaria control interventions to determine the level of equity in intervention access and use, but also as one sees in Liberia, take action to ensure that strategies are in place to reach the poorest and most vulnerable segment of society.

Tanzania: Slow Progress in Preventing Malaria

The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.

So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.

Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.

Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.

The report show that 55% of children under 5 years of age and 51% of pregnant women slept under an ITN. This is down from 72% and 75% respectively in 2011.

We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.

Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..

Malawi Makes Progress and Plans to Defeat Malaria: Directions from the 2017 Malaria Indicator Survey

Malawi has conducted four Malaria Indicator Surveys (MIS), with the most recent being in 2017. Such surveys are crucial tools for [planning and evaluating efforts by national control programs and their partners. Dr. Dan Namarika, Secretary for Health, Ministry of Health in the preface to the 2017 Report sums up the context and progress best, and so first, we have reproduced his narrative below.

Then we look at the example of the insecticide treated net (ITN) data as a way to guide future planning. The MIS format itself has seen improvements with much better color graphics in addition to the traditional tables. Some of these are also shared herein.

According to Dr Namarika, “Malaria is a major public health problem in Malawi where an estimated 4 million cases occur each year. Children under age 5 and pregnant women are most likely to have severe illness. The Ministry of Health, in collaboration with partners, has developed the Malawi Health Sector Strategic Plan 2017-2022, which articulates the priorities for health sector development in the next 6 years and prioritizes malaria. In line with that emphasis, the National Malaria Control Program has just finished the development of the National Malaria Strategic Plan 2017–2022 with the goal of scaling up malaria interventions to reduce morbidity and mortality by 50% in 2022.

“We strive for progress in achieving prompt, effective malaria treatment. We hope to improve access to early intervention and treatment by expanding village clinic services, using insecticide-treated nets, spraying inside residences, managing the environment, encouraging changes in social behaviour and communication, and preventing malaria in pregnancy. We have set for ourselves high targets for these interventions, and we are confident that we will achieve our strategic goals of halving the incidence of malaria and deaths, as well as reducing the prevalence of malaria and malaria-related anaemia.

“Surveys such as the current Malaria Indicator Survey (MIS) are essential measures of progress towards these goals. Without measurement, we can only guess about progress. The 2017 Malawi Malaria Indicator Survey (MMIS) is the country’s fourth nationally representative assessment of the coverage attained by key malaria interventions. Interventions are reported in combination with measures of malaria-related burden and anaemia prevalence testing among children under age 5.

“Overall, there has been considerable progress in scaling up interventions and controlling malaria. We noted a decline in malaria prevalence from 33% in 2014 to 24% in 2017. Insecticide-treated net (ITN) ownership has increased from 70% in 2014 to 82% in 2017.

“Results of the 2017 MIS also show improvement on use of intermittent preventive treatment during pregnancy (IPTp) by pregnant women age 15-49. Coverage has increased from 64% for two or more doses in 2014 to 77% in 2017. The percentage of women who took three or more doses of SP/Fansidar for prevention of malaria in pregnancy increased from 13% in 2014 to 43% in 2017.

“In addition, numbers of children receiving a parasitological test and artemisinin-based combination therapy continue to increase.

“These results represent the combined work of numerous partners contributing to the overall scale-up of malaria interventions. I would like to request that all partners make use of the information presented in this report as they implement projects to surmount the challenges depicted here.”

According to PMI, “The 2017-2022 National Malaria Strategic Plan (MSP) builds on the successes achieved and lessons learned during implementation of previous strategic plans.” The example of ITN targets is illustrative and is included in the target, “At least 90% pf the population use one or more malaria preventative interventions.”

So in addition to showing progress with ITNs, the MIS 2017 report also points to gaps that require strengthened intervention. While there has been an increase of household net ownership we can see in the graph that the target for universal coverage of 1 net for 2 people still needs work. We can also see in the graphs that equity remains a challenge with a lower proportion of poorer households owning a net. In addition net ownership is lower in the Central Region of the Country.

We learn from the graphs that having access to a net in the household does not guarantee that people will actually use or sleep under them. The tables show us that the traditionally defined ‘vulnerable groups’ like pregnant women (62.5%) and children below the age of 5 years (67.5%) were more likely to sleep under nets than household members in general (55.4%). The push towards universal coverage stresses that all household members contribute to the health, welfare and wealth of the family and should be protected from malaria.

Now we should Return the comments by Dr Namarika on the value of having MIS data. All endemic countries need to ensure their malaria data are up-to-date to ensure they use this information to keep their strategic plans on track to defeat malaria.

Malaria by the numbers: are the statistics real or are they a barrier to community involvement?

George Mwinnyaa grew up in a small village in Ghana, West Africa. “I witnessed the death of several people including my siblings and my father. I became a health volunteer and later a community health worker.” George presented at the Johns Hopkins University TEDx event on 10 March 2018. Below are excerpts from that talk focused on his experiences in malaria interventions in Ghana and reflects on numbers found in public health interventions and questions what these numbers really mean to community members on the ground. George is currently an MHS student studying infectious disease epidemiology at the JHU Bloomberg School of Public Health.

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I have always been very skeptical with numbers, particularly numbers that indicate program accomplishments from the developing world. Whenever I see numbers reporting a problem such as the mortality relating to malaria, Pneumonia, or diarrheal diseases- it puzzles me because these are all diseases that have received great attention, and there have been many interventions implemented. Yet these problems still exist, and the question is why?

Today malaria is still among the top causes of infant mortality in many African countries, including Ghana, yet we have mosquito nets, coils, sprays, long sleeved shirts that have been circulating in the country for years……and sometimes I wonder: why?

Total funding for malaria prevention and control was 2.7 billion dollars in 2016. Between 2014-2016, 582 million nets were distributed, of which 505 million were distributed in Africa, yet the number of malaria cases increased from 211 million in 2015 to 216 million in 2016 (WHO-malaria fact sheet, 2017).

I was once a supervisor for the distribution of long-lasting insecticide treated nets in rural communities. The numbers driven world saw big numbers that showed that many pregnant women were not sleeping under mosquito nets and so the solution to solve the malaria problem was to give them mosquito nets.

First, they started out by selling the nets and people would not buy them, then they offered them free to pregnant women and that did not change anything, next they distributed to families in a household and that did not change anything, and finally they implemented what is known as the hanging of long lasting insecticide treated bed nets.

This time we went into a house with a hammer, nails and ropes, and families showed us their bedroom and we hung the net for them. And yet malaria still rules. What happened with the free bed nets is now widely reported across different countries in Africa.
What do the numbers we measure mean to the people they represent?

As an example, there was a man in a small fishing village with seven children. His biggest worry was how to get food for his family. So the world of numbers develops numbers-based interventions, numbers-driven solutions. Reporters found months after the family received the mosquito nets that no one in the family slept under the mosquito nets; instead the man had sown the nets together and used them for fishing to feed his family.

Frustrations abound on both ends of the system, for public health agents and community members. Numbers act as the barrier between the two ends of the “system”, and our goal must be to break the barrier. The numbers that drive interventions can be meaningless to the community people they represent unless we engage the community and learn how our interventions can really help them.

Equity, Inequities and Malaria

The World Health Organization has just released a new report entitled, State of inequality: Reproductive, maternal, newborn and child health. Because of its effort to look across the board at low and middle income countries generally, it does not include more region specific indicators like malaria services. This led us to look at a few recent DHS/MIS  (Demographic & Health and Malaria Indicator Surveys) to see what we can learn about equity or its opposite for malaria.

For RNMCH malaria indicators and equity we can examine coverage of long lasting insecticide-treated nets for both pregnant women (abbreviated as “preg < LLIN” in the attached charts) and children below five years of age (child < LLIN), taking of at least two doses of intermittent preventive treatment by recently pregnant women (IPTp2), and finally receipt of artemisinin-based combination therapy for febrile children below five years of age (ACT child, or where ACT not specified AMD child for antimalarial drug).

Slide4The equity variables presented in these surveys include residence in a rural or urban area, education of the woman, and wealth quintile. Recent reports from Nigeria (DHS 2013), Malawi (MIS 2014), and Angola (MIS 2011) were examined.

The first issue one notices is that these countries have not achieved the Roll Back Malaria coverage target of 80% that was set for 2010, let along sustained it. One could argue that it is not important to talk about equity until a country Slide10demonstrates the health systems capacity to seriously scale up these interventions. On the other hand one could also argue that efforts toward achieving equity at any stage of a program are important as these point to future sustainability and achievement.

The three countries in question each present a very different picture when it comes to equity. Starting with women’s education it is important to note that in two of the countries the proportion women with  post secondary is too negligible to analyze separately. The underlying last of access to post-secondary education is an important equity issue in itself.

Slide7For Nigeria access to both IPTp and ACTs for children is skewed toward those with higher levels of education. Angola’s coverage is also better for more highly educated women. Malawian women with lower education have better IPTp2 coverage, but the other indicators are mixed.

Rural disparity compared to better urban access to malaria commodities is evident in Angola and Nigeria for all Slide2indicators, while Malawi is again mixed. Interestingly in Malawi children in rural areas (41%) show better use of ACTs than those in urban settings (23%).

Angola exhibits the starkest contrast among wealth quintiles with all indicators showing increased coverage as wealth increases. In Nigeria this is true for IPTp and ACTs, but for LLINs, there is a peak in the middle quintile. It is often said in Nigeria that wealthier people prefer screening their homes than sleeping under nets.

Slide9Many factors enter into the picture. Malawi which is poorer in terms of GDP that oil-rich Angola and Nigeria has achieved better overall coverage with less pronounced disparities. One should also consider the differences in physical size with implications for program logistics among the countries.

In its own report, WHO says, “Health inequality monitoring is an essential step towards achieving health equity. It has broad applications and can be conducted across diverse health topics. Applying the best practices in health inequality monitoring presents an opportunity to share the state of inequality with stakeholders, indicate areas in need of improvement and track progress over time.” With tools like DHS, MIS and even national health information systems, endemic countries should also monitor their malaria intervention coverage and bring stakeholders together to address equity gaps.

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.

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.

Five Models of Equitable Access to MCH Services

Five models of equitable access to maternal and child health (MCH) services are the focus on a new article by Talukder and Rob.  We wonder what lessons these models hold for improving access to malaria treatment and preventive services, which should be integrated into MCH.

The five model programs from Asia and Africa listed below do cover malaria-endemic communities –

  • Community Health Volunteers Program in Bangladesh (BRAC)
  • Lady Health Workers Program in Pakistan (LHW)
  • Reproductive and Child Health Alliance Program in Cambodia (RACHA)
  • Community-based Health Planning and Services in Ghana (CHPS)
  • Tanzania Essential Health Interventions Project (TEHIP)

Each model addresses innovative ways of strengthening and managing health systems so that communities are reached and linked with the wider health system. At least four of the models involve community health workers who may be volunteers or receive a stipend.

BRAC is well known for involving community members in health provision and links their sustainability to microfinance opportunities and sales of basic health commodities.  This model has been used in malaria endemic areas of Bangladesh, the Chittagong Hill Tract. An evaluation of the effort reported that …

BRAC and the Ministry of Health implemented the national malaria control programme under GFATM and BRAC would be responsible for supplying LLIN to 80% household, as well as deploying health workers in every union to provide RDT (rapid diagnostic tests) and AL (artemether-lumefantrine) at the grass root level.

Community volunteers were effective in ensuring that the target goal for the supply of LLIN and retreatment of ITN were surpassed, but there was still competition with drug vendors in the provision of malaria treatment.

BRAC is now implementing its model with community health promoters supported by microfinance to implement malaria control as part of its overall health interventions in Liberia.

RACHA takes a different approach to promoting equity, especially gender equity in health service access. “RACHA works almost exclusively in support of the Ministry of Health’s priorities and programs. It does not provide health services or operate health facilities but works through the MOH service network and its community links to translate MOH technical policy and program priorities into quality effective intervention programs in the field.”

RACHA enhances health worker skills, guarantee quality assurance, improve supply mechanisms and create demand in the community.  RACHA also provides midwife training and delivery kits and microfinance to support the midwives. Although malaria is not specifically mentioned, quality assurance is certainly essential to addressing the problem of artemisinin resistance in the region.

Lady Health Workers are an core component of Pakistan’s primary health care efforts. According to WHO LHWs …

…act as a liaison between the formal health system and the community and disseminate health education messages on hygiene and sanitation. The programme is strongly rooted in the primary health care concept and it aims to achieve universal health coverage. Each Lady Health Worker serves around 1000 individuals.

LHWS receive a small salary of about US$ 343 per year. “Lady Health Workers provide essential drugs for treatment of minor ailments such as diarrhoea, malaria, acute respiratory tract infection, intestinal worms, etc., as well as contraceptive materials to eligible couples.”

dscn0272-chps-in-a-market-stma-district-2.jpgGhana’s CHPS program ensures that communities and specially trained community nurses work together to provide primary health care to under-served rural areas, including of course, malaria treatment.  While community volunteers are part of the effort, the overall community takes responsibility for providing a simple structure for a clinic and nurse housing.

Talukder and Rob note that the CHPS effort has resulted in decreased child mortality and and fertility rates in communities with what are known as the CHPS compounds. Up-to date information on the number of CHPS compounds is not available at the Ghana Health Service website, but estimates from 2008 are that “National coverage is now approximately 9% percent of the population.”

Finally, the TEHIP focuses of strengthening planning and management capacity of district health services.  According to ODI, the two pilot districts showed that …

TEHIP has brought about a change in the way that local health policy and practice is planned and resources are allocated across geographical and technical areas. At the district level health care workers and managers are more in control of resources and processes. This has also contributed towards a more robust decentralisation of the health care provision.

Because of TEHIP, “Child mortality in the two districts fell by over 40% in the 5 years following the introduction of evidence-based planning; and death rates for men and women between 15 and 60 years old declined by 18%.”

These results were achieved because the evidence-based planning model yielded an increase in average clinic visits per child from 2.8 to 5.8 a year. “More children were treated for malaria, more early cases of worms were spotted, more eye infections were caught, more AIDS messages were shared, and more mothers had exposure to family planning information.”
While these equity-fostering interventions have resulted in improvements in malaria indicators as well as broader child and maternal health statistics, they appear to have varying levels of scale-up and sustainability.  They all demonstrate the need for new ways of planning and managing district health services, and in at least three cases show the importance of community involvement.  A couple demonstrate innovative ways of using microfinance to sustain community health worker commitment.

Overall the lesson is one that has been voiced since the dawn of the Roll Back Malaria Partnership – we cannot roll back malaria without health system reform.

Net Equity – SUFI or SUFE?

nigeria2.jpgMalaria elimination efforts move along a pathway outlined by the Roll Back Malaria Partnership that begins with limited control, moves on to scaling up and then aims as sustaining the scaled up interventions so that incidence drops and we can enter the pre-elimination phase.  The scale up efforts that have been most intense in the past three-year effort to reach universal coverage (UC) have been known by the acronyn SUFI – scale up for intervention.

SUFI and UC are also viewed against the backdrop of RBM targets set in 2000 to achieve 60% coverage by 2005 and 80% by 2010.  The implication is that we may claim success with 20% of the population still not reached, which appears to counter the aims of UC.  Therefore a bigger question is whether we are simultaneously achieving SUFE – scale up for equity.

liberia2.jpgFrom the standpoint of malaria control equity should focus on whether those people who are most vulnerable to infection have access to interventions.  Vulnerability or risk has been viewed from two perspectives: 1) people who are more likely to experience infection because of their immune status such as children below 5 years of age and pregnant women and 2) people living in poverty whose financial and housing situation expose them more to infection and whose incomes are more at risk when they suffer from malaria.

Presented here are snapshots from health surveys in Nigeria, Liberia and Senegal that compare household net ownership with wealth quintile (Demographic and Health Survey, Malaria Indicator Survey). These countries have achieved differing levels of coverage and access to low income groups that help us question how equity relates to malaria control.

Nigeria is characterized by low overall coverage. During recent discussions at a retreate among maternal and child health professionals, colleagues raised the question of whether we can consider equity when coverage is very low. Nigeria prior to the mass net distribution efforts of 2009-11 provides some interesting information for the discussion. Although households in the lower wealth quintiles are slightly more likely to have any kind of bednet, the ownership of an insecticide treated net (ITN) is much greater in the wealthier homes. This may not be unrelated to the fact that ITNs in the early phases of control were often sold or subsidized, limiting their access to people with better income.

senegal2.jpgLiberia and Senegal with moderate and higher levels of coverage display the same overall trend as Nigeria with poorer household more likely to have some kind of bednet, but when it comes to ITNs, the poorer ones also have some advantage.  At the time of their surveys, both Senegal and Liberia had been doing some mass net distributions, and the benefit to the lower income people in their countries seems apparent.  It should be noted that higher income people may not need nets as a main protecteive measure if they live in better constructed homes that usually have window and door screening, an expensive intervention on its own.

One might conclude that Universal Coverage does have a strong equity or SUFE component.  We also need to investigate whether other interventions like prompt case management and intermittent preventive treatment are also reaching the people in most need.

Health Posts – meeting rural needs

People living in rugged rural terrain often go without formal health services. The population may be remote and even migratory, as some herd cattle.

dscn0659a.JPGAngola is working to ensure that at minimum there are Health Posts staffed by trained nurses to provide services beyond the municipal/district headquarters. And since onchocerciasis is common in many of such areas, we are also talking about providing integrated disease control and health care ‘beyond the end of the road,’ as advocated by the African Program for Onchocerciasis Control.

Life for these nurses is not easy as there is usually just one staff member to run the post. Also this situation means that male nurses predominate – one reason why it is presumed that antenatal care may not be easy to provide.

dscn0699-sm.JPGA visit to such a health post recently showed that not only was the nurse enthusiastic, but that he could provide some of the basic components of antenatal care in all but name.

The post had a good supply of sulphadoxine-pyramethamine that is required for intermittent preventive treatment of malaria in pregnant women. There were other medicines and supplements routinely given pregnant women such as ferrous sulfate and de-worming drugs.  The nurse even had a fetal stethoscope.

Strengthening these rural outposts is a priority for malaria control and health equity. These rural populations do not even have access to medicine shops as found in some areas.

Regular supplies of nets, RDTs, ACTs and SP will guarantee that all parts of Africa can work toward reducing malaria deaths by 2015.